January 13th, 2009  This post has taken a while to percolate, and has turned into two posts. As often happens, what got me thinking was an article in the New York Times, this time on the expanding definition and use of service animals by the disabled. Service animals now go far beyond Seeing Eye dogs. The article introduces us to monkeys, miniature horses, even a parrot. A quadriplegic’s assistance by a trained monkey strikes me as ingenious. In certain respects a horse is better than a dog as a service animal for the blind. But psychiatric service animals are a trickier issue, and quickly lead to complex questions about labels, stigma, entitlement, and how disability is defined.
My introduction to this issue came long before the NY Times article. Years ago a patient asked me to write to her landlord, arguing that her building’s no-pets policy should not prevent her from keeping a dog for emotional support. I felt reluctant to write such a letter. Doesn’t everyone get emotional support from a pet dog? On what basis could I argue that my patient was more entitled to a dog than her neighbors were? On what basis did she believe she was more entitled?
I did not quiz my patient about her rationale. It seemed she would truly benefit emotionally from keeping her dog, and on that basis I did end up writing a short letter. I asked, not demanded, that the landlord consider making an exception in view of my patient’s emotional condition (which of course I did not specify). Whether due to the clout of my letterhead or other reasons, the exception was granted, and my patient kept her dog. Yet I was never quite sure if that was a good outcome.
The law distinguishes service animals and “comfort” or “therapy” animals. The latter are not necessarily trained, and enjoy no special legal status. When I worked on a psychiatric inpatient unit in the early 1990s, a volunteer would usher in animals for “pet therapy.” These were extremely cute and docile dogs, cats, rabbits, and sometimes other fuzzy creatures that brought joy and maybe calm to the patients. They didn’t perform any function other than being themselves. In contrast, a service animal is trained to do a job. According to the Americans with Disabilities Act ( ADA), such an animal is “individually trained to do work or perform tasks for the benefit of an individual with a disability….” Service animals are permitted by law to accompany their disabled owners into almost any business or organization that serves the public.
However, as the NY Times article notes, the line between therapy animals and psychiatric service animals has always been blurry. Does an animal’s ability to actively soothe its owner qualify? Adding to the confusion, the Department of Transportation ( DOT) ruled in 2003 that comfort animals, not just service animals, were allowed to accompany airline passengers: “Animals that assist persons with disabilities by providing emotional support qualify as service animals.” Such animals could be any species and needed no special training. A 2006 NY Times article describes passengers bringing untrained goats and ducks aboard planes for “emotional support.” Even if this was somehow legitimate, the DOT ruling was mistakenly extended to settings other than airplanes. Although the ADA rules had not changed, the article tells of a “veritable Noah’s Ark” of animals brought to cafes, offices, and other businesses for emotional comfort, falsely justified by the rights of the disabled to bring service animals into these settings. The article also relates abuses where healthy owners have brought animals into businesses by falsely claiming they are service animals.
As the menagerie of service and comfort animals has expanded, occasional community backlashes have charged that the animals represent health or safety hazards, or an excessive burden to others. At a general level, this reflects a longstanding American debate between equality and relief from a tyrannical majority on the one hand, versus the view that minority entitlement or “special interests” demand too much of everyone else. Medically disabled Americans have legal entitlements, including the right to use service animals, guaranteed by the ADA and other laws. Such entitlements are a point of endless political contention.
Neurologists, I imagine, readily declare quadriplegics disabled, and harbor no misgivings about endorsing their “special interest” in a service animal. I was less at ease declaring my patient disabled, and hesitated endorsing her “special interest” in keeping her dog for emotional comfort. Is this simply because psychiatric disabilities are harder to quantify? Is subjective disability a coherent concept? In my next post, I will put psychiatric service animals in the larger context of psychiatric disability.
January 4th, 2009  Happy 2009! As promised, I’ll start adding photos to brighten up the page, and maybe illustrate a point at times. This one is a mid-winter tribute to spring.
As you might surmise from past posts, I have long-standing concerns about commercial influence on the practice of medicine generally, and psychiatry in particular. I have two bits of personal news to report on that front. First, I authored the lead article in the current issue of Ethical Times, the quarterly bulletin of the Program in Medicine and Human Values established at the medical center where I teach. Although Ethical Times eventually appears online, I may seek permission to reprint my article here. Basically, I argue that it is incumbent upon ethical physicians to resist commercial influence in making clinical decisions — whatever pharmaceutical companies or device manufacturers do or don’t do.
Also, starting this month, I will serve as chair of the medical center’s CME committee. As I posted in October, continuing medical education (CME) is both required to maintain medical licensure, and is rife with potential conflicts of interest when funded, as most of it is, by industry. It will be interesting to be on the front lines dealing with these challenges.
In related news, the Pharmaceutical Research and Manufacturers of America (PhRMA) recently revised and expanded its voluntary restrictions on interactions with physicians. The full text is available here. The relevant New York Times article emphasizes the new moratorium on branded office items such as pens, notepads, and coffee mugs. While my view is that the onus more appropriately rests with the medical profession itself to resist commercial influence — and accordingly some groups have tried for years to convince doctors not to fill their offices with promotional giveaways — this is a step in the right direction. By my reading, though, the new PhRMA standards are considerably more limiting than the prior version in other areas as well. New restrictions on wining and dining doctors may ultimately wield a bigger impact than the disappearance of cheap pens with drug logos.
Much more commercial influence remains, as an editorial in today’s New York Times points out. Meanwhile, in the current issue of the New York Review of Books, Marcia Angell, former Editor in Chief of the New England Journal of Medicine, presents the field of psychiatry as Exhibit A in a shocking review of undue industry influence on research and practice. We still have quite a ways to go.
December 22nd, 2008 I’ll be taking a break through the end of the year, and thought this would be a good time to size up this blog creature I created.
In nearly two months I’ve posted about 20 essays. Over that time I’ve also read a number of other psychiatry and general medical blogs, having started this one with little prior exposure to blogs at all. I see that “Reidbord’s Reflections” is atypical and, to be honest, rather unbloglike. Unlike mine, most are anonymous, allowing more freewheeling commentary. The popular ones are more casual, personally disclosing, and include human-interest tidbits, photos, graphics, and sometimes embedded videos from elsewhere on the net. They don’t stick to the topic, but are more warm and human.
As a psychiatrist who conducts psychodynamic (neo-Freudian, sort of) psychotherapy, I tend not to disclose facts about my private life to patients. Likewise, I am reticent to offer a lot of personal details here. At some point I’m sure I’ll post something about this; I’m well aware there is no absolute prohibition regarding self-disclosure, and sometimes it can really help. Nonetheless, most blogging is more exhibitionistic than I care to be. My intent is to write about psychiatry, not about myself.
Google Analytics tells me I have a modest readership of about 150 unique visitors so far, widely scattered across the US, with a few in Canada, Europe, and the rest of the world. (Don’t worry, the data do not identify you, just your general location.) Technorati ranks “Reidbord’s Reflections” about number five million in the blogosphere. (Now there’s a humbling statistic.) I’ve been told that readers rarely comment because I am not controversial or inflammatory enough. The post that did attract the most notice was perhaps the most contentious, about my almost becoming a speaker for Wyeth.
On the bright side, I enjoy writing. I have more topic ideas, and I plan to continue doing this. The page hit rate is slowly increasing over time. I also have ideas for improving the blog, and would be very grateful for yours as well. Here are mine:
1. Include some photos to add interest and color to the page
2. Invite colleagues to write guest pieces
3. Include more day-to-day type reflections
4. Change the font size or colors to make the page more readable
If you have any ideas or suggestions for this blog, the best way to reach me is by commenting on this or any other post. Please write “do not publish” so I know not to put your comment on the site. I will read it personally, and I thank you in advance for helping to improve this effort.
Thanks to all my readers for your attention. Happy Holidays, and see you in 2009!
December 22nd, 2008 In my last post I discussed the politics of psychiatric nosology and the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). While the machinations behind specific disorders are fascinating, it is easy to miss the forest for the trees. The basic idea of dividing mental distress and disability into diagnostic categories is itself controversial.
The DSM takes the stance that there are discrete “bins” (disorders) that individual patients can be sorted into. For over 25 years there has been discomfort in the professional community about this, particularly in the case of personality disorders (Axis II of the DSM). One of the architects of Axis II, Theodore Millon, PhD, objected to purely categorical personality diagnosis. His website says:
It is Millon’s view that there are few pure variants of any personality prototype. Rather, most persons evidence a mixed picture, that is, a personality that tends to blend a major variant with one or more subsidiary or secondary variants.
Statistics on Axis II disorders seem to bear this out. Many studies show great overlap between categories, and many patients fit into more than one. Clinical experience concurs: The patients I see are rarely “classic” cases of anything; everyone is unique. Even everyday life experience suggests that personality features exist on a continuum: One person is a bit detail-oriented, another is mildly obsessive, and another has serious problems with obsessiveness. Yet the current DSM-IV-TR only defines “obsessive-compulsive personality disorder” (and allows mention of “obsessive compulsive personality traits,” but this doesn’t count as a disorder). No nuance, no matter-of-degree. Why do we have such ham-handed tools to describe psychiatric problems?
One reason is that psychiatry is a branch of allopathic Western medicine. Unlike, say, traditional Eastern healing, we think in terms of disease categories. And this fits fairly well for the most severe Axis I psychiatric disorders, such as schizophrenia. The German psychiatrist Emil Kraepelin founded contemporary scientific psychiatry in the late 1800s by distinguishing the pattern of symptoms in schizophrenia (“dementia praecox”) from that in manic depression. In the early-to-mid 20th century, Freudian theory deflected such categorization, but it re-emerged as the dominant paradigm since the publication of DSM-III in 1980. The 1990s “Decade of the Brain” heralded intensive research efforts to understand mental disorders from a medical perspective. Today the vast majority of published psychiatric research is biomedical in nature, facilitated by the DSM’s categorical framework.
In contrast to the medical psychiatric tradition, psychology has long pursued dimensional features of personality using empirical data. Perhaps best known is the Five Factor Model. Such models capture the variability and nuance of personality, but do not make sharp normal-versus-abnormal distinctions. Each person exhibits one factor to a certain degree, the next factor to another degree, and so forth. The combinations are nearly infinite.
The good news is that organized psychiatry is waking up to the value of dimensional assessment. Position papers (e.g., here, here, and here) have long argued for this with respect to Axis II. As working groups now meet to plan DSM-V, dimensional adjuncts are being considered for all traditional categorical diagnoses.
Is mental illness categorical or dimensional? The “real” answer, I suspect, is that some psychiatric disorders will eventually be understood to have biological origins. Schizophrenia will likely go the way of general paresis (syphilis) and Alzheimer’s Disease: When the medical cause of a psychiatric condition is finally understood, it is no longer considered a psychiatric condition. It becomes the province of neurology, infectious disease, or another branch of medicine. Psychiatry is left with conditions that defy medical explanation. This is why I feel that, ultimately, dimensional factors are an irreducible feature of psychiatry. Whether understood using Freudian psychodynamics, learning theory, or another psychological paradigm, human emotions and behavior will always be more subtle and nuanced than a categorical nosology can describe.
December 18th, 2008 Laws are like sausages. It’s better not to see them being made.
Otto von Bismarck
German Prussian politician (1815 – 1898)
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published periodically by the American Psychiatric Association ( APA), aims to catalog all recognized mental disorders. As the name implies, it is used both for clinical diagnosis and for various statistical (population) uses. I previously posted how social judgments are inevitable in such a catalog; little wonder DSM has long served as a lightning rod for social debates over what is normal versus abnormal.
The fourth edition (DSM-IV) was published in 1994, followed by a minor “text revision” (DSM-IV-TR) in 2000. Groups of psychiatrists are now drafting sections of DSM-V, due out in 2012.
It would be nice to imagine that the process of creating and updating DSM is scientific and unbiased. However, like laws and sausages, psychiatric nosology (disease classification) is more palatable the less one notices how it is made. As reported in today’s New York Times, putative disorders such as compulsive shopping, sexual fetishes, and binge eating have their advocates and detractors. Transgender people have a personal stake in whether “strong and persistent cross-gender identification” remains a mental disorder. (Interestingly, the stigma of this diagnosis is offset by its utility in obtaining insurance coverage for gender-reassignment surgery and other treatment.) This recalls debates over the inclusion of homosexuality as a mental disorder in earlier editions of DSM. Homosexuality was dropped as a diagnosis in 1973. It was replaced by “sexual orientation disturbance” and then “ego-dystonic homosexuality” before those, too, were dropped in 1987.
Anyone who imagines that these debates are coolly scientific is dreaming. As social norms change, our notions of mental illness change with them. The long-term trend has been an expansion of DSM, both in terms of dividing syndromes more finely, and also widening the scope of behaviors considered disordered. Stakeholders include the APA itself, sole publisher of the 800,000+ copies of this essential tome; pharmaceutical companies who stand to gain or lose fortunes based on whether a particular human deviance is treatable with medication; insurers who cover treatment for disorders but not non-disorders; patients who either have a mental illness or don’t; and scientists trying to collect data and make sense of the whole thing.
It is good to bear in mind that some disorders in DSM-IV-TR, like “nicotine dependence,” do not seem very much like mental disorders — and that one is bound to stay. Meanwhile, other maladies of the human spirit, like living a life devoid of meaning or purpose, are not listed in the current DSM, and are not likely to appear anytime soon. In my next post, I’ll discuss one aspect of psychiatric nosology, categorical versus dimensional ratings, that may improve DSM-V. However, the inclusion of messy social judgments in DSM is with us for the duration, obscured in the finished product by careful prose, numerical labels for disorders, and a little quantitative data. Laws and sausages aren’t bad either — if you don’t think about them too much.
December 15th, 2008 I often remind psychiatry residents that while a patient’s treatment preference is important, it does not take the place of their own evaluation. It is a bittersweet irony that many of us are mistaken about, or repelled by, what would most help us.
Some patients, with depression for example, only consider medications, and have tried many to no avail. Even after a dozen adequate but unsuccessful medication trials by past psychiatrists, some call me in desperation to ask whether the 13th, usually with the newest heavily promoted product, could be the miracle they seek. I generally tell them — right on the phone — that it is unlikely. I also assure them that if they come in for an evaluation anyway, I will respect both their preference and past experience. What I don’t tell them: People who avoid psychotherapy because they fear having to face uncomfortable memories or feelings often end up getting the most benefit out of it. By the end of our first in-person meeting, I hope to engage such a patient’s curiosity about his or her emotional life as more than simply a collection of symptoms.
Conversely, some patients pursue psychotherapy for years, and would never dream of taking psychiatric medication (“mind-altering chemicals”). This makes excellent sense when the problem is based on personality factors and relationship issues. But sometimes it’s not. Even the best psychotherapy won’t quell the hallucinated voices of schizophrenia, nor the behavioral excesses of mania. Some patients are too depressed or anxious to use psychotherapy. (And sometimes the problem is medical, not psychiatric at all.) At these times it becomes my duty to advise medication, to explain why I do, and to explore with the patient their concerns and hesitation.
Some research says the best treatment for depression is a combination of medication and psychotherapy. This often seems to be the case for problems other than depression, too. As a psychiatrist I can provide one or the other or both. And on rare occasions, neither: A few patients have come to me who do not have a treatable problem at all.
The challenge for psychiatrists and other mental health professionals is that patients choose their own providers; they select us knowing their own preferences, and ours. Persons who seek medication and not psychotherapy will likely see a psychopharmacologist who will share their viewpoint and only discuss medication. Even more often, persons who seek psychotherapy and not medications (or a medical perspective) will see therapists who are not physicians. Despite the advantages — there are many more non-psychiatrists to choose from, and the fees are usually lower — patient self-selection carries the risk of confirming their own prejudices. It may sound harsh, but the “customer” is not always right. It is incumbent upon us professionals to look past patient preference to what is most apt to be helpful — even if we do not provide it ourselves.
December 11th, 2008 I met a young man recently in a setting having nothing to do with psychiatry or mental health. He politely introduced himself and tried to learn the names of the others around him. He seemed socially awkward but inoffensive, and after I left I didn’t give the encounter much thought. However, I learned that soon thereafter he showed increasingly odd behavior. He talked to himself, breached social boundaries, and acted aggressively for no apparent reason. Others had to keep an eye on him, and eventually he was escorted peacefully off the premises.
The possible causes of such behavior are myriad: brain injury, psychotropic drugs, medical illnesses such as delirium or thyroid disease, and many others. One possible cause is mental illness, specifically schizophrenia. Schizophrenia is surprisingly common, affecting over 1% of the total population. As with many other disorders, schizophrenia can be mild or severe. Only a small minority of sufferers are institutionalized; the great majority live in society with everyone else. The class of medications called neuroleptics (anti-psychotics) have helped to make this possible, although some people with mild schizophrenia can function without medication.
I do not know whether the young man I met has schizophrenia. It would be presumptuous of me to attempt to diagnose someone I met only briefly in a social setting. But our meeting did spark some thoughts about the symptoms and deficits of this disorder.
A major hallmark of schizophrenia is auditory hallucinations (voices). When people “talk to themselves,” particularly if they do so without regard to others noticing, it may be in response to hallucinated voices. The voices can be ignored for a while if they are not too severe. At the other extreme, if insistent voices command the person to hurt himself or others, this is a very serious situation that usually requires hospitalization. Medications are often helpful in quieting auditory hallucinations.
(Thanks to cellphones, particularly those with wireless headsets, people seen “talking to themselves” could simply be on the phone. More than once I’ve passed someone on the sidewalk and assumed one of these scenarios, only to realize seconds later it was the other.)
Delusions are also prevalent in schizophrenia, as well as in other disorders such as delusional disorder and manic psychosis. Medications help with delusions too, but not as quickly as with hallucinations.
There are also “negative symptoms” in schizophrenia which include lack of emotional expression and a decreased ability to initiate action or speech. These are more resistant to medication, although the “atypical” neuroleptics available for the past 15 years are of some benefit.
More subtle are the “thought process” changes in schizophrenia, and these are what came to my mind regarding the young man I met. Classically, schizophrenic thought is described as concrete. The ability to think abstractly, metaphorically, and symbolically is impaired. For example, in psychiatric evaluations patients are sometimes asked to interpret a proverb such as, “People in glass houses shouldn’t throw stones.” While most healthy individuals understand this is not literally about glass houses, many with schizophrenia will say something like, “because the glass will break.” Likewise, people with schizophrenia often cannot understand jokes or indirect references in the speech of others.
It is a sad and isolated existence to be cut off from so much human interaction, unable to share in common emotional experience. Much of the meaning and flavor of life is contained therein. This is not to say that people with schizophrenia cannot lead productive and meaningful lives. They can, but it’s hard. My “up close and personal” encounter with someone possibly suffering these challenges reminded me that compassion, not fear or disdain, is the most apt response to the tragedy of schizophrenia.
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