Maggie's Farm

This is a re-post:

I mentioned The 48 Laws of Power a couple of weeks ago, labeling it "A Sociopath's Handbook." I now have my hands on a copy. It is, indeed, instructive in understanding what some of the people around us are doing. Here are some of the "48 Laws" that the book discusses:

- Never outshine the master
- Never put too much trust in friends; use your enemies
- Conceal your intentions
- Always say less than necessary
- So much depends on reputation - guard it with your life
- Court attention at all cost
- Get others to do the work - but always take the credit
- Make other people come to you - use bait if necessary
- Win through your actions, never through argument
- Infection: Avoid the unhappy and unlucky
- Keep people dependent on you
- Use selective honesty and generosity to disarm your victim
- When asking for help, appeal to their self-interest
- Pose as a friend; work as a spy
- Crush your enemy totally
- Use absence to increase respect
- Keep others in suspended terror; cultivate unpredictability
- Isolation is dangerous: Do not build a fortress to protect yourself
- Know who you're dealing with: do not offend the wrong person
- Do not commit to anyone
- Play a sucker to catch a sucker: Seem dumber than your mark
- The surrender tactic: Transform weakness into power
- Concentrate your forces
- Play the perfect courtier
- Re-create yourself
- Keep your hands clean
- Play on peoples' need to believe to create a cult-like following
- Enter action with boldness
- Plan all the way to the end
- Make your accomplishments seem effortless
- Get others to play with the cards you deal
- Play to peoples' fantasies

There are more, of course.

I happen to believe, based on experience, that the right psychotherapeutic approach, tailored for the individual, can be enormously helpful.

Two of my favorite quotes:

Freud (often misquoted): "The goal of psychoanalysis is to convert neurotic suffering into everyday (ordinary) misery."

Erik Erikson: "Psychotherapy begins where common sense ends."

Readers know that I am a Psychiatrist (MD) Psychoanalyst whose practice is mainly in psychodynamic psychotherapy, less of a "medical model" practice.

Dr. Dworkin (an anesthesiologist and pundit) has a good summary of the the evolution of psychotherapy in America: Psychotherapy and the Pursuit of Happiness. A quote from his essay:

Psychotherapy has undergone a great transformation since America’s mental health crisis began. Gone are the days when therapists were dedicated to the doctrines of Freud and Jung, when the field was suffused with an air of priestly sanctity, heavy with the odors of tradition and authority. In the old days, psychotherapists constructed vast philosophical fabrics out of the writings of visionaries. They dallied with ideas that bordered on philosophy and religion; their emotional natures were totally absorbed in the partisan passions of their analytic cliques; their subtle intellects concerned themselves with the dialectical splitting of dogmatic hairs. The words they used — id, ego, and superego, among many others — seemed like a transcendent manifestation of divine power, an example of humanity being vouchsafed glimpses of eternal truth flowing down through an elaborate and immense cascade of books, with individual therapists stretching back, through their pedigree of technique, to some godhead. A whole universe of understanding was brought about by means of these words. In this universe the therapist was not as his clients, but, instead, a creature apart.

In the past few decades, a new breed of therapist has emerged — sympathetic, friendly, lighthearted, warm, and caring. His therapeutic style bears everywhere upon it the signs of human imperfection. It is the outcome of efficiency and practicality, of the exigencies of business executives and the ambitions of professionals, of the preferences of society and of the necessities of unhappy people. Gone is the transcendent manifestation, the abracadabra of therapy. Gone are the fervors of piety, the zeal of disciples, and the enthusiasm of intellectuals imagining themselves to have discovered a new theory of human nature.

Once a consecrated priesthood, therapists today walk along the smooth road of ordinary duty. They help people with their everyday problems. They speak in a casual manner and even crack jokes. They are friendly. They smile. They differ neither outwardly nor inwardly from the clients they serve, for whom therapy has become a useful organization, a convenient and respectable appendage to existence, a sometimes necessary form of artificial friendship.

I would cheerfully dispute the notion that physicians no longer constitute a priesthood of sorts, and I would dispute the notion that most people practicing psychotherapy, regardless of their training, are mostly busy with people with "everyday problems." (Some are, most aren't.)

As for "happiness," that's not something either physicians or "caring professionals" have the power to deliver. Relief of unnessary suffering and problematic behavior is difficult enough in itself.

In my view, psychotherapy is a deadly serious endeavor with the ambitious goal of rescuing lives and souls from their emotional problems and limitations, as much as possible. More like a mind-surgeon than a paid friend.

We are friendly, however. Friendly but tough.

There are limits to the "medical model" of Psychiatry. Psychiatrists like me tend to focus on the "psycho-social" aspect, while others go full-bore with pills and symptom check-lists. There is no single form of Psychiatry today and many shrinks my age have never perused the DSM unless to find a plausible insurance code.

Word to the wise: Some shrinks want to understand you in depth, some want to diagnose you and give you pills, and some try to tailor help to you as an individual with talk therapy and/or medicine if needed. Many patients do not wish to open their hearts and souls - it feels too threatening and often is - and just want a pill if it will help them feel better without having to think too hard. My approach is to try to understand a person first but, if they want to try a pill, fine.

Here's something: The Medication Generation - Many young people today have now spent most of their lives on antidepressants. Have the drugs made them 'emotionally illiterate'?

Parts 1 and 2 were re-posted over the past two days.

I mentioned in an earlier post that a person's ability to adjust reasonably well to adult life does not necessarily depend on their DSM diagnosis (if they have one), but instead on their personality traits. Most of the personality traits we observe in people have to do with what we call "ego functions."

For just a few examples, what is their physical, mental and emotional stamina and endurance? What is their stress-tolerance, and how easily are they overwhelmed? How good are they at assigning themselves tasks and completing them? Are they reasonably honest, or connivers? What are their relationships like, and what sorts of relationships do they like to have? Are they socially appropriate? How sound does their judgement seem to be? How do they do with maintaining boundaries? How smart are they? How flexible is their thinking? How do they do with delaying gratification? Are they reliable or erratic? How self-regulating are they, or do they depend on external structures to function well? How often do they make excuses or blame? What do they want out of life? What motivates them? Do they have wholesome outlets? Are they emotionally mature? How do they view themselves, and how consistent is that with the reality?

Furthermore, what traits are out of line and give the person trouble managing life?

As I mentioned before, it is foolish to hold any standard of human perfection: I call that Psycho-utopianism. Let's just say that we are interested in a person's profile.

For the final post on the topic pf Psychiatric Diagnostics, let's take a closer look at Leo Bellak's list of ego functions, from Dr. Blatner's site which I linked last week. (It's not the best list. I wrote up a better one years ago, but cannot find it.)

    1. Reality Testing: This can range from  Disorientation to Distortion to Accurate Perception. Lots of seemingly normal people don't really check out their impressions of reality and operate with mild to moderate levels of distortion!
     2. Judgment. This can range from "Infantile Omnipotence"--that sense that if I want to do it, I can-- to a more sophisticated Degree of Appraisal of Consequences.  Even political leaders can lack this. Again, many of these variables are not always at the top end for many adults.
     3. Sense of Reality.  Most people sense their objective reality and can differentiate it from dream.
     4. Regulation/Control Affects/Impulses:  This can go in either the directions of being too impulsive or on the other hand, too over-controlled.  With maturity and health, people learn to vary the degrees of control, allowing spontaneity in some settings, being more low-key in others, and making the transitions smoothly, but few adults still do this very well, enjoying full spontaneity; many are all too habitually self-controlled. A few allow themselves to be excessively impulsive regarding anger, or shopping, or in dealing with sexual temptation, etc..
     5. Object Relations: What is the person's capacity to engage in a caring or close relationship, with a romantic partner, a good friend, family members, or close co-workers. Does the person tend to be excessively detached or, again, going to the other extreme, overdependent?  Do they shift among these positions, playing a lot of what Eric Berne would call interpersonal "games"?  (i.e., what used to be called "neurotic.") Or can they engage with mutuality and flexibility?
    6. Thought Processes. This variable includes not just intelligence, but also psychological states that avoid the anxiety of thinking, so they fail to engage in abstract reasoning. Or can they, instead, manage conceptual thinking?  Many people are in the middle on this one.
      7. Adaptive Regression in Service of Ego (ARISE): This is a fancy psychoanalytic term to explain the capacity to enjoy imaginativeness, the innocence of daydreaming, the freedom of the best of childhood's pretending and playfulness.  The lack of this can itself add a good deal of  rigidity to the personality.
     8. Defensive Functioning:   Some people use more mature defenses, humor, sublimation, suppression, and the like. Others tend to use more habitual, automatic, and immature defenses, sometimes even fairly primitive ones that waver on the edge (or go over the edge) of mental illness.
     9. Stimulus Barrier:  Some folks are hypersensitive, others too dense. To the extent that one is over-sensitive, what coping maneuvers are they capable of to compensate for this sensitivity?
    10. Autonomous Functioning. Aside from any emotional issues in life, how competent is the person, or free of pervasive inner conflicts, so that they're able to perform daily tasks regarding personal hygiene, communicating with others, being able to do simple or more complex work roles. Many people are pretty functional, but sometimes blocked if they're upset. Some have developed healthy--and occasionally unhealthy--abilities to resist any intrusion of personal issues on their hobbies or work skills.
   11. Synthetic-Integrative Functioning.  Some folks are fairly good in one area and terrible in other areas. How well can they manage to integrate all the other variables being spoken about here?
   12. Mastery-Competence:  Some people have  low initiative and are under-achievers. Others may have significant emotional wounds, but yet able to perform remarkably well in work, sports, and so forth.
   13. Superego Adaptation. Again, this can be too much, or too little, strongly blaming oneself, or shockingly lacking in guilt or shame, tending toward the puritan or happy-go-lucky type. More mature people are able to acknowledge errors and seek to rectify them, moving toward a more balanced type of social conscience.
    14. Strength of Drives:  Some people are more sexual than others, and in some cases this may be more extreme in either direction, from the asexual to the hyper-sexual or driven. This can be affected by hormones, overstimulation, and other factors. Another drive is the aggressive, which can be diverted into hostility, grumpiness, or more focused as competition and work. Other people are less driven, and at the extreme, "un-motivated." 

When we try to assess these things, we know that we are looking at surface manifestations, not at what is going on in depth. Like geologists gazing at a landscape, we speculate about what is underground based on what we see above ground, and then test our speculations with test drilling.

Modern Psychiatrists and Psychoanalysts often tend to focus on the "Object Relations" item, believing that, developmentally, the integration of mental relationships effects the stability and integration of the adult person (and that aberrations can be improved with Psychotherapy). I am a friendly skeptic about that, and more inclined towards the genetic basis of personality traits (which by no means implies that they are immutable).

OK, I am going to avoid depth psychology here because my purpose with these posts was to give a sense of the sorts of things shrinks think about when they evaluate somebody and not about Psychotherapy or Psychoanalysis. As for the medical students who will not specialize in Psychiatry, these sorts of methodical ways of thinking about people are quite practical, not especially theoretical, and, I believe, useful to everybody in their dealings with others.

Photo is Anna Freud, the more-or-less founder of Ego Psychology.

Part 1 was re-posted yesterday

(This series is a peek - a few samples - into what goes on in Third-year Psychiatry in Medical School. Very few of the students will select Psychiatry as a specialty, but all do clinical rotations through Surgery, Pediatrics, Internal Medicine, Psychiatry, OB-GYN, etc. - and further elective rotations in the 4th Year. I focused on Surgery and Orthopedic Surgery in my 4th Year. The Surgeons did their best to win me over, and almost did.)

In one of the teaching sessions, we watch a video of a half-hour intake interview of a patient in the Internal Medicine clinic, done by a third-year medical student. At the end of it, I ask "Let's list everything we now know, or might speculate about knowing, about this patient."

We go through the medical history, the patient's demeanor (what's their style? Dramatic? Passive? Grouchy? Warm? Arrogant? Sneaky? etc), physical appearance, dress, posture, eye-contact, tone of voice, nature of his interaction with the interviewer, apparent intelligence, knowledge about health issues, work history, family, special concerns, and so forth.

The students who have been science nurds and wizards are often astonished by how much information can be collected from a simple half-hour medical - non-psychiatric interview. I write it all down on the whiteboard, some as facts and some with a ?.

It usually fills the entire board, especially if I write large enough.

In Psychiatry, we have no high tech diagnostic tools - just our eyes and ears.

Moving to Psychiatry, let's assume that we are meeting with a patient in the Psychiatric consulting room - a new patient who does not require any sort of acute crisis intervention or triage. What do we want to know about this new patient right away, after they tell us why they are here?

First things first. We want to know about their general health. That is from their story, and via eyeball. (Over the years, I have diagnosed hypothyroidism, brain tumors, Lyme disease, MS, GI cancers, Parkinson's Disease, early Dementia, etc. in people who have come to me for Psychiatric help).

Then the obvious things. Their life story, their family history, their current life situation. We assume we are never getting the whole story, but we need a provisional frame for the picture. In the process of asking our questions and following up topics of interest, there are a number of other things we get from initial interviews, using our bag of tricks and our sensitive ears, which are solid data.

For some examples:

- We determine how self-observing they are, their capacity for "insight"
- We determine their motivation to deal with their problem
- We usually get a provisional DSM Axis 1 diagnosis - if they have one
- We get an idea of what their coping devices are, and when and how they fail
- We get a good idea of their IQ, their life skills, fund of knowledge, their adaptive success - what we call their "ego strengths" and level of functioning in important areas of life (eg relationships, work, avocations, etc)
- We get a sense of how they relate to others (to us, being the case at hand), rapport, relatedness, and a sense of what their personality is like, their appropriateness, manners, boundaries, attentiveness, sense of humor, etc. etc.
- We would like to be able to say something about the style of their thinking, and especially their patterns of defenses
- We would like to know how they respond to our observations and comments (eg defensive? interested? insulted? embarassed?)
- Try to assess their morality and impulse control, reliability, and any sociopathy or secondary gain, or manipulativeness (this can be difficult but, with experience, one can smell it)

(These are the sorts of observations that make some folks uncomfortable with shrinks in social settings. People are often not aware that when we shrinks are out of the office, we probably think about these things less than the average person. For us, it's work.)

The point is that the Psychiatric interview is just a variant of the medical interview, but one which usually takes more than a half hour. Sometimes, much more. With healthy patients with neurotic problems, sometimes it can take me 5 or 6 one-hour meetings just to come up with a provisional case formulation and treatment plan (if needed). With very ill patients, 3 minutes can be enough to make a triage plan (eg Agitated guy fighting with security guards and cops yelling that they are CIA trying to implant more transmitters in his brain. Easy. Get the guards to hold him down and give him IM Haldol and Ativan with a little Cogentin...and wait a while.)

What's our goal? Our goal is a thorough Psychiatric Diagnosis and a Case Formulation. In medical school, in Psychiatric Residency, and in an Analytic Institute you have to write these up as lengthy formal presentations, but at my stage you just kinda do it in your head and store it in your head, except in special circumstances.

As rank amateurs, medical students cannot be expected to do either of these in an expert way, but we require that they produce a couple of these on some of the patients they are following.

For Diagnosis, I ask the students to use Dr. Blatner's The Real Psychiatric Diagnosis (just one page) as an outline.

For Case Formulation, I ask them to use his The Art of Case Formulation.

I like Dr. Blatner's brief outlines because the focus is on portraying and understanding a patient, not just slapping a superficial label on them.

Part 3 tomorrow.

Photo: Harvard Prof Dr. George Vaillant, author of Adaptation to Life - another of the books the students read during my course.

Ed. note: We will post each of the 3 parts daily.

These posts are bits from a short series of presentations which I give to medical students during their required Third Year Psychiatry rotations. Which is to say, it is more or less directed to the general public but oriented towards general-physicians-to-be.

(Very few of these medical students will choose Psychiatry as a career, given all of their choices. More of them will chose Radiology than Psychiatry - wherein they will have plenty of fun and much to learn but never even have to talk to a patient at all - or Dermatology, wherein they will never have to be on call for the hospital. However, most will select Internal Medicine for their internships, which itself is a path to other specialties. FYI, all American-trained Psychiatrists do internships which include Internal Medicine or Pediatrics, plus Neurology, and get Board certification from the American Board of Psychiatry and Neurology.)

My presentation is not about making specific diagnoses (that comes from other Profs) - it's about the preliminaries: how all Docs can think about their patients, if they want to, and how shrinks think about their patients.

It's partly meant to be a corrective to the often-stated idea that the DSM is any gold standard of diagnosis, and it is meant to encourage young docs to think about their patients' lives, not just about their diagnoses - whether psychiatric or otherwise. And if I can interest them in the sorts of things shrinks think about, and gain some appreciation for what shrinks do, so much the better.

My presentation is based on the idea that, in the end, the job we shrinks get paid to do is to figure out what interferes with a person's ability to make a reasonably mature and effective adjustment to life if they wish to do so, and to try to reduce pathological mental pain, impairment, and anguish (but not healthy pain, worry, and anguish, like guilt, regret, sadness, realistic anxiety, or grief).

It's not to try to make people "normal," because "normal" doesn't really apply. People are wonderfully different, each with his own unique fingerprint of strengths, weaknesses, neuroses, interests, abilities, ego strength profile (about which more later), etc. In fact, unusual characters are a fine addition to the fabric of life.

I usually end my first session with a case example, for example, of a 42 year-old patient with hypertension coming in for a routine follow-up with his internist or GP. He has been prescribed 20 mg of Coreg/day for a month, and his systolic BP is 170 (had been 180 at his last visit).

I do my rapid-fire Socratic shtick. I ask them "So, Doctor, what do you want to know about this guy?"

"Is he compliant with the meds?" somebody wonders.

"Compliant!" I say. "What is he, your servant?" "Isn't the right question whether he is concerned enough about it to take the pills every day? Whether he can afford the meds? Does he need your free samples? Whether his life is too disorganized to do it? Whether it's the right medicine or the right dose? Or whether he even cares?"

We go on like this for around ten or fifteen minutes, and end up constructing a picture of a middle-management sales guy who is recently unemployed, divorced with two kids, mildly depressed, worried about money and alimony and child support, living in a small rented condo with rental furniture on take-out junk food and Chinese food, with some tendency for denial because he feels overwhelmed, with some deterioration in his self-care since his divorce made worse by the lack of structure and discipline in his unemployed life. His BP is the least of his concerns, but he does want to maintain a good relationship with the Doc, who he views as a friend and as a caring emotional support.

You rapidly move past the notion of A Case of Hypertension to the uniquely human and individual. It's good fun for all of us, and a good break for them from the fascinating but mechanistic details of caring for the renal functions of unconscious gomers in the ICU. It's about the art of doctoring, not medical science. You cannot do medicine "by the book," because each patient is his own book.

Then I tell them that they have just made a first step towards Real Psychiatric Diagnosis - and the real practice of clinical, office medicine as opposed to our equally wonderful technological medicine. It's about wondering "Who is this person who is asking me for help?" and not just about "What ails them?" After all, hypertension is painless, and doesn't really "ail him" at all. If you want to help this guy, all of this information about him might be useful to you.

In conclusion, I warn them that the same thing applies to Psychiatric diagnostics. Some people with Schizophrenia - a dread and incurable disease - have more satisfactory lives than some addicts - a sort-of fully curable problem. People are complicated, and so, often, are their lives.

Then I command the students to read MacKinnon and Michels' The Psychiatric Interview  as their first of several readings for my series. A Psychiatric interview isn't much different from any other medical consultation with a new Internist or Family Doc, really - except no physical exam other than that of the well-informed medical eyeball (which can detect a lot).

Yes, I will interrogate them on their readings just as the Surgical Profs do with their text on the examination of the abdomen, or Neurologist Profs do with the diagnosis of stupor and coma (or, as we termed it in medical school, the Diagnosis of Stupor, Coma, and Death. Funnily enough, the diagnosis of death isn't always so easy).

Parts 2 and 3, and maybe 4, later. Why am I posting this? To help me collect my thoughts and to improve my presentations.

Photo is Dr. Emil Kraepelin, father of modern Psychiatric diagnosis who, among many other things, distinguished Manic-Depression from Dementia Praecox (Schizophrenia).

That's from a depressed Dalrymple:

For every person who says “I’m unhappy” there must now be a thousand who say “I’m depressed.” The change in semantics is important: the person who says he is unhappy knows that there is something wrong with his life that he should try to alter if he can; whereas the person who says “I’m depressed” is ill, and it is therefore the responsibility of someone else — the doctor — to make him better.

For the sorts of Psychiatrists who find it valuable to probe below the surface, there are many sorts of depression and many causes. Even grief can sometimes lead to a debilitating depression.

In my private office, the most common "cause" of agonizing, if not always debilitating, depression is narcissistic injury. These patients often can benefit enormously by psychotherapy alone, and can end up far healthier and stronger than before.

I posted on the topic of Studying Happiness earlier this week.

It's difficult to study something that nobody can define in a non-circular way. From McCloskey: Happyism - The creepy new economics of pleasure. She makes the point that much of this is pseudo-scientific.

A quote from her very interesting essay:

...in the eighteenth century, our earthly happiness became important to us, in high intellectual fashion. By 1776, “life, liberty, and the pursuit of happiness” was an unoriginal formulation of what we all, of course, now admitted that we chiefly wanted. John Locke had taught, in 1677, that “the business of men [is] to be happy in this world by the enjoyment of the things of nature subservient to life, health, ease, and pleasure”—though he added piously, “and by the comfortable [that is, comforting] hopes of another life when this is ended.” By 1738, the Comte de Mirabeau wrote to a friend, recommending simply, “[W]hat should be our only goal: happiness.”

“Our only goal.” To see how strange such a remark is, consider whether it could have been uttered by a leader of opinion in 1538. Martin Luther? Michelangelo? Charles V? No. They sought heavenly, artistic, or political glory—not something so domestic as happiness. Yet, in the late seventeenth century, even Anglican priests commenced preaching that God wanted us to be happy as much as holy. They called it “eudaemonism.” Anglicans and, astonishingly, some New England Congregationalists turned against the old, harsh, Augustinian-Calvinist line. We are not, declared the eudaemonists, mere sinners in the hands of an angry God, worms unworthy of grace. We are God’s beloved creatures, his pets.

The eudaemonistic turn was a Very Good Thing, resulting in fresh projects to better our stay here on Earth, some of them remarkably successful. Democracy was one, since, if you followed the fashion for universal happiness, it became impossible to go on insisting that what really mattered was the pleasure of the Duke or the Lord Bishop. Enlightened despots of the era claimed to seek the good of all, which paradoxically gave the populace the idea that maybe they themselves could do it.

I will remind our readers that Freud (yes, still relevant in many ways but not in all ways) had a somewhat tragic view of life and figured that pleasure and joy certainly matter, but that, overall, ordinary - "non-neurotic" - unhappiness is man's fate. Some days, I agree with that, other days, I don't.

By coincidence, Schneiderman's Unhappy or Depressed? I will need to return to the Dalrymple piece he quotes, later.

Probably for confidentiality reasons, Dr X took a fictional character as a sample rather than trying to camouflage a real patient. This is my idea of a real diagnostic impression of a patient without a major illness (eg dementia, schizophrenia, narcotic addiction, melancholia and major depression, bipolar disorder, etc.).

He briefly covers the defensive structure, the character structure, the basic conflicts as they relate to the person's life. Outside the major ailments, the DSM is useless in depicting a patient - a person with his flaws and weaknesses. In these times of the the low-rent superficial, check-list, cook-book Psychiatry, I find internists often more interested in the whole person than some Psychiatrists who just want to give you the right pill without delving into your psyche beyond the surface complaint. In my view, that is not serious medical practice. I do not approve of it, nor do I think it is cost-effective in the end. Some people are attempting to hyper-medicalize and simplify my field of work, but the human soul is too complex for that to work most of the time.

My field is deeply divided these days. It makes things interesting, controversial, and sort-of fun.

Unlike Dr. X, I never write these things down anymore. It takes too much time, can be subpoenaed and distorted in divorce court (some bad experiences with that before I quit writing things down), and otherwise nobody will ever read it before it is shredded. However, I store them in my brain. My brain has plenty of storage capacity.

I will re-post, for those who might be interested, my series on serious diagnosis over the next few days.

Character is destiny. Mostly, except for bad luck.

Except for some clearly defined, obvious ailments (eg dementia, the schizophrenias, PDD, autism, addiction, melancholia), most diagnoses in the handbook (the DSM, which many of us refer to as "the insurance manual") attempt to define common clumps of symptoms or behaviors without assuming any validity (ie, without any assumption that the clumping refers to any one cause or underlying abnormality) to those clumps.

Many of our "diagnoses" are akin to saying that a patient has a fever. There's a problem of some sort, but you don't know what it is yet, or whether it's serious or not. Lots of them are "life problems." The DSM is, sorry to say, largely pseudo-scientific. That's because we have very little validity to demonstrate.

Since the validity of most of our diagnoses cannot be tested in any way, all people do is to test their reliability (ie how often will two docs make the same diagnosis in a given patient). In a sense, measuring reliability is nothing but a measure of group-think and, in Psychiatry, the reliability of our diagnoses is quite low - in the "poor" range. (This is measured by a "kappa" score of inter-rater reliability.)

A pain researcher discusses use of kappa:

Landis and Koch⁴⁵ have proposed the following as standards for strength of agreement for the kappa coefficient: ≤0=poor, .01–.20=slight, .21–.40=fair, .41–.60=moderate, .61–.80=substantial, and .81–1=almost perfect. Similar formulations exist,^46–48 but with slightly different descriptors. The choice of such benchmarks, however, is inevitably arbitrary,^29,49 and the effects of prevalence and bias on kappa must be considered when judging its magnitude.

OK, Psychiatry has only a few rare spots of validity, but even its reliability is mostly in the "poor" to "fair" range. The good Psychiatrist here discusses the abysmal reliability of Psychiatric diagnoses.

As Robin Hanson discusses, Psychiatry uses "depressingly low standards" for reliability. Indeed, most of the time Psychiatrists disagree on how to label a given patient because few patients fit the molds, and most sort-of "fit" multiple categories. Furthermore, many diagnoses fade imperceptibly into normal variants: ADD, anxiety, mild depression, pbobias, PTSD, Bipolar 2, and OCD, and personality disorders, for some common examples. (I recently read that 40% of people have some obsessional symptoms at some point in their lives.)

In Psychiatry, you have to be able to tolerate ambiguity. It's not a mechanical profession except for the amateurs. Most if not all people on the sidewalk are at least what we might term "normal-neurotic" in some ways.

As a result, the American Psychiatric Association recommends that the DSM not be applied clinically in the cook book manner in which it is written, but as a guideline to which clinical experience - and understanding the patient in as much depth as possible - inform one's clinical impression. As Dr. Frances says, "It's not a Bible," and should not be applied as if it were.

Indeed it is not. Scientifically, it's mostly a failure but it's a kind of casual dictionary. I do not take it too seriously, and often use diagnostic descriptions which do not appear in the DSM (such as "neurosis"). I can usually find a way to help people anyway, regardless of how I might label them (and often I do not bother to label them at all). Generally, the more clinical experience a doc has under his belt, and the more psychodynamically-oriented he is, the less seriously he takes the diagnostic obsessional nit-picking.

We muddle through, struggle to understand, and still are able to help lots of people in the end. A true diagnosis of a patient goes far beyond anything in the superficial DSM. For example, a real diagnosis must consider the nature and quality of somebody's "object relations," their character strengths and weaknesses, their sublimatory capacities, their defensive structure, their superego functioning, etc. etc. In other words, really knowing what a person is all about.

Wikipedia has a surprisingly good review of the DSM, with the major critiques. They seem to omit a discussion of its massive profitability.

That's enough for now. More later.

"There is no constituency for 'normal'," he says.

Dr. Francis, who had been an editor of the DSM 3 and Editor of the 4, and was a teacher of mine back in the day, discusses some of the current diagnostic craziness related to the DSM 5 (h/t to 1 Boring Old Man).

His talk also contains some good general comments about Psychiatric medical practice, for those who might be curious about it. Sensible fellow, and articulate without teleprompter.

I will post some more items about diagnosis this week for the two or three readers who find the topic interesting.

It often confuses me why so many in my "helping professions" are Lefties. In fact, it probably makes more sense for us all to be Libertarians at heart. Like many Maggie's people, I am sort-of Conservative-Libertarian, if that makes any sense to you.

What it means is that if people want to smoke, or to get fat and out of shape, or play with guns, or shoot animals, or watch TV or play video games all day, or do reckless or stupid things, it's fine with me as long as it doesn't cause me any personal trouble or impinge meaningfully on my family's life. Does tax-funded medical care alter that balance?

Adults make their own decisions. I don't care a whit what other people do. The main thing that bothers me, socio-politically, are those who have somehow concluded that they are my betters and believe that they have a better plan for my - and for your - life. Such people often gravitate to government careers where there is some power to be wielded. We used to term such people "cranks," but cranks have gone mainstream.

Desire for power over others is almost a sickness, or is a sort of sickness (except for parenthood). The desire for freedom for others is, I believe, a virtue. (In case you wonder, I am against the criminalization of drug use despite believing that it is a poor life plan.)

That's a fairly-consistent Maggie's Farm theme, isn't it? Experts tend to lack common sense.

Case in point: Harvard Prof advocates government coercion to deal with obesity.

How about a little government coercion to deal with intrusive, annoying, nanny state busybodies who would claim to have either a) my best interest or b) the Greater Good, in mind? The world is run by crazy people.

It's because of "jumping genes."  These genes may be residues of viral genes which, over millions of years of cellular evolution, inserted themselves into the DNA of cellular forms of life.

Jumping genes are conjectured to play a role in at least some autism mutations.

We are inundated with pseudo-science. I have a few relevant links:

Via Fast Science:

... the pace of scientific discovery is slow. This does not mean that we need to hide every step of it from view until we get the results that we deem worthy of sharing. On the contrary, I agree with those who think that sharing at the more interim steps can only improve what we do. Yet the innumeracy, fame and fortune are forces that put such free sharing in peril by misrepresenting it as the final answer to everything. And when the answer is changed, which is not only expected, but indeed desired in scientific pursuits, the public opinion punishes science.

From Science vs. PR:

That’s the whole substance of the paper. Straight-ahead chemistry, exploring a possible explanation for an observed phenomenon and drawing out one tentative prediction. “Showing that it could have happened this way is not the same as showing that it did,” the author most properly concedes. He should have quit while he was ahead. What imp of the perverse induced him to add two more sentences?

Such life forms could well be advanced versions of dinosaurs, if mammals did not have the good fortune to have the dinosaurs wiped out by an asteroidal collision, as on Earth. We would be better off not meeting them.

Maybe the PR guy talked him into it.

From The New Phrenology - How liberal psychopundits understand the conservative brain:

That the “rich and powerful” are identical to conservatives and Republicans—Edsall’s assumption—is a hoary idea dear to many Democrats and essential to their self-image as the opponents of privilege. It persists even though many of the plushest and most powerful institutions of American life are in the hands of liberal Democrats: public and private universities, government bureaucra-cies, nonprofit foundations, movie studios, television networks, museums, newspapers and magazines, Silicon Valley .  .  . Among the fabled “1 percent,” according to Gallup, the number of self-identified Republicans is only slightly greater than the number of Democrats. As Christopher Caldwell has pointed out in these pages, political donations from 19 of the 20 richest ZIP codes in the United States go overwhelmingly to Democrats, by a ratio of four to one or more. Democrats are the party of what Democrats used to call the superrich. Only Democrats seem not to realize this.

From Pathologizing Normalcy and Overdiagnosing Pathology:

In the U.S, the DSM boils down to three critical issues: reimbursement, reimbursement and reimbursement. It should be renamed the American Diagnostic and Reimbursement Manual, so that those who use it outside the U.S. better understand the influences behind it.

A therapy patient of mine recently sat thoughtfully for a few minutes, then exclaimed "Oh my God, I've been acting as if I really had power over all these things, as if I had the power to prevent bad things from happening."

"Yes you have," I said. "That's your good insight for the day."

"I've been doing this all my life. Am I crazy?"

"Not at all," I said. "You just discovered one of your underlying assumptions about things. We call them 'unconscious fantasies' - or we call them that until you become aware of them."

One of the rewards of my work is helping people discern their hitherto unattended-to, unexamined, "unconscious" operating principles. When these are held up to the light, it can be disorienting, humbling, and distressing for many to realize that much of their problematic or ineffective behavior has been determined by following a false map, as it were. To mix metaphors even further, to realize that they were standing on unsolid ground.

My very pleasant businesswoman patient came to the realization that one of her dominant operating principles was to keep everybody in her world, everyone she knew, safe from distress, worry, discomfort, disease, and misfortune. Not only did this principle run her ragged, but it often failed. When it failed, she blamed herself for not having done enough. The unconscious fantasy she uncovered might be called a "fantasy of omnipotence."

Everybody operates, to varying degrees, according to unconscious fantasies about themselves, others, and the world in general. Nobody is 100% in reality. Problems can arise depending on how far the hidden assumptions diverge from reality. Reality is the harshest teacher, and never spares the rod.

What are these things made of? Freud discovered/defined them, although writers and students of human nature have always been interested in the irrational consistencies of personality. Freud said that they are constructed from wishes, fears, hopes, dreams, experiences, temperaments, and especially defenses. I think that is true. During maturation, they become organized like pieces of mental software. Like the beating heart and the digesting bowel, they are part of what and who we are while operating outside our awareness.

Unfortunately, we cannot ask people what their deep operative fantasies are, because they are, by definition, unaware of them. That's where Psychoanalytic skills come in, like soul-surgeons, to try to biopsy and, perhaps, extract the problem software. However, our medical rule is primum non nocere so we try not to let the best become the enemy of the good-enough.

Fortunately, the human mind seems to have a relatively limited repertoire of unconscious fantasies, so we experts are expected to be able to identify them, in time. That's a topic for another post, maybe.

By the time they get done, we'll all be addicts.

In my view, this whole DSM enterprise is one big Obsessional Disorder driven, in considerable part, by insurance requirements and by pharmaceutical companies.

Arthur Brooks played French Horn in the Barcelona Symphony, but returned to the USA:

Learned helplessness was what my wife and I observed then, and still do today, in social-democratic Spain. The recession, rigid labor markets, and excessive welfare spending have pushed unemployment to 24.4%, with youth joblessness over 50%. Nearly half of adults under 35 live with their parents. Unable to earn their success, Spaniards fight to keep unearned government benefits.

Meanwhile, their collective happiness—already relatively low—has withered. According to the nonprofit World Values Survey, 20% of Spaniards said they were "very happy" about their lives in 1981. This fell to 14% by 2007, even before the economic downturn.

That trajectory should be a cautionary tale to Americans who are watching the U.S. government careen toward a system that is every bit as socially democratic as Spain's.

Humans are very responsive to incentives, even to their own detriment (eg addiction).

How the ‘love myth’ is preventing Americans from finding true love. The piece quotes Jonathan Haidt:

As I see it, the modern myth of true love involves these beliefs: True love is passionate love that never fades; if you are in true love, you should marry that person; if love ends, you should leave that person because it was not true love; and if you can find the right person, you will have true love forever. You might not believe this myth yourself, particularly if you are older than thirty; but many young people in Western nations are raised on it, and it acts as an ideal that they unconsciously carry with them even if they scoff at it. (It’s not just Hollywood that perpetrates the myth; Bollywood, the Indian film industry, is even more romanticized.)

I believe that "true love" is an adolescent fantasy, a psycho-utopian fantasy. All real relationships have problems and challenges. And real life presents endless problems and challenges which effect relationships lasting longer than days or months. In Western, monogamous cultures, the trick is making it work. What else do I believe? That there is no single "right person" for anybody, that humans are not emotionally monogamous, and that many people expect far too much emotional fulfillment from their spouses than any one person can provide.

I would never disparage feelings like passion, desire, "urge to merge," and "chemical attraction". These things are intoxicating. They have prevented Homo sapiens from going extinct. However, they are temporary, and often not sturdy foundations for building a life or raising a family.

Related, Mate Expectations from F- Feelings:

Discovering that your long-term partner isn’t really the person you thought she was can be shattering. It’s not just a loss of love and a certain way of life, it’s feeling like you’ve lost your ability to see the world accurately, protect yourself, and know whom to trust. Suddenly, your marriage seems like the Matrix.

More fundamentally, you can no longer trust your ability to know what’s meaningful and what’s predatory. In case you think you’re alone, think of all the novels and films made about this phenomenon. You’ve been stripped of a pillar of your self-confidence, and you have to build yourself back up. At least you’re just searching for your self-esteem and not a one-armed man.

Nobody is who you thought they were, and vice versa.

"Sometimes thinking is a bad idea. Ian Leslie draws on Dylan, Djokovic and academic research to put the case for unthinking.":

Unthinking is the ability to apply years of learning at the crucial moment by removing your thinking self from the equation. Its power is not confined to sport: actors and musicians know about it too, and are apt to say that their best work happens in a kind of trance. Thinking too much can kill not just physical performance but mental inspiration. Bob Dylan, wistfully recalling his youthful ability to write songs without even trying, described the making of “Like a Rolling Stone” as a “piece of vomit, 20 pages long”. It hasn’t stopped the song being voted the best of all time.

Here's the vomit:

I am asked to do a brief post about Disability and have been sent a couple of links. "Disability," as in our Social Security Disability welfare program, is one about which I have unpleasant feelings which some might view as cruel. I prefer to view it as Tough Love.

However, it comes from experience. The fact is that I will not consult with anybody on Disability, nor will I participate in anybody's Disability application unless they are in a coma, severely brain-damaged, or the like. Can people with (treated) schizophrenia work, be useful, and maintain some dignity? Of course they can. Every patient of mine with schizophrenia works, except for one housewife.

Here are my reasons for that, from a psychiatric standpoint:

1. Nobody with a treated mental problem is incapable of doing something useful
2. Helping a patient obtain Disability is a way of saying that you have given up on their future
3. Many people on Disability give up on making a life, and just mope around for years
4. I see people with severe disabilities working all sorts of jobs, maintaining their pride and independence
5. The scam component is huge, I believe: free money. I've seen it plenty of times. I even get spam emails weekly inviting me to fill out a form for Disability lawyers: "Find out if you're entitled." Also, lots of people with Disability seem to work off the books.

Few people have any idea of how easy it is to get on Disability these days. Here is one of the links: Workers Comp. and Unemployment

Stigmatizing Resistance to Authority - The medicalization of rebellion.

America’s false autism epidemic.

The DSM, like the Psychiatric section of the ICD-9, was developed to provide a common language to people who work in mental health. Actually, for four basic purposes: a common language, as a basis for research, as clinical guidelines, and for filling out insurance forms and disability forms.

In our daily work, many Psychiatrists do not take it too seriously but use it as a rough guideline. Unfortunately, the DSM has been over-medicalized, reified, such that everything in there is sometimes regarded as a real, discrete, "disease." Some are, some are not. In many cases, it doesn't matter, because we approach each patient as an individual human and not as a diagnostic code.

As one of my wise old mentors says, "I've never seen a patient of mine in the DSM."

Physicians, like clergy, are more comfortable with terminal illness and death than others. Routine proximity to death and dying makes it feel natural and normal instead of a great enemy. From the WSJ's Why Doctors Die Differently - Careers in medicine have taught them the limits of treatment and the need to plan for the end:

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. It was diagnosed as pancreatic cancer by one of the best surgeons in the country, who had developed a procedure that could triple a patient's five-year-survival odds—from 5% to 15%—albeit with a poor quality of life.

What's unusual about doctors is not how much treatment they get compared with most Americans, but how little. Charlie, 68 years old, was uninterested. He went home the next day, closed his practice and never set foot in a hospital again.

It's a rare doc who elects heroic and torturous treatments for his own terminal ailment.