But the recent suspension — and possible expulsion — of San Francisco high school student, Courtni Webb, is a fine example of how not to deal with suspected school violence.

Ms. Webb was suspended, according to news reports, for writing a poem about the Newtown killings, which apparently violated the school’s policy against threats of violence.

Poets, of course, have been deemed a threat to society ever since Plato banned them from his ideal “Republic.” Poetry, Plato argued, spoke to the heart, not the mind — and thus encouraged rebellion against the natural order of things.

But having heard Ms. Webb read her poem in its entirety, I found little in the way of violent rebellion, and certainly no overt threats to her classmates. Yes, the poem might be called self-absorbed — but isn’t that part of normal adolescence?

When Ms. Webb writes, “When you don’t feel loved/ you hate the world,” she could easily be expressing the feelings of thousands of alienated young people from time immemorial. Most of the poem seems to be an attempt to express her personal frustrations, and to understand the motivation of the Newtown shooter — not to threaten new violence.

We would be fortunate, as a society, if more lonely and alienated young people expressed their feelings in poetry, and fewer, through acts of violence.

We have yet to create a well-validated “profile” of those who carry out acts of so-called targeted violence, such as school shootings. The evidence to date suggests that perpetrators of such attacks tend to have very low self-esteem, a “persecutory/paranoid” outlook, depressive symptoms, narcissistic traits, and feelings of rejection. Perhaps one can find intimations of a few of these characteristics in Ms. Webb’s poem.

But as my colleague, Dr. James Knoll, has pointed out, focusing too heavily on these factors by “profiling” students would deluge school officials with “false positives.” Profiling alone — in the absence of careful, on-site assessment — casts far too broad a net to be useful.

Furthermore, as Prof. Eric Madfis of the University of Washington at Tacoma has pointed out, “zero tolerance” policies with mandatory arrests, suspensions and expulsions appear to do little to thwart targeted violence in schools.

Rather, schools do best by heeding the early warning signs of planned, targeted violence, such as when a would-be perpetrator “leaks” elements of the plan to another classmate, or posts threats on a website. Indeed, research from Finland found that adolescents aged 3-18 who expressed “massacre threats” online were a riskier group than adolescents who expressed the threats offline — for example, those who made online threats had often begun making actual preparations for the attack.

Of course, utilizing these early warning signs presupposes that knowledgeable peers or family members are willing to come forward to school authorities or police — and this happens all too rarely. As Prof. Madfis has noted, there is often a “code of silence” among adolescents that discourages coming forward with such information — which is widely regarded as “snitching.”

Nevertheless, the recent case of Blaec Lammers, in Bolivar, Missouri, shows that timely, personal intervention can make a huge difference. The young man’s plans for an Aurora-style movie theater massacre were thwarted when his mother reported him to local police.

Perhaps the most sensible recommendations for preventing targeted violence in schools come from the Interdisciplinary Group on Preventing School and Community Violence, writing in the aftermath of the Newtown, CT shootings. Among their conclusions was that the most effective way of preventing violence targeted at schools is by

“…maintaining close communication and trust with students and others in the community, so that threats will be reported and can be investigated by responsible authorities.”

The group did not endorse the use of “profiling” or checklists of personality traits. Rather, they urged the use of trained staff members who would investigate specific instances of apparent threats. Of course, schools strapped for funding will find it hard to implement such staff training — yet arguably, this may be more effective in preventing violence than posting armed guards at all our schools.

I also believe that greater cooperation between school health personnel and outside mental health specialists is sorely needed. For example, the school nurse or school psychologist could meet periodically with family physicians and psychiatrists in the community, to discuss students believed to be at high risk for targeted violence. This could be done via anonymous case presentations that would protect the privacy of potentially innocent students — and without simplistic “profiling.”

Some of these adolescents might be tugged off the path of violence through appropriate, voluntary counseling or mental health intervention. In cases of extreme or imminent threats of violence, involuntary treatment might be required, via appropriate judicial processes.

What will not help, in my judgment, is targeting students like Courtni Webb, who engage in acts of poetic expression, rather than savage violence.

References and Further reading    

Sankin A:  Courtni Webb, San Francisco High School Senior, Suspended For Writing Poem About Sandy Hook Shooting. Accessed at: http://www.huffingtonpost.com/2012/12/28/courtni-webb_n_2376833.html

Dibble L: 3Qs: Analyzing and preventing school shootings. Accessed at: http://www.northeastern.edu/news/2012/03/madfis/

Zarembo A: Plotters of school killings tend to tip off someone in advance. Los Angeles Times, Dec. 23, 2012. Accessed at: http://articles.latimes.com/2012/dec/23/nation/la-na-massacre-prevention-2012122

Interdisciplinary Group on Preventing School and Community Violence.  Accessed 12/20/12: http://curry.virginia.edu/articles/sandyhookshooting

Knoll JL: Mass Shootings: Research & Lessons. Psychiatric Times (in press).

Knoll J: Mass Shootings and the Ethic of the Open Heart. Medscape Psychiatry Dec 20, 2012. Accessed at: http://www.medscape.com/viewarticle/776427

Nina L, Atte O, Eila S, Riittakerttu KH: Adolescents expressing school massacre threats online: something to be extremely worried about? Child Adolesc Psychiatry Ment Health., 2012; 6(1):39.

Many voices have already been heard on this vexing question. But only a few commentators have recognized that such rare and tragic events are but a small part of the widespread violence in this country.

A mass shooting may be likened to the sudden eruption of a volcano on a slowly sinking island — the volcano gets the attention and publicity, and few stop to ask why the island is sinking.

To be sure, we must reduce the easy availability of lethal weapons and ammunition in this country; improve access to mental health services for severely disturbed persons; and enhance our coordination with school personnel, so that we can prevent alienated and disaffected youth from acting on their violent impulses. No other considerations should distract us from these goals, or be used as an excuse for inaction on any front — particularly with respect to firearms control.

And yet, more fundamentally, we must also address what I call “the romancing of rage” in our society — the many ways in which American culture fosters and even valorizes angry, aggressive behavior.

In their 2004 study of angry and violent youth, Sandra P. Thomas, PhD and Helen Smith, PhD cited data showing that among U.S. teenagers, 75 percent of boys and more than 60 percent of girls had hit someone in the past 12 months “because they were angry.” Thomas and Smith opined that, “Out-of-control anger behavior appears to be rampant among youth, perhaps echoing the behavior modeled by adults who engage in road rage, air rage, and desk rage.”

I believe that poor role models for our children are more likely than violent movies or video games to foster violence — though grotesque, video depictions of casual killing may sometimes “tip the balance” toward violence, in susceptible young people.

Along with widespread anger and aggressive behavior in our society is “…the relentless rise of narcissism in our culture,” as Jean M. Twenge, Ph.D and W. Keith Campbell, Ph.D described in their book, The Narcissism Epidemic: Living in the Age of Entitlement. All too often, our adolescent children are encouraged to believe that there is nothing more vital than meeting their own immediate needs, regardless of how others are affected. When this excessive focus on one’s own wishes merges with surging anger and resentment — often in the context of bullying by peers — violence may follow. Add to this mix the millions of readily-available, lethal weapons in the country, and we have the proverbial recipe for disaster.

There are no quick or easy solutions to these deep-seated societal problems. But on the level of parent-child relations, I believe we must teach our children how to self-monitor and modulate their anger, so that when they are provoked or bullied, they have the appropriate skills to restrain their natural inclination to retaliate.

The great spiritual traditions have emphasized the need to control anger in all its pathological forms. In Judaism, anger is compared to idolatry — for when we are consumed with rage, we engage in a kind of self-worship. In the Buddhist tradition, anger is considered one of the “three poisons,” along with greed and ignorance. And in the philosophy of the ancient Stoics, intense anger is considered “… the most hideous and frenzied of all the emotions,” to cite Seneca’s words. All these traditions teach methods for reducing anger, and our secular culture can learn a great deal from these ancient sources.

We will never eliminate anger or violence, nor will any single remedy prevent more Newtowns. We will need a multi-faceted effort at all levels of school, government, and family, over the course of many years. But right now, all of us can help by counteracting our culture’s “romance of rage” — and by inculcating the importance of self-restraint.

For further reading and reference:

Thomas, S.P., & Smith, H. (2004). School connectedness, anger behaviors, and relationships of violent and nonviolent youth. Perspectives in Psychiatric Care, 40, 135-148

Stuart H: Violence and mental illness: an overview. World Psychiatry. 2003 June; 2(2): 121–124.

Vossekuil B, Fein RA, Reddy M et al: The final report and findings of the safe School Initiative. U.S. Secrete Service and U.S. Department of Education, Washington DC, 2002. Accessed at: http://www.secretservice.gov/ntac/ssi_final_report.pdf (PDF)

Ash P: Violent children and adolescents. In: The American Psychiatric Publishing Textbook of Violence Assessment and Management, pp. 359-380. Edited by Simon, R.I. and Tardiff, K., Washington, DC: American Psychiatric Pub., 2008

Reddy M, Borum R, Berglund J et al: Evaluating risk for targeted violence in schools: comparing risk assessment, threat assessment, and other approaches. Psychology in the Schools, 2001; 38:157-72

A Call for More Effective Prevention of Violence. Interdisciplinary Group on Preventing School and Community Violence Accessed 12/20/12: http://curry.virginia.edu/articles/sandyhookshooting]

Friedman RA: In Gun Debate, a Misguided Focus on Mental Illness. New York Times, Dec. 17, 2012.

Davis SD, Young EL, Hardman S, Winters R: Screening for Emotional and Behavioral Disorders

Batchelor S: Buddhism Without Beliefs: A Contemporary Guide to Awakening, Riverhead Trade, 1998

Chagdud Tulku: Gates to Buddhist Practice: Essential Teachings of a Tibetan Master. Padma Publishing, 2001

Ellis A, Harper R: A Guide to Rational Living, Melvin Powers/Wilshire Book Co., 1961

Telushkin J: The Book of Jewish Values, Harmony Books, 2000.

Pies R: Everything Has Two Handles: The Stoic’s Guide to the Art of Living. Hamilton Books, 2008

Pies R: Becoming a Mensch: Timeless Talmudic Ethics for Everyone. Hamilton Books, 2011

Seneca: Letters from a Stoic. Transl. by Robin Campbell, Penguin Books, 1969

I certainly don’t pretend to have reached any final “truth” in the matter of physician-assisted suicide (PAS). At the same time, I believe that Dr. Grohol’s conclusions (1) rest on several misapprehensions regarding my own position; the ethical responsibilities of physicians; and the relevant medical facts pertaining to terminally ill patients.

Dr. Grohol argues that the debate is really “…about patient empowerment, human dignity and choice.”

I fully agree with Dr. Grohol that the patient’s autonomy is of great importance; indeed, autonomy is considered one of the four cardinal principles of medical ethics, along with benevolence, nonmalfeasance and justice (2).

But sometimes, medical ethics must set limits on a patient’s autonomous requests, even in the context of an understandable choice on the patient’s part. Thus, a patient may feel completely justified and “empowered” in requesting that the dose of her pain medication be doubled, even though that would be extremely dangerous to her health.

Governed by the principle of nonmalfeasance, the physician will wisely decline the patient’s request, and explain why that is necessary. So, too, in my view, with a dying patient’s request for lethal medication or “assisted suicide.” As Dr. Barbara Rockett, President of American Medical Association’s Foundation, cogently noted:

Centuries ago the physician Hippocrates wrote the Hippocratic Oath, which many of us took when we became physicians and guides us in the ethical practice of medicine. It states that when treating patients, physicians will “First do no harm.” It goes on to state that “I will give no deadly medicine to anyone if asked nor suggest any such counsel.” Physician-assisted suicide is in direct conflict with this statement which, when followed, has protected the patient, physician, society and the family, and at the same time has committed doctors to compassion and human dignity. (3)

Similarly, Dr. Lisa S. Lehmann, director of the Center for Bioethics at Brigham and Women’s Hospital, commented that, “Writing a prescription that allows a patient to acquire a lethal dose of a medication with the explicit intention of ending their own life really goes beyond the accepted norms of what physicians do…” (4) Proponents of so-called “death with dignity” laws need to ask themselves why only two states in the U.S. have adopted such laws; and why the American Medical Association, the Massachusetts Medical Society, the American Nursing Association, and the Massachusetts Academy of Family Physicians (5) all oppose physician-assisted suicide.¹ A partial answer is likely to be found in the foregoing statements by Dr. Rockett and Dr. Lehmann.

As regards “human dignity,” reasonable and compassionate people will differ on what, exactly, constitutes “dignity” and a “dignified death.” For some, a “dignified” death is one in which pain is endured with stoic resignation. My late mother, for example—a strong-willed and very independent-minded psychiatric social worker—frequently refused pain-relieving medication during her final days, much to the consternation of her physician son. But that was her idea of a “dignified” death. For other terminally ill patients, death with “dignity” may involve refusing any further food or drink. Indeed, as my medical ethicist (and theologian) colleague, Dr. Cynthia Geppert points out (personal communication, 10/3/12), refusing food and drink during the final days of life has long been considered a dignified way of dying in virtually all the world’s major religious faiths. (Importantly, declining appetite is a natural, bodily process during the final days of the dying process). I will return to this much misunderstood (and frequently misrepresented) option later. For now, I’ll simply say that I am not persuaded that ending one’s life with a prescribed medication is more “dignified” than declining further sustenance—which requires nobody’s authorization or prescription, and has been considered a morally acceptable way to end one’s life for many centuries.

That said, Dr. Grohol and I stand shoulder to shoulder as regards the physician’s absolute responsibility to alleviate the suffering associated with a terminal illness. And, it must be acknowledged that physicians — until very recently in medical history — have fallen woefully short in their willingness to alleviate the suffering that often attends a terminal illness. Unfortunately, this failure has helped fuel the understandable fear, on the part of the general public, that they will endure great suffering during their final days and therefore ought to be allowed to take a lethal overdose to end their lives. (Loss of autonomy and being a “burden” on others are also very common fears).

Probably every psychiatrist who has consulted in terminal illness cases has a horror story about the attending physician who was afraid to use adequate doses of pain medication in treating the patient nearing death, for fear of “addicting” the individual! But I believe that with the emergence of palliative care medicine as a subspecialty, this picture is beginning to change, and that expert palliative care represents a better and more ethical alternative to so-called “physician-assisted suicide” or “physician-assisted dying.” Indeed, Dr. Ezekiel Emanuel and colleagues concluded that “Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.” (6)

Contrary to Dr. Grohol’s impression, no conscientious physician—and certainly, not this writer—feels it is “…perfectly okay for a physician to let his or her patient die of willful starvation and dehydration.” (1). For me, as for most physicians, any decision to end one’s life, or hasten one’s death, requires scrupulous examination and represents an occasion of profound sadness and loss—hardly an event to feel “perfectly okay” about.

But it is not a question of “letting” a competent patient refuse food or drink during the dying process. It is not a physician’s prerogative to “let” or not “let” a patient choose that route, assuming the patient is mentally competent (i.e., not psychotic, delirious, severely depressed, and also apprised of the risks and benefits of all available options). No physician’s order is required to allow a competent patient to refuse food and drink, nor can a physician countermand a competent patient’s decision to do so. While there is no recognized “right” to commit suicide in this country, competent, terminally ill patients are at liberty to stop eating and drinking.²

This is not necessarily what I or many other physicians would counsel or recommend; indeed, I would consider it my duty to explore with the patient every appropriate palliative care option. But it is not in the physician’s purview to prevent a competent, dying patient from refusing sustenance.

More broadly, in the U.S., competent patients have a legal right to decline intrusive or “heroic” measures that artificially prolong the dying process. Indeed,

“…the law already permits patients or their surrogates to withhold or withdraw unwanted medical treatment even if that increases the likelihood that the patient will die. Thus, no one needs to be hooked up to machines against their will. Neither the law nor medical ethics requires that “everything be done” to keep a person alive. Insistence, against the patient’s wishes, that death be postponed by every means available is contrary to law and practice. It is also cruel and inhumane.” (7)

Just so. As physician and ethicist Dr. Fred Rosner has observed, for the physician, “To prolong life is a [commandment], to prolong dying is not.” (8)

1. In 1997, the AMA was joined by the American Psychiatric Association, the American Nurses Association, and nearly 50 other health care-related organizations when it filed an amicus curiae (“friend of the court”) brief with the U.S. Supreme Court opposing PAS. [Nair S. Virtual Mentor Ethics. Journal of the American Medical Association December 2005, Volume 7, Number 12]
2. It is important to distinguish “rights” from “liberties,” as well as “reciprocal obligation” from “compulsion.” As Szasz notes (Fatal Freedom, p. 113), rights require an “obligor” who must fulfill the right; a liberty is exercised without any other party’s direct, active involvement. It is also crucial to understand that neither rights nor obligations are absolute; they are always balanced against competing rights and obligations. People in this country have a right to free speech, and, in general, government has an obligation to protect it. But people do not have a right to yell “Fire!” in a crowded theater, nor is the government obligated to protect such behavior. There is no recognized “right” to kill oneself in the U.S., but mentally competent people, in my view, ought to be at liberty to end their own lives, even though I would almost always counsel against it.

   Most recognized obligations in this country have “opt out” provisions; e.g., in general, there is a recognized “right” to abortion, and physicians are, in general, “obligated” to respect and fulfill that right—but they are not compelled by law to do so. Similarly, if we make PAS a “right,” as the Massachusetts bill would effectively do, we would confer a generalized reciprocal obligation on physicians to respect and fulfill that putative right, all other things being equal. This is not the same as compelling physicians to carry out a PAS request; however, it might well open the door to frivolous litigation against physicians who “denied me my right to a PAS prescription”—even though such lawsuits would almost certainly be dismissed.

Fortunately, he is still well enough to walk, and finds himself one night near a tall bridge. Having contemplated the suffering he believes will attend his final days, he decides to end his life by jumping off the bridge. However, he is too weak to hoist himself up atop the protective railing.

Suddenly, he sees his very own physician, Dr. Jones, walking by. He begs Dr. Jones to help him climb atop the railing, adding, “Don’t worry, Doc, it will be my decision to jump.” The doctor is taken aback, but quickly determines that his patient is not psychotic or severely depressed, and is capable of making a rational decision regarding suicide. The doctor tries to persuade your dad that pain and suffering can usually be well-controlled during the final days, but the patient is insistent: he wants to end his life.

Would you agree that Dr. Jones is fulfilling his obligations as a physician by assisting your father in jumping off the bridge?

If not, would you support the doctor’s providing your father with a lethal dose of medication?

From the standpoint of medical ethics, I see no fundamental moral difference in a doctor’s assisting a patient to jump off a bridge — without, of course, pushing him off — and a doctor’s prescribing a lethal dose of medication to “assist” in the patient’s suicide. The main difference is that, whereas anybody can assist a suicidal patient in climbing over a bridge railing, only physicians and a few other health care professionals are authorized by law to prescribe medication — and, in Oregon and Washington state, to prescribe lethal medication for “physician-assisted suicide” (PAS).

Of course, there are important procedural differences between my bridge scenario and the way PAS is handled in these states. There are numerous procedural safeguards in place to ensure that dying patients are thoroughly evaluated, and not pressured or coerced into requesting lethal medication — though the evidence is mixed as to how effective these safeguards have been. One study of physician-assisted suicide in Oregon and the Netherlands found no evidence that disadvantaged groups (such as the elderly or disabled) are being disproportionately affected by the laws (Battin et al). On the other hand, another study (Finlay and George) concluded that, “…there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS.”

From a strictly ethical perspective, I believe physicians have no more business helping patients kill themselves with lethal drugs than they do helping patients jump off bridges — regardless of how “voluntary” the patient’s decision may be. Clearly, neither action is compatible with the traditional role of the physician as healer. Indeed, psychiatrist and ethicist Dr. Thomas Szasz has argued that “physician-assisted suicide” is merely a euphemism for “medical killing.” For these reasons, I am opposed to the November ballot initiative in Massachusetts for a measure that would allow terminally ill patients to be prescribed lethal drugs.

And yet, as always, there are two sides to the story. When my 89-year-old mother was in her final days, she was in a good deal of discomfort much of the time. Despite having first-rate home hospice care, and the availability of powerful pain relievers — which my mother often refused to take — her dying was not an easy or peaceful process, for her or for our family.

There were times when I wondered if I could ever bring myself to provide her with the Oregon “solution.”  Fortunately, my mother never requested this, and overall, I believe my family made her final days as dignified and comfortable as she would permit.

The debate over PAS often is clouded by a mistaken understanding of the dying process. Some advocates of the Oregon and Washington approach argue that the dying patient who wants to end her life has no recourse but to take a lethal drug prescribed by her physician. But in truth,  competent, dying patients may end their lives by simply refusing food and drink. Indeed, medical ethicist Cynthia Geppert MD, PhD informs me that voluntary refusal of food and drink is now considered an accepted approach to dying, in palliative care medicine.

Many readers will instinctively recoil from this claim. “How could you let your loved one die of hunger and thirst?” they will understandably ask. But we usually ask this based on our own unpleasant experiences of hunger and thirst, as healthy, active persons. For the dying patient, voluntary refusal of food and fluids does not result in an agonizing or painful death, as a report in the July 24, 2003 New England Journal of Medicine concluded. According to the 307 hospice nurses surveyed in this study, most patients will die a “good” death within two weeks after voluntarily stopping food and fluids.

We may agree, as a society, that competent adults ought to be at liberty to end their own lives. But this is not the same as asserting their “right” to commit suicide, much less insisting that physicians should be complicit in fulfilling such a right. Unlike liberties, rights impose reciprocal obligations on others. And, in my view, the physician’s obligation during a patient’s final days is to do everything medically possible to relieve pain and suffering — not to relieve the patient of his life.

Acknowledgement: Thanks to Bret Stetka MD and Medscape for permitting use of some material contained in my essay, “Do We Need ‘Thanaticians’ for the Terminally Ill?”, available at: http://www.medscape.com/viewarticle/771274.

References:

Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-Philipsen BD: Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups. J Med Ethics. 2007 Oct;33(10):591-7.

Finlay IG, George R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups–another perspective on Oregon’s data. J Med Ethics. 2011 Mar;37(3):171-4. Epub 2010 Nov 11.

Ganzini L, Goy ER, Miller LL et al. Nurses’ Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death. N Engl J Med 2003; 349:359-365 Accessed at: http://www.nejm.org/doi/full/10.1056/NEJMsa035086

Further Reading

• Death with Dignity: Why I Don’t Want to Have to Starve Myself to Death – Dr. John Grohol

• The proposed Death with Dignity Act in Massachusetts (PDF)
• Pies R: End-of-life care and contingent vs. non-contingent duties: contributions from WD Ross’s ethics and the Judaic tradition. Accessed at: www.hektoeninternational.org/End-of-life-care-and-contingent.html
• Szasz T. Fatal freedom: the ethics and politics of suicide. Syracuse: Syracuse University Press; 1999.
• Arehart-Treichel J: A Few Psychiatrists Choose Path Strewn With ‘Heartbreaking Work.’ Psychiatric News,  2012;47:8-25. Accessed at: http://psychnews.psychiatryonline.org/newsArticle.aspx?articleid=1217914

Do you remember the first time you heard or said these words? Maybe it was while playing hopscotch, tag, or “Monopoly” with your friends or siblings. Or, like me, you may recall that expression from the school playground, when someone broke the rules of the touch football game. The fact is, most of us grew up in a culture that places great value on “fairness” and “playing by the rules.”

There’s just one problem with this noble ideal: the world simply doesn’t work that way. As the biblical book of Ecclesiastes observed, “The race is not to the swift, nor the battle to the strong, neither yet bread to the wise… but time and chance happens to them all.”

Indeed, the physicists tell us that the universe tends toward maximum disorder, or “entropy” — not fairness! And yet, most of us react to injustice, mistreatment, and even natural disasters with a sense that we have been treated unfairly — as the B.J. Thomas song put it, we feel that “Somebody done somebody wrong!”

This is perfectly understandable. If someone assaults you, steals from you, or cheats on you, you have every right to feel upset or angry — so, too, if you have suffered verbal or emotional abuse.  Many of you who have gone through, or are going through, a painful separation or contested divorce may understand what I mean. You will almost certainly need time to grieve the loss of your marriage or relationship. You may also need a good deal of time to work through feelings of anger, betrayal, and the downright “unfairness” of it all.

These feelings are entirely understandable — but past a certain point, they may do you more harm than good. They may even trap you in an endless loop of paralysis and negativity.  Freeing yourself from this trap is critical to moving on with your life. As Dr. Mark Banschick put it in his blog of Jan. 31, 2012, “Radical Acceptance means that you understand that bad things do indeed happen to good people… all the time. You can stay mired in your sense of injustice and self-righteousness…But what purpose does it [serve]? …You lose a second time because you become a victim of your own victimhood.”

But what can be done to achieve this “radical acceptance” of life’s unfairness?  Enter the Stoics.

These disciplined thinkers flourished in ancient Greece and Rome, and strongly influenced later Jewish and Christian theologians.  There are also strong similarities between Stoicism and Buddhism. And, as we’ll see, the Stoics have helped shape our modern schools of cognitive-behavioral therapy. But before discussing some basic Stoic beliefs, it’s important to debunk a few myths.

Myths about Stoicism

When you hear the term “Stoic,” you might picture those stiff-upper-lip types on Masterpiece Theater, repressing their roiling emotions as they look down their noses at the kitchen staff. Or maybe you associate the term “Stoic” with the ever-logical and unflappable Mr. Spock, on “Star Trek.” But these caricatures have only a remote connection with the great Stoic philosophers, like Epictetus, Seneca, Cicero, and Marcus Aurelius.

The Stoics were not joyless, godless, logicians! They saw a divine order in the world that united all mankind. They did not want to eliminate emotion, so much as to refine it. Rather than “sweating the small stuff,” the Stoics saw the larger picture of life, and focused on developing ethical and virtuous action — the only real and lasting “good,” in Stoic philosophy.

Coping with Life Through Stoicism

So, with this background in mind, how might Stoic philosophy help you cope with painful losses and traumas in your own life?

Fundamentally, the Stoics taught that we need to live in harmony with Nature and the Universe. No, that doesn’t mean hugging a tree, or eating organically grown grapes. The Stoics meant that we need to accept the world for what it is.

The Thai Buddhist Master, Ajahn Chah, put the idea this way: “If you want the duck to be a chicken and the chicken to be a duck, you are really going to suffer!”  Indeed, part of accepting life for what it is means accepting — not liking! — that there are many “bad actors” out there who sometimes try to hurt us. Stoicism teaches us that we don’t have to be blown away by their bad behavior — nor need we become enraged or hateful toward those who treat us unjustly.

The Stoics recognized that, in the end, we are all in the same, storm-tossed boat, filled with fallible human beings. The emperor-philosopher Marcus Aurelius put it this way:

“First thing every morning tell yourself: I am going to meet a busybody, an ingrate, a bully, a liar, a schemer, and a boor.  Ignorance of good and evil has made them what they are. . .  None of them can harm me, for none can force me to do wrong against my will, and I cannot be angry with a brother or resent him, for we were born into this world to work together . . .” (from The Emperor’s Handbook, by C. Scott Hicks and David V. Hicks.)

So, are the Stoics saying we should simply “turn the other cheek” and put up with injustice or shabby treatment at the hands of abusers? Certainly not! They believed that when it was in our power to change the bad behavior of others, or to correct an injustice, we should do so.

But once having exerted our best efforts, we need not torment ourselves if a bully is still a bully; a duck still a duck — or an exploitative ex-spouse still exploitative.  Stoic philosophy may be summed up in that well-known maxim associated with 12-step programs, but originating with theologian Reinhold Niebuhr (1892-1971):

“God grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference.”

Stoicism holds that “things,” events and people do not really upset or disturb us — it is only our opinion of these that has the power to distress us. This is a very odd, counterintuitive idea for many people to grasp.

I often hear patients say, “C’mon, Doc! Are you saying that if somebody insults me at a party, in front of all my friends, that isn’t upsetting?!” Well, the Stoics would answer, “It isn’t the insult that upsets you, but your opinion regarding the insult.”

Our modern-day cognitive therapists would agree. For example, the late psychologist, Dr. Albert Ellis, divides the experience of being upset into three components: A. The event that seems to set off the emotion. C. The emotion itself. And what is the “missing B”? It is our belief or opinion about “A,” the event.

Often these thoughts are barely in our consciousness, but may emerge upon careful self-examination. So, for example, the target of the insult probably had thoughts such as, “Oh, my God, this is so embarrassing! How am I ever going to live this down? I can’t stand that I’ve been humiliated like this!”

Ellis would call this sort of thinking “catastrophizing” or “thinking irrationally.” The Stoics would say that you have placed excessive value upon the opinion of others, and too little value on your own virtue. After all, if you have done nothing wrong — like tossing your gin and tonic at the person insulting you — you have no reason for being terribly upset.

Marcus Aurelius put it this way: “Seek refuge in yourself. The knowledge of having acted justly is all your reasoning inner self needs to be fully content and at peace with itself.” Shakespeare undoubtedly understood the Stoic position when he has Hamlet say, “There is nothing either good or bad, but thinking makes it so…”

There is much more to say about Stoicism, and I have provided some useful references for further reading. But before we close, let’s see how the principles we’ve discussed may apply in a painful domestic dispute:

Marge, a 35-year-old mother of two, was involved in a bitter, hotly contested divorce proceeding, in which her estranged husband, Rick, had been completely unbending in his demands. One day, in front of both children, Rick accused Marge of being “a crappy, selfish mother” and “destroying our family.” Marge had secretly hoped that the children might rally to her defense, but they ran off to sulk in the car. Marge, at first, felt devastated, and began to wonder if Rick was right about her. Then, she began to feel furious with Rick, and started having violent revenge fantasies.

Later that day, Marge spoke with her friend, Daun, who had some training as a grief counselor. Daun pointed out that while it was natural for Marge to be upset, she need not fall victim to Rick’s insult, and that Marge had done nothing wrong. Marge began to realize that she had consistently behaved ethically and responsibly toward Rick and the kids, and began to feel better about herself. “I guess Rick is always going to be Rick,” she told Daun, “and I had better deal with it.”

When buffeted by life’s many “slings and arrows,” you might find it helpful — as I do — to keep in mind an important ethical teaching of Marcus Aurelius: “I do my duty. Other things trouble me not.”

Recommended Reading:

William Irvine: A Guide to the Good Life: The Ancient Art of Stoic Joy, Oxford University Press, 2008.

Albert Ellis, Robert A. Harper: A New Guide to Rational Living, Wilshire Books, 1975

Acknowledgment: A slightly different version of this essay first appeared on Dr. Mark Banschick’s website, www.TheIntelligentDivorce.com.

The author thanks Dr. Banschick and Dr. Grohol for supporting this work.

“Why don’t you wear the right T-shirts?” my father would ask, with genuine bafflement. “You’ll be a lot cooler in the summer!”

“I like colored T-shirts, with sleeves!” I’d shout back. “Leave me the hell alone!”

I was 14, and anything but the son my father would have chosen. He was a natural athlete who loved nothing better than starting up a softball game with the kids at Kibbe Park, who knew him simply as “Jake.” He liked crooning along with “Dean Martin Sings Parisian,” channeling Groucho Marx (“I hate to be Russian, but I Mos-cow…”) and downing a cold glass of Genesee Beer with a few slices of pepperoni.

I was a studious nerd, given to spouting verses from Dylan Thomas and listening to Simon and Garfunkle, alone in my room. I hated almost anything connected with sports and, as my classmates frequently pointed out on the baseball diamond, I threw “like a girl.” On some level, I probably sensed that the arguments my father and I had over T-shirts were really about the kind of kid I was, and the kind he wanted me to be.

But when I turned 15, my father and I found common ground in the soft, leather seats of our 1962 Pontiac Bonneville. I was still too young to drive legally, but my dad and I would take the “Bonnie” out into the countryside, and he would let me take the wheel.

At first, I’d sit scrunched up against him in the driver’s seat — “Just in case the cops should stop us!” — with my father’s oniony breath hot on the back of my neck. But as he grew more confident in my driving skills, my father would take the passenger seat and let me drive on my own. Sailing along on the hot, sticky tar of those country roads, with watery mirages shimmering ahead of us, my father and I were almost at peace — or at least, abiding by the terms of some undeclared truce. I might throw like a girl, but I could drive like a man. My father sat smiling beside me and seemed almost proud.

Two years later, he was diagnosed with metastatic renal cancer. As I was already determined to become a doctor, my father’s physicians took me into their confidence, and under their wing. The oncologist from Buffalo held up a vial of vincristine, drew me close, and said somberly, “Your dad has a 30 percent chance of remission with this.”

Back in the 1960s, this kind of news was routinely kept from the patient, particularly if the family and the doctor agreed it was in the patient’s “best interest.” And so, my father was told he had a “cyst” on his kidney, and that it could be surgically removed. My uncle, a renowned surgeon, actually performed the operation. “It went very well,” he said afterward, “very, very clean.” But six months later, my father was dead.

We never resolved our argument over which T-shirt to wear, and I never became the kind of ball-playing, back-slapping son my father would have liked. But to this day, I can feel his breath on the back of my neck, as we cruised in the rough freedom of the summer countryside.

In some ways, I have kept the parts of my father that could reside comfortably in my poet’s heart. I’m no Dean Martin fan, but Paris is my favorite city. And, as I often say to my wife when I hurry out the door, “Honey, I hate to be Russian, but I Mos-cow!”

This might well be the attitude of many in the general public, having read the misleading news coverage of a debate over the DSM-5 — the still-preliminary diagnostic classification of mental disorders, often referred to as “psychiatry’s Bible.” Now, I am no fan of the DSM model of diagnosis — in fact, if the DSM is the “bible,” I’m something of a heretic. In my view, the DSM’s superficial symptom checklists are great for research purposes, but not very useful for most clinicians or patients.

Nevertheless, I don’t like seeing the work of my DSM-5 colleagues misrepresented. So when I see bogus headlines like, “Grief Could Join List of Disorders” in the usually circumspect New York Times, I cringe.

Before discussing the arcane debate over the “bereavement exclusion,” it’s important to understand what most psychiatrists really believe about grief, bereavement, and depression.

No psychiatrist I know believes that grief is a disorder, disease, or abnormal condition that requires treatment. And nobody connected with the DSM-5 believes that either! Grief is ordinarily a useful, adaptive emotion that follows a major loss, such as the death of a loved one (bereavement) or the breakup of an intimate relationship.

Indeed, the 15th century monk, Thomas a Kempis, recognized that there are “proper sorrows of the soul,” and that “…we often engage in empty laughter when we should rightly weep.” Psychologist Kay R. Jamison — writing in the wake of her husband’s death — described grief as “…a generative and human thing… it acts to preserve the self.” (from Nothing Was the Same). Grief might be considered the price we pay for forming deep and intimate attachments.

It is true that following the death of a loved one, many bereaved individuals will show some signs or symptoms that overlap with those of clinical depression — what psychiatrists call major depressive disorder (MDD). In addition to feelings of intense sadness or anguish, the recently bereaved person may eat and sleep poorly for several weeks; have difficulty concentrating; and withdraw from most social activities.

But it’s important to note that most recently bereaved individuals will not meet the full DSM-IV criteria for a major depressive episode. Most are able to carry on their everyday functions and activities at a higher level than individuals with MDD. The current debate over the bereavement exclusion (BE) arises when someone who has lost a loved one within the past two months consults a doctor, and is noted to meet the full symptom and duration criteria for a major depressive disorder. To understand the implications of this, let’s consider two hypothetical scenarios:

“Mrs. Brown” is a 28-year-old mother of two, whose husband was killed in Afghanistan three weeks ago. She sees her family doctor and says, “I’m still in shock. Of course, I knew Bob was always at risk, but I still can’t believe it. I barely functioned at all for the first week after he died, then I dragged myself back to work at the office — but it’s really hard to concentrate on anything. God, I miss Bob so much! I’m taking care of the kids pretty well, but I am in so much pain, I cry almost every day. I keep seeing Bob’s face, his smile. Sometimes, I have wonderful memories of all the things we did together. I’m having a terrible time falling asleep, though, and I’m wondering if maybe I could get something for that? My appetite isn’t very good, either, and I don’t make any effort to go out and meet people. But I do appreciate it when friends call or drop by, though. I guess I’ll eventually get back to being my old self, and I do want to go on with life, but it’s really hard! What should I do, Doctor?”

Most good doctors will recognize Mrs. Brown as having the expected and “normal” grief that follows bereavement—and nothing we anticipate from the DSM-5 will change that. While some physicians might prescribe medication to help Mrs. Brown sleep, very few knowledgeable physicians would prescribe an antidepressant, assuming this is the totality of Mrs. Brown’s complaints. Based just on the information above, there is good reason to reassure Mrs. Brown that—with love, support, and enough time — she will get through this tragedy without professional help. Those diligent doctors who actually bother to pick up the DSM-IV (or the expected DSM-5) will discover that Mrs. Brown falls short of the criteria for a major depressive episode. Indeed, there is nothing anticipated from DSM-5 that would deny Mrs. Brown a diagnosis of “appropriate grief due to bereavement” or that would “label” her as having a mental disorder. Dropping the BE from DSM-5 would make no difference in a case like this, since the BE is an option only when the bereaved patient fully meets symptom and duration criteria for a major depressive episode within two months of a love one’s death.

Now let’s consider “Mr. Smith.” He is a 72-year-old retired businessman whose wife died of cancer three weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc—really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. And sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”

Though it’s still early after his wife’s death, wise and experienced clinicians will be very concerned about Mr. Smith. He easily meets DSM-IV and DSM-5 (draft) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the current DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because — based on the facts presented — Mr. Smith doesn’t have the features that would “override” use of the BE, such as severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM rules — go figure!

So, if the bereavement exclusion is retained in DSM-5, patients like Mr. Smith would likely be told, “You are just having a normal reaction to the death of your wife.” Probably, no treatment would be offered, and none covered by insurance. My colleagues and I believe this is a serious mistake, with potentially devastating consequences — including the risk of suicide.

Contrary to much fear-mongering in the press, our position does not imply that Mr. Smith should be started on an antidepressant. It means that the doctor should seriously consider a diagnosis of MDD; meet again with Mr. Smith in another 1-2 weeks; and consider the advisability of supportive psychotherapy. Medication could be an option if Mr. Smith significantly worsens or becomes suicidal. Combined “talk therapy” and medication would also be an option if he is much worse in a week or two. And, yes — some patients with Mr. Smith’s clinical picture may spontaneously improve within a few more weeks. That, of course, does not mean Mr. Smith’s grief will be at an end.

I never imagined that 40 years later, as a psychiatrist, I’d be reading about this incident in connection with one of the most mysterious mass outbreaks of neurological symptoms in recent memory. And yet, this past January, the environmental-activist-cum-movie-star, Erin Brockovich, began investigating a possible connection between that chemical spill and the bizarre outbreak among a group of LeRoy Junior-Senior High School students.

I truly don’t know what explains the strange constellation of signs and symptoms seen in this group of young people. I’m not sure anybody does. Most of the expert opinion has settled on the description of “mass psychogenic illness.”

Some clinicians have used the term “conversion disorder,” which, in the older psychiatric classification (DSM-II), was considered a type of “hysterical neurosis.” (Subsequent DSMs expunged the terms “hysteria” and “neurosis” for a variety of reasons.) From the reports I have read, the teenagers involved have had a thorough medical and neurological evaluation. Dr. Gregory Young of the N.Y. Department of Health told NBC News, “We have conclusively ruled out any form of infection or communicable disease and there’s no evidence of any environmental factor.’’

My colleague and CNN mental health expert, Dr. Charles Raison, recently reviewed this story in a thoughtful commentary. He concluded—quite reasonably—that “conversion disorder is a plausible explanation” for the tics, verbal outbursts, and apparent seizures afflicting this group of 12 or more adolescent females. (It seems that one male and a 36-year-old female are also among those now showing tic-like symptoms).

But as Dr. Raison rightly observed, “No one likes conversion disorder as an explanation for the tic epidemic. Patients feel insulted, stigmatized and dismissed. Their parents feel dismissed and terrified that something medical has been missed… And what doctor worth his or her salt would be truly satisfied with an explanation that tells us nothing about the cause of the disease or how to specifically treat it?”

Indeed, there are many difficulties with both the concept of conversion disorder and the secondary explanation of “mass contagion.” When I was in residency, one of my revered teachers used to say, “Beware of diagnosing hysteria. It’s usually the last diagnosis the patient will ever receive.” She meant that once a patient had been labeled with “conversion disorder” or “hysteria,” no doctor would ever again take the patient’s symptoms seriously. The patient could end up in the emergency room with crushing, substernal chest pain radiating to her jaw—classic symptoms of a heart attack—and still be labeled “a hysteric!”

But the problems with “conversion disorder” go much deeper. First of all, what exactly is being “converted” in this disorder? This particular diagnosis—listed among the so-called somatoform disorders– is actually an anomaly in the modern-day classification scheme. As even many non-psychiatrists know, the current DSM-IV normally uses a combination of personal history, behavioral observations, and reports from the patient as the basis for diagnosing a given disorder. The premise behind the post-DSM-II classification schemes is that the diagnostic criteria should not speculate on “hidden” or internal causes, such as the “unconscious defense mechanisms” so dear to psychoanalysts.

Indeed, with a few exceptions—for example, Adjustment Disorders, Post-traumatic Stress Disorder, and certain disorders due to medical or neurological causes—the DSM-IV steers clear of “explaining” much of anything. So again: what is being “converted” in conversion disorder? In truth, nobody knows. In psychoanalytic theory—not necessarily synonymous with the truth—it was hypothesized that a repressed idea or unconscious conflict was “converted” into a bodily (somatic) symptom, such as a paralyzed limb. In effect, the psychoanalysts argued that the body would “speak” for the mind’s dark, submerged impulses—particularly in young females. For example, a wife’s unconscious, “forbidden wish” to strike her husband might lead to sudden paralysis of her arm.
But no scientific study or experiment has ever proved this theory—nor is such proof likely, given the obvious difficulties in spotting those repressed ideas as they are mysteriously transformed into bodily impairments.

But even if the psychoanalytic theory were somehow proved, we would then have the further difficulty of explaining the “contagion” effect—how the “hysterical neurosis” leaps from the initial sufferer to other nearby individuals, as has been theorized in LeRoy. Does the original unconscious conflict get converted into some sort of electromagnetic wave that travels to the brains of susceptible victims? Or, more plausibly, do we need to invoke sociological theories, involving empathic “identification” of suggestible subjects with the initial sufferer? Perhaps so—but here, too, we are more in the realm of speculation than of science. And yet, there is no denying that history records many outbreaks of what, for lack of a better term, we call “mass psychogenic illness” –often, but not always, among young females.

In recent years, advances in neuroimaging have fostered more “brain-based” studies of so-called conversion phenomena. For example, Dr. Jon Stone and colleagues in Edinburgh, Scotland, studied patients diagnosed with conversion-related ankle weakness, and compared them with control subjects instructed to simulate the same symptom—that is, control subjects were told to “fake” ankle weakness. Using a technique called functional magnetic resonance imaging (fMRI), these researchers found a distinctive pattern of regional brain activation in the conversion subjects. The pattern overlapped with, but differed from, that seen in the “simulators.”

But it’s not yet clear whether the pattern in the conversion subjects represents a cause or a consequence of the underlying problem. And, thus far, there is still no consensus on the underlying neurobiology of conversion symptoms. Some evidence suggests that individuals (mainly females) with conversion symptoms have higher-than-expected rates of childhood trauma, including physical or sexual abuse. While this could point to “psychological” explanations of conversion, it may also suggest that early childhood trauma has long-lasting effects on brain structure or function. Indeed, the more we examine conversion phenomena, the less useful the “mind vs. brain” dichotomy appears. Calling conversion symptoms “psychogenic” – suggesting that they are mere phantasms of the mind — may greatly oversimplify their underlying nature. Many cases of apparent “hysteria” eventually prove to have underlying medical or neurological causes. Furthermore, there are documented cases in which “hysterical” symptoms have been found to co-exist with bona fide neurological disease.

Whatever the ultimate cause or causes of conversion, it seems clear that this condition does not represent “malingering” or an attempt to deceive others. Unfortunately, individuals diagnosed with conversion symptoms are often written off as “crocks” or “fakers” and denied a thorough medical evaluation. For some patients with apparent conversion symptoms, “hysteria” is indeed the last diagnosis they are likely to receive. In time, we may discover a number of distinct causes for the symptoms experienced by the LeRoy students, varying from person to person. For now, we need to keep an open mind about whatever is afflicting these young people, and treat them with respect, understanding, and patience.

Thanks to Dr. Charles Raison for his helpful comments on this piece.

Image courtesy of Wikimedia Commons.

Most psychiatrists, and many patients, sense that psychiatry is in trouble these days. The reasons are complex, but boil down to a crisis of confidence: many in the general public — if they ever had faith in psychiatry — have begun to lose it.

Many psychiatrists who, like me, began their careers with hopeful idealism are now expressing pessimism or cynicism. Here, too, the reasons are complex, and have much to do with the sense that psychiatry has drifted away from its core values and central mission: the relief of human suffering and incapacity. Of course, the corrosive influence of “Big Pharma” and the gradual decline in the use of psychotherapy have contributed to this down-beat attitude.

And the highly-publicized dust-up over revision of psychiatry’s diagnostic classification — the DSM-5 (what the media love to call, “Psychiatry’s Bible”) — has certainly not filled psychiatrists with joy.

A number of prominent psychiatrists have criticized both the process and content of the still-developing DSM-5. Some have alleged that the DSM work groups have been too insulated from outside review, and that their proposed revisions will lead to an unwarranted “medicalization” of life’s normal stresses and strains. For example, critics worry that conditions like ADHD or major depressive disorder will be “over-diagnosed” using the proposed new criteria, and that this will lead, in turn, to excessive use of psychotropic medication. There are arguments to be made on both sides of these issues — but in my view, the critics are merely nibbling around the edges of the real problem.

In truth, the entire premise underlying the DSMs is severely flawed—and many psychiatrists routinely ignore the DSM in their clinical practices. Indeed, if the DSM is psychiatry’s “Bible,” it is fair to say that a great many psychiatrists are heretics. In my view, psychiatry needs to scrap the present diagnostic system and begin afresh, with its core ethical and clinical mission firmly in mind. This means getting rid of the “One from column A, one from column B”, research-oriented, diagnostic criteria, and providing clinicians with a manual that is practical and useful.

The present model of psychiatric diagnosis is useful primarily for researchers. It suits their needs for uniformity in diagnosis, by providing a set of “necessary and sufficient” signs and symptoms that define a particular disorder. These cut-and-dried criteria help ensure what researchers call “inter-rater reliability.” But this well-intentioned attempt to “carve Nature at its joints” doesn’t capture the diverse ways psychiatric illnesses actually appear in clinical settings; nor does the DSM’s penchant for pigeon-holing comport with how most psychiatrists actually “diagnose” their patients.

Most experienced clinicians listen carefully to the patient’s personal and family history; weigh this narrative in light of some general diagnostic categories, and arrive a “gestalt” understanding of their patient’s condition. Sure, psychiatrists — like other mental health professionals — are required to “play ball” with third-party payers, and provide the official DSM code for a given patient’s disorder. But this doesn’t mean that psychiatrists place much stock in the DSM’s categorical approach to understanding so-called “mental disorders”. This term is itself highly problematic, as it perpetuates the Cartesian “mind-body” split. Indeed, the original DSM-IV (1994) acknowledged this problem. No term is perfect, but I’d rather see a “Manual of Neurobehavioral Disease” — or simply, “Manual of Psychiatric Disorders”–than one of “mental disorders.”

Titles aside, here is the core problem: the DSM framework does very little to enlighten the clinician regarding the “inner world” of the suffering patient.

Let me be clear: I have great respect for my friends and colleagues who have spent many years developing the DSMs. And, I do not mean to disparage the assiduous efforts of the DSM-5 workgroups to refine the present set of diagnostic criteria. Clinical research is crucial for psychiatry, and there is a need for very specific diagnostic criteria in order to assure that subjects in a research study actually warrant a particular diagnosis.

Indeed, I believe the present (DSM-IV) criteria could serve as a launching point for a more refined set, based on the latest scientific studies, which could then be used by psychiatric researchers. Whether to publish these research-oriented criteria as a separate manual, or to include them in an appendix to the main document, is not critical. The real issue is that, from the work-a-day clinician’s standpoint, the DSMs that have appeared in the last thirty years (DSM-III and IV) have managed to embody “the worst of both worlds”, despite the good intentions of their authors.

Why is this so? Well, on the one hand, none of the major DSM psychiatric disorders, such as schizophrenia and bipolar disorder, is linked to any specific biological abnormality or “biomarker” — the proverbial “lab test” so many in my profession have been seeking. This is nobody’s fault: it simply reflects our limited (though growing) biological knowledge in what is still a relatively young science.

On the other hand, the observation-based, symptomatic criteria of the DSMs shed little light on the inner workings of psychiatric illnesses — how the patient suffering from, say, schizophrenia actually experiences the world. It is one thing to list a few symptoms of schizophrenia, such as auditory hallucinations or paranoid delusions. It is quite another to understand the illness from the patient’s perspective — an approach known as phenomenology. I would argue that many recently-trained psychiatrists have had little exposure to the phenomenology of the major mental illnesses. Most have been steeped in the culture of symptom check lists — not in the sorrows of the soul.

The present DSM categories convey the impression that diseases have “necessary and sufficient” features that define them—akin to the Platonic concept of ideal “forms.” A contrasting view is that of the philosopher Ludwig Wittgenstein, who argued that such “essential” definitions do not represent how language actually works. Wittgenstein wrote, instead, of “family resemblances” that help characterize a particular word or category, in a particular context. By analogy, no single feature or features characterize all five members of, say, the Jones family; however, four of the Joneses have blond hair, three of those four have blue eyes, and four are very tall. We can see the “resemblances” when the Joneses stand together for the family photo. Wittgenstein compared family resemblances to the overlapping fibers of a rope—no single fiber is present throughout the rope, but a large number of fibers overlap so as to create a continuous and recognizable object. The same may be posited with respect to any given psychiatric disease category. There may be no single set of “necessary and sufficient conditions” that define schizophrenia or bipolar disorder; but patients who suffer with either illness resemble one another in very characteristic ways.

Almost contemporaneously with Wittgenstein, philosophers such as Edmund Husserl—and later, existentialists like Jean-Paul Sartre—began to emphasize the unique structure and contents of the individual’s experience: her way of “being in the world.” It is this phenomenological perspective that would inform what I call “disease prototypes” in psychiatry. Essentially, these are narrative accounts of illness that try to capture the most salient and typical features of the condition, emphasizing the typical patient’s subjective experiences. Such prototypes would compose the core of the diagnostic system I am proposing.

What might a narrative prototype of a psychiatric illness sound like? In the case of schizophrenia, perhaps something like this:

Sal is a 30-year-old single male whose chief complaint is, “I can’t find pieces of me, and the pieces I do have are fading, fading, fading, into inter-dimensional space.” Sal’s problems began when he was about 14. According to his parents, Sal began to withdraw from friends and schoolmates and “seemed to enter a world of his own.” He became increasingly unable to maintain his hygiene, school performance, or social relations, often spending days at a time secluded in his room and refusing to shower or speak. He would eat only foods that had been “de-contaminated from radiation”, which he believed was being “beamed” into the house. By age 18, Sal complained of “gamma rays eating away at my brain”, and described hearing several persons discussing him in derogatory terms while alone in his room. Sal sometimes feels that “my thoughts are leaking out of my head” and that others “can read my mind.” At times, Sal will laugh or giggle inappropriately, as when attending the funeral of a family member, and his family reports difficulty in understanding Sal when he does speak…

An actual disease prototype would be much more detailed, of course, and would incorporate most of the signs and symptoms now listed in the DSM criteria. For disease entities that have highly variable presentations, more than one prototype would be provided. Each prototype would be accompanied by the latest data on any known biological abnormalities associated with the particular condition; detailed demographic correlates; and common findings on the mental status exam. (Ideally, this would be followed by information on the best-validated treatment strategies for a given condition, but that might well require a separate treatment manual). Each prototype would be compatible with its corresponding “research diagnostic criteria” (RDC), but would be framed in very different terms. (The proposed DSM-5 criteria for schizophrenia may be viewed here).

In short, it is not enough for psychiatrists simply to peck away at the proposed DSM-5. True, we will be stuck with the DSM-5 for the next decade or two, and we should strive to improve it while we still can. But in the longer term, psychiatrists and other mental health professionals owe it to themselves and their patients to think more boldly — and more philosophically — about their diagnostic system.

For further reading:

Frances A: DSM-5 Will Not Be Credible Without An Independent Scientific Review. Psychiatric Times, Nov. 2, 2011. http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1982079

Phillips J: The missing person in the DSM. Psychiatric Times, Dec, 21, 2010. http://www.psychiatrictimes.com/blog/dsm-5/content/article/10168/1766260

Mishara A, Schwartz MA: Who’s on First? Mental Disorders by Any Other Name? (Word document). Association for the Advancement of Philosophy and Psychiatry (AAPP) Bulletin 2010;17:60-63

Paris J: Commentary in : The Six Most Essential Questions In Psychiatric Diagnosis: A Pluralogue: Edited by James Phillips, M.D., & Allen Frances, M.D. Philosophy, Ethics, and Humanities in Medicine (PEHM) in press.

Pierre J: Commentary in The Six Most Essential Questions In Psychiatric Diagnosis: A Pluralogue: Edited by James Phillips,M.D., & Allen Frances, M.D. Philosophy, Ethics, and Humanities in Medicine (PEHM), in press.

Kecmanovic D. Conceptual discord in psychiatry: origin, implications and failed attempts to resolve it. Psychiatr Danub. 2011 Sep;23(3):210-22. Review.

Pies R: Reclaiming our role as healers: a response to Prof. Kecmanovic.
Psychiatr Danub. 2011; 23:229-31.

Pies R, Geppert CM. Psychiatry encompasses much more than clinical neuroscience. Acad Med. 2009; 84:1322.

Wittgenstein L: The Blue and Brown Books, New York, Harper Torchbooks,
1958.

Knoll JL IV: Psychiatry: Awaken and return to the path. Psychiatric Times, March 21, 2011. www.psychiatrictimes.com/display/article/10168/1826785

You have asked me about the cause of your mood disorder, and whether it is due to a “chemical imbalance”. The only honest answer I can give you is, “I don’t know”—but I’ll try to explain what psychiatrists do and don’t know about the causes of so-called mental illness, and why the term “chemical imbalance” is simplistic and a bit misleading.

By the way, I don’t like the term “mental disorder”, because it makes it seem as if there’s a huge distinction between the mind and the body—and most psychiatrists don’t see it that way. I wrote about this recently, and used the term “brain-mind” to describe the unity of mind and body.¹ So, for lack of a better term, I’ll just refer to “psychiatric illnesses.”

Now, this notion of the “chemical imbalance” has been much in the news lately, and a lot of misinformation has been written about it—including by some doctors who ought to know better ². In the article I referenced, I argued that “…the “chemical imbalance” notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.”¹ Some readers felt I was trying to “re-write history”, and I can understand their reaction—but I stand by my statement.

Of course, there certainly are psychiatrists, and other physicians, who have used the term “chemical imbalance” when explaining psychiatric illness to a patient, or when prescribing a medication for depression or anxiety. Why? Many patients who suffer from severe depression or anxiety or psychosis tend to blame themselves for the problem. They have often been told by family members that they are “weak-willed” or “just making excuses” when they get sick, and that they would be fine if they just picked themselves up by those proverbial bootstraps. They are often made to feel guilty for using a medication to help with their mood swings or depressive bouts.

… most psychiatrists who use this expression feel uncomfortable and a little embarrassed…

So, some doctors believe that they will help the patient feel less blameworthy by telling them, “You have a chemical imbalance causing your problem.” It’s easy to think you are doing the patient a favor by providing this kind of “explanation”, but often, this isn’t the case. Most of the time, the doctor knows that the “chemical balance” business is a vast oversimplification.

My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.” If you are thinking that this is a little lazy on the doctor’s part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room. I’m not offering this as an excuse–just an observation.

Ironically, the attempt to reduce the patient’s self-blame by blaming his brain chemistry can sometimes backfire. Some patients hear “chemical imbalance” and think, “That means I have no control over this disease!” Other patients may panic and think, “Oh, no—that means I have passed my illness on to my kids!” Both of these reactions are based on misunderstanding, but it’s often hard to undo these fears. On the other hand, there are certainly some patients who take comfort in this “chemical imbalance” slogan, and feel more hopeful that their condition can be controlled with the right kind of medication.

They are not wrong in thinking that, either, since we can get most psychiatric illnesses under better control, using medication—but this should never be the whole story. Every patient who receives medication for a psychiatric illness should be offered some form of “talk therapy”, counseling, or other kinds of support. Often, though not always, these non-medication approaches should be tried first, before medication is prescribed. But that’s another story—and I want to get back to this “chemical imbalance” albatross, and how it got hung around the neck of psychiatry. Then I’d like to explain some of our more modern ideas of what causes serious psychiatric illnesses.

Back in the mid-60s, some brilliant psychiatric researchers—notably, Joseph Schildkraut, Seymour Kety, and Arvid Carlsson– developed what became known as the “biogenic amine hypothesis” of mood disorders. Biogenic amines are brain chemicals like norepinephrine and serotonin. In simplest terms, Schildkraut, Kety, and other researchers posited that too much, or too little, of these brain chemicals was associated with abnormal mood states—for example, with mania or depression, respectively. But note two important terms here: “hypothesis” and “associated”. A hypothesis is just a stepping-stone along the path to a fully-developed theory—it’s not a full-blown conception of how something works. And an “association” is not a “cause”. In fact, the initial formulation of Schildkraut and Kety ³ allowed for the possibility that the arrow of causality might travel the other way; that is, that depression itself might lead to changes in biogenic amines, and not the other way around. Here is what these two researchers actually had to say back in 1967. It’s pretty dense biology-speak, but please do read on:

“Although there does appear to be a fairly consistent relationship between the effects of pharmacological agents on norepinephrine metabolism and on affective state, a rigorous extrapolation from pharmacological studies to pathophysiology cannot be made. Confirmation of this [biogenic amine] hypothesis must ultimately depend upon direct demonstration of the biochemical abnormality in the naturally occurring illness. It should be emphasized, however, that the demonstration of such a biochemical abnormality would not necessarily imply a genetic or constitutional, rather than an environmental or psychological, etiology of depression.

Whereas specific genetic factors may be of importance in the etiology of some, and possibly all, depressions, it is equally conceivable that early experiences of the infant or child may cause enduring biochemical changes and that these may predispose some individuals to depressions in adulthood. It is not likely that changes in the metabolism of the biogenic amines alone will account for the complex phenomena of normal or pathological affect. Whereas the effects of these amines at particular sites in the brain may be of crucial importance in the regulation of affect, any comprehensive formulation of the physiology of affective state will have to include many other concomitant biochemical, physiological, and psychological factors.”^{3 (italics added)}

Now remember, Mrs. ——, these are the pioneers whose work helped lead to our modern-day medications, such as the “SSRIs” (Prozac, Paxil, Zoloft and others). And they certainly did not claim that all psychiatric illnesses—or even all mood disorders—are caused by a chemical imbalance! Even after four decades, the “holistic” understanding that Schildkraut and Kety described remains the most accurate model of psychiatric illness. In my experience over the past 30 years, the best-trained and most scientifically-informed psychiatrists have always believed this, despite claims to the contrary by some anti-psychiatry groups.⁴

Unfortunately, the biogenic amine hypothesis got twisted into the “chemical imbalance theory” by some pharmaceutical marketers,⁵ and even by some misinformed doctors. And, yes, this marketing was sometimes aided by doctors who—even if with good intentions–didn’t take the time to give their patients a more holistic understanding of psychiatric illness. To be sure, those of us in academia should have done more to correct these beliefs and practices. For example, the vast majority of antidepressants are prescribed not by psychiatrists, but by primary care physicians, and we psychiatrists have not always been the best communicators with our colleagues in primary care.

Neuroscience research has moved beyond any simple notion of a “chemical imbalance”…

All that said, what have we learned about the causes of serious psychiatric illness in the past 40 years? My answer is, “More than many in the general public, and even in the medical profession, realize.”  First, though: what we don’t know, and shouldn’t claim to know, is what the proper “balance” is for any given individual’s brain chemistry. Since the late 1960s, we have discovered more than a dozen different brain chemicals that may affect thinking, mood, and behavior. While a few seem particularly important—such as norepineprhine, serotonin,  dopamine, GABA, and glutamate—we have no quantitative idea of what the optimal “balance” is for any particular patient. The most we can say is that, in general, certain psychiatric illnesses probably involve abnormalities in specific brain chemicals; and that by using medications that affect these chemicals, we often find that patients are significantly improved. (It is also true that a minority of patients have adverse reactions to psychiatric medications, and we need further study of their long-term effects).⁶

But neuroscience research has moved beyond any simple notion of a “chemical imbalance” as the cause of psychiatric illnesses. The most sophisticated, modern theories posit that psychiatric illness is caused by a complex, often cyclical interaction of genetics, biology, psychology, environment, and social factors. ⁷ Neuroscience has also moved beyond the notion that psychiatric medications work simply by “revving up” or toning down a couple of brain chemicals. For example, we have evidence that several antidepressants foster the growth of connections between brain cells, and we believe this is related to the beneficial effects of these medications.⁸ Lithium—a naturally occurring element, not really a “drug”—may help in bipolar disorder by protecting damaged brain cells and promoting their ability to communicate with each other. ⁹

Let’s take bipolar disorder as an example of how psychiatry views “causation” these days (and we could have a similar discussion of schizophrenia or major depressive disorder). We know that a person’s genetic make-up plays a major role in bipolar disorder (BPD). So, if one of two identical twins has BPD, there is better than a 40% chance that the other twin will develop the illness, even if the twins are reared in different homes. ¹⁰ But note that the figure is not 100%–so there must be other factors involved in the development of BPD, besides your genes.

Modern theories of BPD hold that abnormal genes lead to abnormal communication between various inter-linked regions of the brain—so-called “neurocircuits”—which in turn increases the likelihood of profound mood swings.  There’s growing evidence that BPD may involve a sort of top-down, “failure to communicate” within the brain.  Specifically, the frontal regions of the brain may not adequately dampen over-activity in the “emotional” (limbic) parts of the brain, perhaps contributing to mood swings. ¹¹

So, you ask—is it still all a matter of “biology”? Not at all—the person’s environment certainly matters. A major stressor may sometimes trigger a depressive or manic episode. And, if a child with early-onset BPD is raised in an abusive or unloving home, or is exposed to many traumas, this is likely to increase the risk of mood swings in later life¹²—though there is no evidence that “bad parenting” causes BPD. (At the same time, abuse or trauma in childhood may change the “wiring” of the brain permanently, and this in turn may lead to more mood swings—truly, a vicious circle).¹³ On the other hand, in my experience, a supportive social and family environment can improve the outcome of a family member’s BPD.

Finally—while the individual’s approach to “problem-solving” is not a likely cause of BPD—there is evidence that how the person thinks and reasons makes a difference.  For example, cognitive-behavioral therapy and family-focused therapy may reduce the risk of relapse, in BPD.¹⁴ And so, with appropriate support, the person with bipolar disorder can take some control of her illness–and maybe even improve its course– by learning more adaptive ways of thinking.

So, boiling it all down, Mrs.——–, I certainly can’t tell you the exact cause of your or anybody’s psychiatric illness, but it’s a lot more complicated than a “chemical imbalance”.  You are a whole person–with hopes, fears, wishes, and dreams—not a brain filled with chemicals! The originators of the “biogenic amine” hypothesis understood this over forty years ago—and the best-informed psychiatrists understand it today.

Sincerely,

Ronald Pies MD

Note: The above “letter” was addressed to a hypothetical patient. A full disclosure statement for Dr. Pies may be found at: http://www.psychiatrictimes.com/editorial-board

References

1. Pies R: Psychiatry’s new brain-mind and the legend of the chemical imbalance. Psychiatric Times, July 11, 2011. http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1902106
2. See, for example, M. Angell MD, in the New York Review of Books: “The shift from “talk therapy” to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs…”  http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/
3. Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science. 1967; 156:21-37.
4. See, eg, “The cornerstone of psychiatry’s disease model today is the theory that a brain-based, chemical imbalance causes mental illness.” http://www.cchr.org/sites/default/files/Blaming_The_Brain_The_Chemical Imbalance_Fraud.pdf (PDF)
5. Lacasse JR, Leo J. Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature. PLoS Med. 2005; 2(12): e392. doi:10.1371/journal.pmed.0020392
6. El-Mallakh RS, Gao Y, Jeannie Roberts R. Tardive dysphoria: the role of long term antidepressant use in-inducing chronic depression. Med Hypotheses. 2011; 76:769-73.
7. Moran M: Brain, Gene Discoveries Drive New Concept of Mental Illness. Psychiatric News, June 17, 2011.
8. Castrén E, Rantamäki T. The role of BDNF and its receptors in depression and antidepressant drug action: Reactivation of developmental plasticity. Dev Neurobiol. 2010;70:289-97.
9. Machado-Vieira R, Manji HK, Zarate CA Jr. The role of lithium in the treatment of bipolar disorder: convergent evidence for neurotrophic effects as a unifying hypothesis. Bipolar Disord. 2009;11 (Suppl 2):92-109.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800957/?tool=pubmed

10. Kieseppä T, Partonen T, Haukka J et al. High concordance of bipolar I disorder in a nationwide sample of twins. Am J Psychiatry. 2004 161; 1814-21.
11. Lagopoulos J, Malhi G. Impairments in “top-down” processing in bipolar disorder: a simultaneous fMRI-GSR study. Psychiatry Res. 2011; 192:100-8.
12. MacKinnon D, Pies R. Affective instability as rapid cycling: Theoretical and clinical implications for borderline personality and bipolar spectrum disorders. Bipolar Disord. 2006;8:1–14.
13. Heim C, Newport DJ, Bonsall R, et al: Altered pituitary-adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse. Am J Psychiatry. 2001;158:575-81.
14. Zaretsky AE, Rizvi S, Parikh SV. How well do psychosocial interventions work in bipolar disorder? Can J Psychiatry. 2007;52:14-21.

Recommended reading:

Kramer P: In defense of antidepressants. New York Times Sunday Review, July 9, 2011. http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html?pagewanted=all

You needn’t use much imagination. In Florida, Gov. Rick Scott is expected to sign a bill (SB-432) that will prohibit doctors from asking patients if they own guns, except when “…the information is relevant to the patient’s medical care or safety or the safety of others…”

The Florida bill was written with the help of — no surprise here — the National Rifle Association, which insists that this legislation is designed to prevent doctors from intruding on a patient’s privacy; “harassing” gun owners; and interfering with the patient’s second amendment “right to bear arms.” Similar bills are being considered in North Carolina and Alabama.

Now, the “relevance exception” clause may sound quite reasonable, at first blush. Evidently, it persuaded the Florida Medical Association, who ultimately went along with the bill. But the exception clause has not persuaded many Florida pediatricians, who believe such a law would have a chilling effect on the doctor’s evaluation. According to a report on National Public Radio², one specialist in adolescent medicine recently told a Florida Senate committee, “What if I have an adolescent who’s been bullied, [but] who’s not suicidal? I don’t think, under the current bill, I’m entitled to ask him if there’s a gun in the home, or if he’s carried a gun to school, or if he’s thinking of harming someone else with a gun.”

Indeed, the newly-added “relevance” clause may actually put the physician — and perhaps other clinicians — in a medico-legal “double bind”. If he or she fails to inquire about gun possession because it is not deemed “relevant”, and the patient goes on to commit some act of gun-related violence, the physician may be held liable for failing to ask the “relevant” questions. On the other hand, if the physician decides that a query about gun possession is relevant; but the patient believes otherwise, and becomes angry about the “invasion of privacy”, he or she could initiate a suit against the doctor, on the grounds that the gun possession query was not clinically “relevant” as per state law.

There are, of course, important constitutional issues raised by bills of this sort, not least of which is the physician’s right to freedom of speech, under the first amendment. Since when is it the role of government to control what may or may not be said, in the supposedly confidential relationship between physician and patient? Since when are such communications subject to monitoring and muzzling by a state government? And, by the way — how, exactly, is the second amendment’s right to bear arms infringed upon by a doctor’s mere inquiry, regarding guns in the home? Is the idea that the doctor is going to lead a group of left-wing, anti-gun zealots out to the patient’s house, and confiscate legally-owned firearms?

But these are questions best left in the hands of constitutional scholars and jurists. As a psychiatrist, I have a more direct interest in protecting the safety of patients, their families, and society. In fact, I am professionally obligated to inquire about firearms (and many other risk factors) whenever I believe there is a potential danger to the patient or others. As a therapist, in many jurisdictions, I am legally obligated by either case law or state statutes to consider notifying police or a third party who may be the target of violence on the part of a patient I have evaluated; for example, a distraught, angry patient in psychotherapy who reveals his intent to shoot a particular individual. What effect would a Florida-style law have on assessing the risk of gun-related violence, if the physician fears legal sanctions for stepping across the line of “relevance” specified in the exception clause?

These are hardly academic issues. Recently, a three-year-old South Carolina girl fatally shot herself in the head, using a pistol that was left loaded on a windowsill in her parent’s bedroom. In another case from California, reported in the May 11, 2011 New York Times, a 10-year-old boy shot his father to death, at home, using a handgun. Of course, lax firearms regulations in the U.S. contribute to such tragedies. Indeed, according to data from UCLA and Harvard researchers, the U.S. firearm-related suicide rate is almost six times higher than in comparison countries, and unintentional firearm-related deaths are about five times higher in this country.¹

Some proponents of the Florida bill respond to critics with a classic reductio ad absurdum argument. They ask, “If doctors need to inquire about guns in the home, why don’t they ask about poisonous snakes or dangerous dogs in the neighborhood? Why don’t they ask about tall buildings with unprotected balconies, open sewers, etc?” The emptiness of this argument should be evident to any clinician with a modicum of forensic experience. Obviously, there are infinite risks a physician, psychologist, or social worker could inquire about, but our time with the patient is finite — and few domestic dangers pack the lethality of a loaded gun in the house. Moreover, the possession of firearms in the home is a professionally-recognized risk factor for both gun-related homicide and suicide. As noted by Garen J. Wintemute, M.D., M.P.H. (Professor of Emergency Medicine and director of the Violence Prevention Research Program at the University of California, Davis, School of Medicine):

“Gun violence is often an unintended consequence of gun ownership. Americans have purchased millions of guns, predominantly handguns, believing that having a gun at home makes them safer. In fact, handgun purchasers substantially increase their risk of a violent death. This increase begins the moment the gun is acquired — suicide is the leading cause of death among handgun owners in the first year after purchase — and lasts for years. The risks associated with household exposure to guns apply not only to the people who buy them; epidemiologically, there can be said to be “passive” gun owners who are analogous to passive smokers. Living in a home where there are guns increases the risk of homicide by 40 to 170% and the risk of suicide by 90 to 460%.¹

These facts confer a very high degree of responsibility on the part of the physician. As Norris and Price have pointed out:

“Access to firearms is an important factor for clinicians to consider in any risk assessment of suicidal patients. Miller and Hemenway report that “in 2005, an average of 46 Americans a day committed suicide with a firearm, accounting for 53% of all completed suicides.”… All discussions with the patient and his or her family regarding firearms should be documented. When clinicians are doing a psychiatric examination of suicidal patients, they should inquire about the availability of firearms in the household. If a firearm is available, concerns about safety should be raised with the family and police. This is particularly true when children and adolescents reside in the household.”²

Obviously, the “gun possession” question will rarely be raised when a patient goes to the ER with a sore throat — any more than an astute physician would do a rectal exam under such circumstances. Furthermore, patients who decline to answer a physician’s questions about gun possession should never be harassed, disparaged or denied care — but doctors do not need a law to instruct them in such basic medical ethics. More important: the physician should not be looking over his or her shoulder at the question of how much legal risk is entailed in asking clinically-indicated questions about firearms.

These judgments should be guided by the physician’s medical training and clinical evaluation — not by misbegotten legislation that intrudes on the physician’s freedom of speech, and on the privacy of the doctor-patient relationship.

Acknowledgments: The author wishes to thank Michael P. Hirsh, MD, FACS, FAAP; and James L. Knoll IV, MD, for their helpful comments on earlier drafts of this piece.

References

1. Wintemute GJ. Guns, fear, the Constitution, and the public’s health. N Engl J Med. 2008 Apr 3;358(14):1421-4. Epub 2008 Mar 19.

2. Allen G: Florida Bill Could Muzzle Doctors On Gun Safety. National Public Radio, May 7, 2011. Accessed at: http://www.npr.org/2011/05/07/136063523/florida-bill-could-muzzle-doctors-on-gun-safety

3. Norris D, Price M: “Firearms and Mental Illness” Psychiatric Times, Oct. 30, 2009

You got other problems? Talk to your therapist!

If the front-page article in the March 6 New York Times¹ can be believed — and who wouldn’t believe America’s “Paper of Record”? — this is essentially what the practice of American psychiatry has become. But how accurate was the Times’ portrait of outpatient psychiatry? How grounded was it in the best available research? And given the roughly 30,000 psychiatrists in the U.S., how clear a picture can we get by peering through the eyes of one beleaguered practitioner who believes that psychotherapy is no longer “economically viable”?

As an occasional contributor to the Times who has great respect for its journalistic integrity, I’m sorry to say that this story was a disservice both to the Times readership, and to the profession of psychiatry. Although the article may have been a well-intended expose of malign insurance company practices, it amounted to a jaundiced caricature of psychiatric care — accurate in some respects, but distorted in many others. Furthermore, by disparaging the role of psychiatric medications, the Times article reinforced the “mind-body” split that has bedeviled psychiatry for the past 50 years, as Tanya Luhrmann showed in her classic study, Of Two Minds: The Growing Disorder in American Psychiatry.

But before critiquing the Times article, let’s own up to some real problems associated with current psychiatric practice.

It’s true that some psychiatrists have become more comfortable with molecules than with motives.  And, alas, as James Knoll MD has recently argued, some psychiatrists have gotten caught up in the “business” of psychiatry and strayed from the path of insightful and compassionate listening.² The beleaguered psychiatrist profiled in the New York Times piece certainly seems to have lost his way, despite his good intentions.

Let’s also acknowledge that the general trend reported by the Times — the diminishing use of psychotherapy by psychiatrists — is quite real. Over the past decade or so, the percentage of psychiatrists offering psychotherapy to all or most of their patients appears to have dropped. One study — very selectively cited in the Times article — found that “just 11 percent of psychiatrists provide talk therapy to all patients…”¹ This was based on a study by Mojtabai and Olfson,³ which found a decline in the number of psychiatrists who provided psychotherapy to all of their patients — from 19.1% in 1996-1997 to 10.8% in 2004-2005. The study also found that the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005, which “…coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications.”²

But the very same study found that almost 60% of psychiatrists were providing psychotherapy to at least some of their patients. Also, the threshold for considering a session “psychotherapy” was set quite high in the Mojtabai-Olfson study: the meeting had to last 30 minutes or longer. But as my colleague Paul Summergrad MD has pointed out, common practice and standard CPT billing codes (e.g., 90805) specifically include 20-30 minute visits for psychotherapy, with or without pharmacotherapy.⁴ Furthermore, Mojtabai and Olfson acknowledged that

“Some visits likely involved use of psychotherapeutic techniques but were not classified as psychotherapy in the current analysis. Psychotherapeutic techniques can be effectively taught and used in brief medication management visits by psychiatrists and other health care providers.”³ (p.968)

This last point was totally lost in the New York Times report. When I used to see patients for “medication checks” in my private practice, I would sometimes spend more time providing supportive psychotherapy than dealing with the medication issues, if the patient’s emotional needs warranted it. (If the patient was seeing another therapist in formal psychotherapy, I would try to remain an empathic listener, while encouraging the patient to raise the issue with the therapist).  Furthermore, in providing medication for some severely personality-disordered patients, it is often impossible to maintain the therapeutic alliance without understanding the patient’s self-sabotaging defenses. As Glen Gabbard MD has observed, “…psychotherapeutic skills are needed in every context in psychiatry” — including during the much-maligned 15-20 minute “med check.”⁵

Moreover, other data, omitted from the Times article, contradict the impression that psychiatrists have given up on psychotherapy, or that most meetings with psychiatric patients are just 15 minutes long.   For example, Reif et al (2010) found that, in a managed care psychiatric practice setting, two-thirds of claims involved medication management, and two-thirds involved psychotherapy — with an overlap of about 30%.⁶ The authors concluded that

“Despite potential financial disincentives for psychiatrists to conduct psychotherapy,  our findings show that billed claims for psychotherapy by psychiatrists were common… [and] it appears that the broader skill set of psychiatrists is still being tapped, with provision of both medication management and psychotherapy.”⁶

Furthermore, according to Dr. Mark Olfson, there has been a decline of about 9% in the mean visit duration for psychiatric appointments, in the past 11 years. That may sound like a lot, but it amounts to only a modest change: from 36.8 minutes (1995-1996) to 33.3 minutes (2006-2008) (M. Olfson, personal communication, 3/31/11).  This finding also contradicts the impression — strongly reinforced by the New York Times article — that 15-minute “med checks” are now the most common pattern of interaction with psychiatrists.

Although the Times article did not deal specifically with psychiatric residency training, there is a perception in some quarters that psychiatric residency no longer provides adequate training in psychotherapy.  A corollary of this view is that younger psychiatrists no longer regard psychotherapy as important; and hence, are at a disadvantage with respect to other mental health professionals, such as psychologists and social workers.  In fact, there are sound reasons for being skeptical of this downbeat assessment — or at least for tempering it with more hopeful information.

It is true, on the one hand, that many academic psychiatrists have expressed concern for the diminishing role of psychodynamic psychotherapy in residency training. There are also indications that while over half of psychiatry residents believe their programs provide high-quality psychotherapy training, about 28% express concerns about the adequacy of time and resources in their programs.⁷

You probably lost sleep, and didn’t feel much like eating. You may have felt this way for a few weeks, a few months, or even longer. All this belongs to the world of ordinary bereavement — not of clinical depression.

Yet the two constructs of “normal grief” and major depression are a source of continued controversy and confusion — and not just among the general public.

Many clinicians still find it hard to disentangle grief and depression, inspiring countless debates over “where to draw the line” between normality and psychopathology.

But the problem is not one of “fuzzy boundaries.” Grief and depression occupy two quite different psychological territories, and have vastly different implications with regard to outcome and treatment.

For example, ordinary grief is not a “disorder” and doesn’t require treatment; major depression is, and does. Unfortunately, the inner worlds of grief and depression are hardly glimpsed in the symptom check lists of our present diagnostic classification, the DSM-IV. And, alas, it’s not clear that the DSM-5 will bring great improvement in this regard.

What is Grief Anyway?

The classic studies of bereavement, performed by Dr. Paula Clayton in the 1970s, made it clear that some depressive symptoms were often present early in the course of grieving, sometimes lasting several months after the death of a loved one. Indeed, sadness, tearfulness, sleep disturbance, decreased socialization, and decreased appetite are features seen in both normal, adaptive grief and in major depression — sometimes confusing the diagnostic picture.

Clinicians therefore look at other “objective” features of the patient’s presentation to help make the diagnosis. For example, in ordinary bereavement, the grieving person is generally able to carry out most activities and obligations of daily living, after the first two or three weeks of grieving. This is not usually the case in episodes of severe major depression, in which social and vocational functioning is markedly impaired for many weeks or months. Moreover, early morning awakening and pronounced weight loss are more common in major depression than in n uncomplicated bereavement.

But by themselves, observational data do not always distinguish ordinary grief from clinical depression, especially during the first few weeks of bereavement. Accordingly, my colleague, Dr. Sidney Zisook, and I have tried to describe the phenomenology or “inner world” of grief, as distinct from that of clinical depression. We believe that these experiential differences provide important diagnostic clues.

Thus, in major depression, the predominant mood is sadness tinged with hopelessness and despair. The depressed person often feels that this dark mood will never end—that the future is bleak, and life, a kind of prison-house. Typically, the depressed person’s thoughts are almost uniformly gloomy. If an optimist sees life through rose-colored glasses, the depressed person sees the world “through a glass darkly.”

The writer William Styron, in his book, Darkness Visible, describes depressed individuals as having “their minds turned agonizingly inward.” Their thoughts are almost always focused on themselves — usually in a self-negating way. The severely depressed person thinks, “I am nothing. I am nobody. I am rotting away. I am the worst sinner that ever walked the face of the earth. Not even God could love me!”

At times, these nihilistic thoughts reach delusional proportions — so-called psychotic depression. And, despite the best efforts of friends and family to “cheer up” their depressed loved one, the sufferer is often inconsolable. Neither love, nor riches, nor the blessings of art and music can penetrate the core of despair. Suicide becomes an ever more tempting option—and often, the only option the sufferer can imagine.

The Inner World of the Bereaved

The inner world of the bereaved is unquestionably one of loss and sadness, but it differs in crucial ways from that of the depressed. In depression, sadness is constant and intractable; in bereavement, it is intermittent and malleable. The bereaved individual typically experiences sadness in “waves”, often in response to some reminder of the deceased. Usually, painful recollections of the loved one are interspersed with positive thoughts and memories. Unlike the seriously depressed person, the grieving individual usually feels that life will someday get back to “normal”, and that she will once again feel like her “old self.” Suicidal intentions are rarely present, though the bereaved may fantasize about “joining” or “reuniting” with the deceased.

Unlike the severely depressed person — alone on an island of self-loathing — the bereaved person usually maintains her self-esteem, as well as an emotional connection with friends and family. Perhaps the hallmark of ordinary grief, as psychologist Kay Jamison has noted, is the ability to be consoled. Indeed, in her book, Nothing Was the Same, Jamison astutely distinguishes between the grief she felt after the death of her husband, and her frequent periods of severe depression.

“The capacity to be consoled,” she writes, “is a consequential distinction between grief and depression.” Thus, during her bouts of major depression, poetry was of no consolation to Jamison; whereas during her grief, reading poetry was a source of comfort and solace. Jamison writes: “It has been said that grief is a kind of madness. I disagree. There is a sanity to grief… given to all, [grief] is a generative and human thing…it acts to preserve the self.”

Since they are distinct conditions, grief and major depression can occur together, and there is clinical evidence that concurrent depression may delay or impair the resolution of grief. Contrary to widespread claims in the media, the DSM-5 framers do not want to limit “normal grief” to a two-week period — which would be foolish, indeed. The duration and intensity of grief is extremely variable, depending on a variety of personal and interpersonal factors. Research by Dr. George Bonnano has found that after the death of a spouse, chronic grief was associated with pre-loss “dependency” upon the deceased spouse. In contrast, more resilient subjects showed less interpersonal dependency, and greater acceptance of death. Resiliency was by far the most common pattern observed, with most of the bereaved showing a return to relatively normal functioning within 6 months of the loss.

What are the implications of all this for the DSM-5? I believe that symptom check lists alone provide only a narrow window into the patient’s inner world. The DSM-5 should provide clinicians with a richer picture of how grief and bereavement differ from major depression — not just from the observer’s perspective, but from that of the grieving or depressed person. Otherwise, clinicians will continue to have difficulty distinguishing depression from what Thomas a Kempis called, “the proper sorrows of the soul.”

Acknowledgments: Thanks to Dr. Sid Zisook for his comments on this piece, and to Drs. Charles Reynolds and Katherine Shear for their important research contributions.

For Further Reading:

Bonanno, G. A., Wortman, C. B., Lehman, D. R. et al: Resilience to loss and chronic grief: A prospective study from pre-loss to 18 months post-loss. Journal of Personality and Social Psychology, 2002;83: 1150-1164.

Jamison KR: Nothing Was the Same. Vintage Books, 2011.

Pies R, Zisook S: Grief and Depression Redux: Response to Dr. Frances’s “Compromise” Psychiatric Times Sept. 28, 2010. Accessed at: http://www.psychiatrictimes.com/dsm-5/content/article/10168/1679026

Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008; 3: 17. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442112/

Zisook S, Shear K: Grief and bereavement: what psychiatrists need to know.

Zisook S, Simon N, Reynolds C, Pies R, Lebowitz, B, Tal-Young, I, Madowitz, J, Shear, MK. Bereavement, Complicated Grief, and DSM, Part 2: Complicated Grief. J Clin Psychiatry. 2010;71(8): 1097-8.

While the facts are still unfolding, and the accused shooter’s motivations — Jared Lee Loughner — still unclear, the murders in Arizona have once again raised a number of troubling questions: what if any link is there between violence and mental illness? Which problems in our health care system may contribute to untreated or inadequately treated mental illness? How should we balance civil liberties — including legitimate second amendment rights — against society’s very real safety concerns, when deciding whether guns should be sold to those with a history of severe mental illness? And would the answers to these questions have made any substantial difference in the case of the Arizona shootings?

In dealing with these complex questions, I don’t claim to “represent” psychiatrists, physicians, or any particular interest group. I am writing as a concerned citizen who happens to be a psychiatrist and bioethicist. I do not propose to offer any armchair “diagnoses” of the person now charged with murder in the Arizona shooting. Nor do I want to pre-empt a determination of the shooter’s degree of responsibility and culpability — those will be determined, one hopes, through due process of law and appropriate expert testimony. (Mental illness, so-called, is sometimes a partial explanation of someone’s behavior — is not an “excuse” for carrying out evil acts, nor does it rule out personal or political motives for a given action). Finally, by way of personal disclosure, I am a supporter of both single-payer, national health insurance; as well as more stringent controls over the sale and possession of lethal firearms.

Let’s start with the supposed link between mental illness and violence. Though the data are complicated, the overall conclusion from recent research is that violence is not closely linked to the major psychiatric disorders (major depression, bipolar disorder, and schizophrenia) per se. For example, the 1998 MacArthur Violence Risk Assessment Study, led by John Monahan and Henry Steadman, evaluated psychiatric patients recently discharged from the hospital. Unlike some studies that relied solely on self‐reports of violence, the MacArthur study used a combination of self‐reports, collateral informants, and police and hospital records.

The study found that the prevalence of violence among discharged psychiatric patients without a substance abuse disorder was similar to that among community‐dwellers who did not abuse substances. Furthermore, violence by these discharged patients rarely involved vicious attacks on strangers or clinicians. Usually, it resembled violence committed by other community‐dwellers, such as hitting a family member inside the home. The study revealed 6 homicides committed by 3 of the 951 discharged patients — thus, approximately 0.3% (3 in 951) of the released population were homicidal or committed acts of lethal violence. This rate is indeed higher than that in the general population, and is certainly not to be dismissed lightly. Still, in my view, the findings suggest that lethal violence among discharged psychiatric patients is quite rare.

To be sure, the MacArthur study has been criticized on various methodological grounds (see Torrey et al, 2008). Furthermore, mental disorders do increase susceptibility to substance abuse, and thus, indirectly increase risk of violence.

Nevertheless, a recent study by Eric Elbogen and colleagues at the University of North Carolina Chapel Hill School of Medicine tends to confirm the MacArthur findings.  Based on face-to-face surveys conducted by the National Institute on Alcohol Abuse and Alcoholism, and involving nearly 35,000 subjects, Elbogen and his team found that when psychiatric diagnosis was examined, severe mental illness alone was not associated with increased risk of violence — but severe mental illness plus substance abuse/dependence was significantly associated. Indeed, severe mental illness per se did not independently predict future violent behavior; rather, other factors — such as a history of physical abuse, environmental stressors, or parental arrest record — predicted violent acts.

The image of the violent mentally ill person must also be tempered by research from Linda A. Teplin and colleagues, of Northwestern University. Teplin et al have found that those with mental illness are much more likely to be victims than perpetrators of a violent crime. They discovered in their work that among psychiatric outpatients, about 8 percent reported committing a violent act, whereas about 27 percent reported being the victim of a violent crime.

Aside from being poor and dealing with some physical limitations, Patrice had no discernible cause for her chronic depression. Her marriage was good, and despite her straitened
circumstances, Patrice lived in a modest but comfortable home. Unlike many depressed patients, Patrice herself had no “narrative”— no internalized account of how she came to be depressed. Her mood disorder was as much a puzzle to her as to me — the kind of illness that, in the 1960s, would have been called “endogenous depression”— arising, rather mysteriously, from within.

Patrice had the usual symptoms of major depression — lack of energy, poor concentration, inability to experience pleasure, suicidal thoughts, etc.— but there was another layer to her pathology. She had a quality textbooks describe as “importuning,” and which most people would call “clingy” and “demanding.” When I listened to Patrice ’s complaints, it was as if my pant leg were being tugged by someone groveling piteously on the ground. When I examined my emotional reaction to Patrice, I could see that on some level, her “neediness” angered me—perhaps because it left me feeling helpless. This, generally, is not a feeling those in the medical field handle well.

Patrice had been on several of the most robust antidepressant regimens I knew of, to little avail. She was too uncomfortable to sit through an “exploratory” or psychoanalytically-oriented therapy, so I used a supportive approach. Contrary to popular belief, “supportive psychotherapy” does not consist of patting the patient on the shoulder and saying, “There, there!;” rather, it is aimed at shoring up the patient’s more mature coping mechanisms and helping him acquire new problem-solving skills.

But after many months, Patrice was no better. I began to conclude that underneath her depression, Patrice suffered from a personality disorder—what the textbooks describe as “a lifelong pattern of maladaptive behavior.”  Indeed, Patrice fit quite nicely into what was once termed “Passive-Dependent Personality Disorder” and what later became “Dependent Personality Disorder” in the current DSM-IV classification. Individuals with DPD are described as having a long-standing need to be “taken care of;” “clinging” behavior; a fear of being abandoned and difficulty making everyday decisions without excessive reassurance from others. Patrice fit the bill, all right. And yet, she had apparently functioned adequately in her life, marriage, and career, until about ten years prior to my seeing her, when her mood inexplicably began to plummet.

One day, I received a call from the emergency room. Patrice had been admitted after a “moderate overdose” on the medications I had prescribed. After speaking with the inpatient service, which quickly agreed to admit her, I felt myself foundering in the waters of guilt, anger and denial. Rather than admit to myself how badly my treatment had failed, I felt that Patrice had failed me—by “acting out” in this “passive-aggressive” manner. After discussing my patient’s voluminous treatment history with the inpatient unit director, I was surprised to hear her say, “Maybe it’s time for electricity.” This, of course, was “shop talk” for electroconvulsive therapy, or ECT—one of the most controversial treatments in psychiatry, and the stuff of innumerable myths and misunderstandings. “She’s been tried on everything,” the unit director pointed out, “and I think we owe her our best treatment.”

Indeed, there is no question that ECT is the most effective treatment available for severe, intractable major depression. Remission rates with ECT are in the range of 60-90%—much higher than rates with initial antidepressant treatment, which hover around 25%. ECT is also known to decrease suicidal ideation during the course of treatment. Yet this valuable intervention is often used as a “last resort,” even by experienced psychiatrists, frequently as a result of misconceptions on the part of clinician, patient, or both.

I recently heard a talk by Mrs. Kitty Dukakis—whose own ECT treatment was clearly lifesaving—in which she implored the audience of psychiatrists to use ECT earlier in treatment. Contrary to the myth fostered by Ken Kesey’s movie, “One Flew Over the Cuckoo’s Nest”—in which Jack Nicholson’s character, McMurphy, receives punitive ECT without a muscle relaxant –modern ECT methods do not cause convulsions. Neither does ECT cause detectable damage to brain tissue, based on several biological measures. (Many viewers of “Cuckoo’s Nest” seem to confuse ECT with lobotomy, which is no surprise, since McMurphy is later forced to undergo this barbaric neurosurgical procedure!). In fact, some preliminary evidence suggests that ECT actually increases certain “nerve growth factors” that enhance connections between brain cells. The beneficial effects of ECT treatment may last for many months, but some patients require occasional “maintenance” treatments, once a month or so, in order to stay in remission.

The biggest concern — memory loss — is usually mild, transient, and circumscribed, using the latest technical modifications of ECT technique. Recent data suggest that ECT’s effects on memory are comparable to those associated with long-term pharmacotherapy. While a small percentage of patients may report significant and enduring memory problems after ECT*, the vast majority do not, when the most advanced and “conservative” ECT methods are used. Most studies find that, six months after a course of ECT, neuropsychological testing reveals no substantial mental impairment in patients whose depression is in remission. Furthermore, cognitive risks must be weighed against the enormous degree of suffering, incapacity, and mortality—i.e., at least a 4% rate of suicide—associated with severe major depressive disorder. Nonetheless, candidates for ECT must receive detailed “risk-benefit” information as part of the informed consent process, and consultation with family members is often an important part of that process. It should go without saying—but I will say it!—that nobody should be coerced into accepting ECT, or undergo the procedure without having provided informed consent.

Somewhat to my surprise, Patrice did consent to the ECT, and I fully concurred. When I saw her a month later, as an outpatient, she had undergone a routine course of unilateral ECT, in which the electrical stimulus was administered to the “non-dominant” side of her brain. This method is known to minimize cognitive side effects, all other factors being equal. I was impressed, but not entirely surprised, that Patrice’s depression had been knocked back on its heels—she was clearly in remission. Her mood, energy, and zest for life had returned. She did not complain of any significant memory problems. What I found absolutely jaw-dropping was Patrice’s profound change in personality: she seemed, in every meaningful sense, a “new woman.”

The piteous and needy demeanor that I had attributed to a personality disorder had been completely transformed. The radiant woman who now sat before me wore the confident, beaming and assertive face of her youth. Patrice began spouting off on plans, projects, and long-postponed pleasures—without a hint of dependency or neediness.

The “real Patrice” had emerged, butterfly-like, from the cocoon of inadequately-treated depression. And I had learned two valuable lessons: first, patients don’t fail treatments; treatments fail patients. And second: what appears to be etched in the hard stone of personality is sometimes merely scratched in the shifting sand of treatable illness.

Note: “Patrice” is not the patient’s actual name.

Sources for Further Reading:

An Overview of Electroconvulsive Therapy (ECT) – Psych Central

Electroconvulsive therapy (ECT) – Mayo Clinic

Electroconvulsive therapy (ECT) – McLean Hospital

Smith GE, Rasmussen KG Jr, Cullum CM et al: A randomized controlled trial comparing the memory effects of continuation electroconvulsive therapy versus continuation pharmacotherapy: results from the Consortium for Research in ECT (CORE) study. J Clin Psychiatry. 2010 Feb;71(2):185-93.

Bocchio-Chiavetto L, Zanardini R, Bortolomasi M et al: Electroconvulsive Therapy (ECT) increases serum Brain Derived Neurotrophic Factor (BDNF) in drug resistant depressed patients. Eur Neuropsychopharmacol. 2006 Dec;16(8):620-4.

Shock: The Healing Power of Electroconvulsive Therapy, by Kitty Dukakis and Larry Tye; New York, Avery, 2006.

*For one patient’s personal perspective on her memory loss associated with ECT, see:

Donahue AB: Electroconvulsive therapy and memory loss: a personal journey. J ECT. 2000 Jun;16(2):133-43. [The PDF is available on line. This patient reported substantial and enduring problems with her memory, yet says she probably owes her life to her ECT treatment—RP]

Acknowledgment: I wish to thank Psychcentral’s Sandy Naiman for her careful reading of this article; however, the opinions expressed herein are solely mine.