The Map Is Not The Territory

 

I ran into a quote this week that I must have read and forgotten from the past – because it was referenced in Bateson’s Steps to an Ecology of the Mind.  That was a book I read back in the hippie era after seeing it referenced in the Whole Earth Catalogue.  It happens at a time when I was writing about the usual philosophical rhetoric used to criticize psychiatry.  The circular logic argument I have encountered frequently by philosophers seeking to either destroy the profession or portray psychiatrists as unthinking buffoons.  That quote was “A map is not the territory” and it is attributed to Alfred Korzybski.

When I saw it – I associated immediately to the map I know the best and that is Hwy US2 running across northern Wisconsin between Minnesota and Upper Michigan.  I have travelled that road hundreds of times.  In fact, in 1988 I drove it over 200 times that year to keep a small inpatient psychiatric unit open. Maps these days are much better than they used to be.  For the old road maps to have the same scale and sufficient detail meant a large size that had to be folded and refolded to get it back into the glove compartment.  The above map is a clip from Google Maps and it can be scaled down to the individual house level and from there a street view that is regularly updated.

Thinking about old maps and new maps it is easy to see Korzybski’s argument. Driving US 2 late at night it is common to encounter characteristics of the territory that are not listed or even included in your GPS updates. The territory at night is much different than the territory during the day.  A major difference is deer on the highway.  There are the occasional deer crossing signs but I have suddenly found myself driving among a herd of 30 or 40 deer running next to my car and alongside the road.  The Google camera cars fail to update the video information fast enough to account for social and cultural changes that happen in the small towns along the way.  Am I going to encounter a large influx of out-of-staters for the Blueberry Festival in Iron River or the Strawberry Festival in Bayfield?  Is that small general store still there or is it finally gone? Is the posted or suggested speed limit accurate or do I have to correct for the weather?  

In the era of climate change even modern maps have uncertainty.  Highway 2 has been washed out and under water – both events that have never happened at any other point in my lifetime.  Using modern GPS guidance – I ended up on what appeared to be a dirt wagon trail that eventually got me back to Minnesota.  Every inch of that terrain looked like it had been seen by very few people in the last 50 years and no Google camera cars.  Most people unconsciously adapt to the terrain on the drive home – that sunken manhole cover or pothole to avoid.  We automatically adjust to the hazards even though they are not indicated on any map.  

Korzybski’s argument is basically twofold. First – no matter how far you drill down with a map – even a much-detailed map you will not find what you are experiencing – what your perceptions tell you is there. The map after all is an abstraction by someone and that is not a perfect representation of geography but also not your reality.  From consciousness science - your reality or experience of it is not my reality.   From information theory – the human brain is acquiring much more information going forward than you can get from one derived across a series of finite dimensions and time.  Second – this has clear implications for the ideas of subjectivity and objectivity.  In medicine we construct clinical trials – with exclusion and inclusion criteria that eliminate large real populations and at this point cannot account for the heterogeneity in the remaining research subjects. That does not preclude progress but it should introduce humility into the eventual results. No matter how broad or narrow those selection criteria are – they are only an approximation of the real population who will be treated.

Lest these connections be seen as speculative – here is what map makers and geographers have to say about the situation.  Basic geographic data is a space-time location. In addition, there is other relational data that contextualizes a location.  Data and relationships are discussed in terms of model and how the model is a simplified representation of reality but not reality itself.  A good example was John Snow’s map of cholera during the 1854 epidemic in London and how he used that to determine the source and isolate it. Cartographers are aware of these relational loops to space-time location as well as the limitations that are due to the large number of contextual features.  The map cannot account for them all.  

What does it say about philosophy and rhetoric applied to psychiatry?   

It says a lot about classification systems.  Much research today is preoccupied with ideal classifications.  The DSM for example is criticized for not being a perfect diagnostic system when in fact (like all medical classifications) it is a crude system with additional landmarks.  The graphic below illustrates the problem and how the assumptions made for the diagram on the left do not reflect the reality of the diagram on the right. That diagram is more complex – but not nearly as complex as the real clinical situation. After all – if the clinical situation was accurately reflected in the diagram on the left everyone with schizophrenia would be the same.  Psychiatrists would not have to concern themselves with a developmental history, a social history and life narrative, a medical history, and a family history.  They would not have to consider critical psychological events in a person’s life and putting all that together in a formulation about what is unique about that person.  The territory of that person would include supportive people and important contacts. Like the map of Highway 2 – the DSM gets us into the ballpark but it is not specific about what we will find. 

Korzybski has been described as an independent scholar.  He is credited with inventing the field general semantics.  There is a research institute founded on his ideas. There are not a lot of scholars taking his work forward.  There is an excellent online biography of Korzybski that describes the controversies associated with his writings and varying degrees of acceptance.  Interestingly he wrote about psychiatry and in his biography, there was apparently a group of psychiatrists interested in his work.  He referenced “neuropsychiatry” as a field that had generally been ignored by the rest of medicine.

 

Irrespective of the complexity and controversy of general semantics – I am still focused on the map is not the territory concept for several reasons.  First it reflects what is going on in the DSM classification system.  Second, it describes limitations of any classification system and how that abstraction differs from reality. That is probably the reason that medical diagnostic systems die hard, especially after decades or centuries of the same observations.  Is there any reason to suspect a dimensional or sub phenotyping system would be any better?  Probably not at least until very detailed observations can be made.  A classic paper (4) suggested that hundreds of true/false questions identified psychological traits and that this was an actuarial method superior to clinical judgment.  Despite that alleged superiority many of the methods suggested in that review like the Minnesota Multiphasic Inventory or MMPI have fallen out of use and are no longer used for screening purposes or making diagnoses.  Machine learning and artificial intelligence can produce these results faster and on a larger database but continue to have limited applications.   Third, it reflects expert opinion by at least one of the top theorists in the field (5).  Fourth it reflects good clinical practice that includes a formulation with additional commentary on psychopathology, associated observations and theories. 

At the minimum I hope that you find Korybski’s observation as interesting as I do.  I probably will not read his voluminous works – but I am always aware of the fact that no matter what classification system you are using it is always an abstraction with various degrees of precision.  Further it is an abstraction by one person or a group of people.  The way the DSM (and all of medicine) is structured the precision of both the diagnosis and treatment of a particular patient depends on what occurs during the encounter and the experiences and abstractions of that physician.   

George Dawson, MD, DFAPA

 

Supplementary: Doing research for this post, I encountered another quote that expresses a similar idea:  "The menu is not the meal".  Alan Watts is credited with that quote. 

References:

1:  Korzybski: A Biography (Free Online Edition) Copyright © 2014 (2011) by Bruce I. Kodish.  See chapter 30 for Korzybski’s contact with psychiatry including Harry Stack Sullivan and William Alanson White:  https://korzybskifiles.blogspot.com/2014/06/korzybski-biography-free-online-edition.html?spref=tw

2: Doerr E. General Semantics. Science. 1958 Jul 18;128(3316):156.

3: Gardener M. General Semantics. Science. 1958 Jul 18;128(3316):156.

4:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74

5: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

.

Even More Epistemic and Hermeneutical Injustice......

My latest foray into the philosophical was reading a paper by Bennet Knox (1) called “Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity”. In it he argues for inclusion of persons affected by mental illnesses or at least as they are defined in the DSM into the scientific process of revising the DSM. He prefers the term psychopatholigized that he shortens to pathologized to other terms used in the philosophical literature. He makes the argument against a severely truncated form of psychiatry that he can conveniently describe as hermeneutically ignorant while characterizing a brief comment by Spitzer as hostile. His argument hinges on a concept of social objectivity that necessarily means all viewpoints of the psychiatrically involved including those who want to burn the profession down are valid and must be considered.

As I have stated before on this blog (and given examples) – this is a standard philosophical approach to criticizing psychiatry while ignoring what actually goes on in the field and how psychiatrists are trained. So, I will start there.

Let me start with the concept of “social objectivity” since the early claim by the author is:

“Further, insofar as the objectivity which psychiatry should aspire to is a kind of “social objectivity” which requires incorporation of various normative perspectives, this particular form of epistemic injustice threatens to undermine its scientific objectivity.”

I am not completely sure of how philosophers use the term normative here so I am assuming that it means – what other people approve of or endorse.  The other people here would be the pathologized.  He uses examples of the pathologized in this paper as members of the Hearing Voices Movement and the Autistic Self-Advocacy Network (ASAN).  He states that social objectivity is defined in two books by Helen Longino but does not include an operational definition.  Instead, he comments throughout the paper on how various circumstances do not meet these criteria.  He openly acknowledges that his argument is deficient:

“Although I can provide only a limited argument for embracing the social objectivity model in psychiatry here, my main goal is to show fellow proponents of social objectivity that the particular kind of hermeneutical ignorance I describe presents a significant obstacle to achieving it in psychiatry.”

I agree that the argument presented is very limited.  If that is the case, why should it be achieved in psychiatry?  Will it be theoretically useful in some way? 

His introduction to the need for social objectivity and objectivity in general in psychiatry is based on the philosophy of psychiatry.  More to the point non-empiricist philosophy. If that is considered, an empirically adequate model is all that is required.  Instead, he introduces three models that all suggest that values play a role in psychiatric diagnosis. He acknowledges that dysfunction is a value free criterion for diagnosis but then goes on to separate out a category of mental disorder that also contains judgements about dangerousness.  He lands on the DSM definition of dysfunction but explains it away as “there is reason to believe that it is impossible (and undesirable) to uncover dysfunctions in mental processes without reference to values.”  He goes on to explain how “a scientific process is more objective insofar as it engages a diverse array of points of view with different normative background assumptions in a process of “transformative criticism.”

There are multiple points of disagreement with this viewpoint starting with a basic misunderstanding of what psychiatry is and how psychiatrists work. The key element in the DSM that is ignored here are all of the qualifications for subpopulations ranging from cultural differences to gender differences that include a moving threshold for the diagnosis of disorders and recognizing that in some cultures or subcultures varying degrees of psychopathology are tolerated (or not) and that also includes a tendency to stigmatize individuals with that psychopathology. Breaking that down – psychiatry parses scientific objectivity and normative perspectives when it comes to diagnosis and treatment planning. That not only occurs in psychiatry but in all of medicine and it may actively include the outside input from philosophers on ethics committees.  Here are a couple of clear examples.

Example 1:

Bob is a 65-year-old married man admitted for hepatic encephalopathy from alcoholic cirrhosis. The Internal Medicine team requests psychiatric consultation for further diagnosis and referral.  The psychiatrist assesses the patient as improved (less delirious) and competent.  No other psychopathology is noted. He discussed treatment options for the alcohol use disorder and the patient is willing to listen.  He has never attended an AA meeting or been in treatment in the past. The family (wife and adult children) enter the room and are all adamant about taking the patient home with no treatment. They are angry and state several times “If he wants to drink himself to death it is none of your business doctor. Let him drink himself to death.”  The family and the patient are approached by social workers and the Internal medicine team over the next two days but he is discharged home with no treatment.

All of the people in this case were white 4^th or 5^th generation Americans. There are no assumed cultural differences, but they are implicit. Patients and families affected by substance use disorders have known patterns of adapting and some of them are not functional adaptations. Was an attempt at involuntary treatment needed in this case? The psychiatrist knew that hardly ever happens by local probate courts in substance use disorders unless there was an actual suicide attempt or the family supported civil commitment. Should adult protection social workers have been involved?  Referrals could have been made to county social workers who might invoke a societal level value judgment on this situation but instead dialogue was established with the family and they agreed to call if problems occurred and take referral numbers for additional assistance. They were also informed that the patient had a life threatening alcohol use disorder and severe complications (including death) could occur with any future episodes of drinking.

To the point of the article this example points out that DSM diagnosis (alcohol use disorder, delirium plus dysfunction) were the objective considerations. It also illustrates a point about social objectivity and that is that it needs to be elaborated for every individual patient, family, and culture/subculture specifically. Suggesting that physicians or psychiatrists don’t have the capacity for recognizing these exceptions and planning according is not accurate. Suggesting that the patient and family were ignored or that their opinions were not considered is also inaccurate.  The entire treatment and discharge plan was based on those opinions - even after the recommended treatment was rejected and the high level of risk was explained.

Example 2:

Tony is a 28-year-old man seen in hospital following a suicide attempt. He shot himself through the shoulder and is on the trauma surgery service. When interviewed by psychiatry he says” “I did not shoot myself. Sure, I had the gun pointed at myself but it just went off.  I am not suicidal and I want to leave.” He gives the additional explanation that he was using large quantities of alcohol even though he has been hospitalized for alcohol poisoning in the past. When the psychiatrist points out the dangers of alcohol poisoning including death he says “Look I already said I was not suicidal.  I was just trying to get high.  I get to the point where I don’t care if I live or die but I am not trying to kill myself.”  He has had multiple admissions for depression and suicide attempts in the past.  He is currently on a 72-hour hold pending a court hearing at that time. The psychiatrist requests a review from the Ethics Committee composed of a number of local philosophy professors. They decide that the patient should be released despite the recommendation to the court for extended treatment of the substance use disorder and depression.  During the hearing the psychiatrist testifies that he has seen this type of treatment work and that he considers the patient to be at very high risk.  The court releases the patient. A week later he is found dead from acute alcohol poisoning.

Again, there are no major cultural differences in this case but clear subcultural differences based on the patient’s family and social history.  The psychiatric diagnoses are clear and indisputable.  The clinical judgment of the psychiatrist based on risk factors was also clear. The value judgments introduced here are the probate court and Ethics Committee as a proxies for society’s charge to balance a persons need for autonomy against their need for protection.  Those decisions were spread over multiple people and agencies outside of the field of psychiatry.  

These basic case examples (I say basic because they are encountered in acute care psychiatry every day and multiple times a day) illustrate a few facets of social objectivity.  First, it is poorly defined.  Second, it is impossible to achieve primarily because is consists of an infinite number of subsets that cannot be averaged if the expected result is to achieve active input into the field of psychiatry. Third, for social objectivity to be useful it needs to be recorded as unique for every person that comes into treatment and handled as it was in the above vignettes.  That way the relevant considerations of every unique history and constellation of signs and symptoms can be evaluated in the proper context. It turns out that technique has been around in clinical psychiatry for as long as I have been a psychiatrist and it is called cross cultural psychiatry.

For 22 years, I practiced on an acute care unit where we had access to professional interpreters who were fluent in both the language and cultures of several countries as well as the hearing-impaired population who used American Sign Language to communicate.  There were 15 language interpreters who spoke a number of African and Asian languages in addition to Spanish. Professional interpreters do a lot more than translate languages - they also interpret cultural and subcultural variations as well as normative behaviors. We had access to telephone interpreters in any language if we encountered a patient outside of the hospital staff expertise. The interviews were lengthy and often incorporated family members, community members, and in some cases local shaman. Without this intensive intervention attempting to assess and treat these problems would be a set up for the epistemic and hermeneutical injustices the author refers to. In fact, treatment would have been impossible. In completing these assessments there was not only an elaboration of the stated problem, how the relevant community conceptualized that problem, a discussion of how it may be treated psychiatrically and the rationale for that treatment, as well as whether the family wanted the patient treated in general or more specifically in the hospital and whether their shaman or medicine man would be involved.

These are just a few examples of how social objectivity is approached in clinical psychiatry.  The result is that values are incorporated that are important to the patient and their family even if they affect diagnostic thresholds and treatment planning.  That is also clearly stated in the DSM.  It is a much more practical and personalized approach than trying to incorporate all of those opinions into the DSM diagnosis and it gives a voice to many more people than would be involved in that process. It also considers a multitude of local factors (budgets and attitudes of social service agencies, budgets and attitudes of local courts, community resources, etc.) that all factor prominently in values-based decision making.

The other important aspect of an all-inclusive process for social objectivity is that the normative thinking of some - may result in exclusion rather than inclusion. Normative thinking based on beliefs can be political thinking and in the past two years we have seen that lead to fewer rights for women, the banning of books, a widening scope of gun permissiveness in a society rocked by gun violence, gross misinformation about the pandemic, and an attempt to overthrow the elected government of the United States. These are all good examples of how including normative thinking outside the scope of medical practice could lead to disruption of the entire field. The author suggests that the opinions expressed do not need agreement - they only need to be aired. That strikes me as the basis for a very bad meeting. Unless there is basic agreement on the values and rationale for a diagnostic system – I think Spitzer has a point that opinions for the sake of stating an opinion is a futile exercise especially if it is not in basic agreement with medical and psychiatric values and ethics.

The author defines hermeneutical ignorance in psychiatry somewhat clearer. He suggests that marginalized groups (like the pathologized) develop their own conceptual resources that are not shared with other groups.  The example suggests that willful hermeneutical ignorance results when the marginalized group does not share the conceptual resources and the dominant group (inferring psychiatry) are unaware of the resources or dismiss them.  There are numerous examples of how this is not the case with psychiatrists.  Obvious examples include Alcoholics Anonymous and other 12 step groups as well as community psychiatry programs that actively use advocates and develop resources with the active input from people with severe mental illness who are affiliated with specific programs. Psychiatrists see a general knowledge about non-psychiatric resources as necessary to provide people with additional assistance.  In many cases that can include discussions of how to better utilize the resource and what to expect.  

There are several additional points of disagreement with the author on many points where he seems unaware of how psychiatrists actually practice or he is unwilling to give credit where credit is due. The best example is his description of Spitzer’s brief commentary (2) on a paper written in Psychiatric Services. He was responding to a lead paper (3) on including patients and their families in the DSM process. The author characterizes Spitzer’s general attitude toward the idea as hostile and characteristic of injustices that he writes about but important context is not given.  Spitzer was the major architect of DSM criteria and studied the process for decades. He wrote a comprehensive defense of psychiatric diagnosis in response the Rosenhan study that has been discredited. He was also responsible for removing homosexuality from the DSM and he did that by directly engaging with activists who presented him with clear information about why it was not a diagnosis. Critics like to use the homosexuality issue as a defect with psychiatry while never pointing out it was self-corrected and that correction happened decades before progress was made at societal levels.  Even now there is a question about whether societal progress is threatened by the normative thinking and agenda of conservative groups. Spitzer was responding to the political aspects of the process with political rhetoric. 

The best argument against inclusion in the original paper was:  “The DSM process is already compromised by excessive politics.” by several groups who are not psychiatrists.  That argument has been expanded in the past 18 years to the point where it is a frequent criticism in the popular media. Even in the original paper the authors suggest that these political processes may have stifled innovation and scientific progress.

Psychiatry has not “escaped” from considering values – as noted in the above examples they are incorporated into clinic practice when the specific social and cultural aspects that apply to a certain patient are explored and considered.  Contrary to philosophical opinion – the pathologized are not a marginalized group to psychiatrists. It is who we are interested in seeing and treating.  Our interest in treatment goes beyond what is typically considered evidence-based medicine. We are interested in any modality that might be useful and that includes using resources developed or available to the people who need them. It is clear that the DSM has been overly politicized and it is routinely mischaracterized in the media. Adding  additional elements - some that have strictly political agendas that include the destruction of the field - adds nothing to improving that process. There are existing avenues for that input and they are readily available outside of the DSM process in day-to-day psychiatric practice.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Knox B. Exclusion of the psychopathologized and hermeneutical ignorance threaten objectivity. Philosophy, Psychiatry, & Psychology. 2022;29(4):253-66.

2:  Spitzer RL. Good idea or politically correct nonsense? Psychiatr Serv. 2004 Feb;55(2):113. doi: 10.1176/appi.ps.55.2.113. PMID: 14762229.

3:  Sadler JZ, Fulford B. Should patients and their families contribute to the DSM-V process? Psychiatr Serv. 2004 Feb;55(2):133-8. doi: 10.1176/appi.ps.55.2.133. PMID: 14762236.

4:  Dawson G. More on epistemic injustice.   https://real-psychiatry.blogspot.com/2023/01/more-on-epistemic-injustice.html

5:  Dawson G.  Epistemic injustice is misapplies to psychiatry.   https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html

A DSM for Psychiatrists?

 

 

No matter what version - the DSM is clearly a flash point for criticism by psychiatrists and non-psychiatrists alike. There are too many diagnoses.  People don’t like certain diagnoses or complain when some categories are eliminated. There are endless debates about diagnostic criteria, reliability, and validity. Categories are a wrong approach and we need dimensions. Philosophers have a field day imagining what the DSM is and making suggestions.  In an early post on this blog, I responded to the philosophical suggestion that the DSM was supposed to be a blueprint for living. Antipsychiatrists have no problem rejecting the entire volume of course because they are stuck in the 1970s with Szasz and maintain that there are no mental illnesses. The more flexible antipsychiatrists reframe this into everyday problems in living another decades old formulation that did not stand the test of time. Others suggest that the DSM exists to make diagnoses that lead to pharmaceutical treatment and make profits for drug companies.  The more legitimate criticism from psychiatrists is focused on the criteria and whether any diagnostic categories exist. Some of that criticism comes full circle back to why a classification system was needed in the first place. Clinical psychiatrists tend to use a fraction of the available diagnoses and in most practices can recall the diagnostic codes without looking them up. In fact, most psychiatrists use the DSM as a reference, pulling it off the shelf for rarely encountered diagnoses and then typically to look up a diagnostic code for coding and billing purposes. 

The title Diagnostic and Statistical Manual – is the first clue about the original intent of the manual and it antedates the psychiatric profession and the APA in the United States by several decades. The abbreviated history is available on the APA web site and several other Internet sites.  Initially it was to determine numbers of people by diagnosis both in the varied mental illness facilities across the country and later in military service. This function was described as administrative but there was also a consensus building aspect in the early 20^th century as diagnoses shifted from a unitary psychosis model to more nuanced.  The advent of the DSM-III was a turning point because it provided atheoretical definitions of disorders that were subsequently adopted by the ICD-9. Subsequent revisions in the DSM-IV and DSM 5 included revisions based on professionals and professional organizations, assigned work groups and their research, and eventually the general public. The original goal of classification and statistics has remained but it is used for various reasons by non-psychiatrists.

There are many examples of non-psychiatric use.  In the legal and political sphere, most states have rationed services for people with severe mental illnesses who are at high risk for hospitalization and other morbidities. Qualifying for those benefits depends on a  DSM diagnosis.  The same is true for state sponsored services for autism and developmental disabilities. In forensic settings experts are called upon to give diagnoses in an adversarial setting.  Disability, veteran’s benefits, and worker’s compensation are all linked to diagnoses.  All medical billing to insurance companies and government payers depend on DSM equivalent diagnostic codes in the ICD-11. Managed care companies ration care based on many of these codes by refusing to cover them. None of these functions were designed as an original intent for the diagnostic manual.

Heterogeneity – either explicit or implicit is another frequent criticism of the manual. Human biology and the biology of diseases and disorders teaches us that the etiopathogenesis of illnesses is diverse. There are many possible underlying biological and nonbiological causes.  Many genes and lesions can often lead to the same apparent presentation or phenotype.  That lead to the idea of intermediate phenotypes or endophenotypes to get a more consistent population to study but that has only been partially successful. The DSM was never designed to biologically classify mental illnesses, but DSM diagnoses are used for studies of biology and pharmacology. Other systems have been suggested for that purpose – most notably the RDoC system, but so far it has not exhibited any widespread success.  There is no reason to think that a verbally based system will accurately describe biologically based illness whether those descriptions are in the DSM or RDoC.

Apart from classification for statistical, administrative, and planning purposes what good is the DSM to psychiatrists? I recently saw it criticized for not including enough psychopathology. The criticism was bitter and partisan but apart from some very basic definitions the DSM is not a course in psychopathology.  All psychiatric residents need to be taught psychopathology to the point that they are experts in it. That will never happen from reading the DSM. It also doesn’t happen from reading a psychopathology text or taking a college course in psychopathology.  It happens from seminars, reading, and clinical experience – discussing psychopathology with colleagues, supervisors, and instructors.  It happens from learning in treatment relationships with people who have psychopathology not just a list or criteria but experiencing firsthand the interpersonal aspects. The DSM explicitly states that it is for use by trained professionals and that it can be used to facilitate communication between trained professionals.  

The DSM is clearly not a treatment manual of any kind. That is why I have always found the charge that it is a source of prescriptions for the pharmaceutical industry ludicrous.  There are roughly six times as many prescribers of psychiatric drugs as there are psychiatrists and the only medication in that category that is more likely to be prescribed by psychiatrists is lithium. It is easy to speculate that the prescribing patterns of that larger group are not contingent about what is in the DSM.

What about the diagnostic side and what psychiatrists need? Although there was some criticism that the neo-Krapelinians have had too much influence on the manual it is time to acknowledge that verbal descriptions have come to their logical limits. It is also time to acknowledge that psychiatrists need to know a lot more about medical diagnoses in general in order to function in a medical environment. If medical conditions are in the differential diagnosis – how many medical conditions do psychiatrists need to know about and diagnose?  Every psychiatrist I know has stories about medical conditions that were referred to them as a psychiatric disorder where they made the correct medical diagnosis. They are typically conditions from neurology, endocrinology, and infectious disease but also general medical conditions like diabetes mellitus, hypertension, and atrial fibrillation. Approaches I have seen in other specialties include lists of conditions that the trainee or practitioner needs to know about.  That is a useful approach but lists like that in a DSM are likely to raise objections about medicolegal risk and that a larger recipe book is being made for what it takes to be a psychiatrist. There are also many psychiatrists in settings where medical assessments are impossible, where they are referred out, or where the practitioner may feel inadequately trained. I see all of those reasons as being an opportunity to advance the quality of psychiatric treatment.   

A related issue is the diagnostic process in psychiatry as opposed to the rest of medicine.   Nassir Ghaemi, MD had a recent commentary about this on his blog suggesting that the DSM approach prioritizes comorbidities rather than differential diagnosis like the rest of medicine.  He describes the typical pattern matching that occurs early in the process and suggests that the differential diagnosis point, the DSM encourages listing all of the comorbidities rather than going through a differential diagnosis process.  In other words there is a lack of a hierarchical process. 

That has not been my experience. Granted – I may be a more medically oriented psychiatrist than most (but then again had 20 colleagues doing the same work) – but when I see a patient the universe of diagnoses are all possible both in and outside the DSM. The number one priority was making sure that a life threatening medical condition was not misdiagnosed as a psychiatric disorder.  Every physician can recall being taught about differential diagnosis and having to write an exhaustive list for the first few Internal Medicine inpatients. That process illustrated that a lot of the “rule outs” occurred as a mental exercise and really did not need to be written down. By the end of that rotation the differential diagnosis list collapse from the low double digits to the low single digits. There was also a triage element based on the more pressing problem or diagnosis.   A DSM for psychiatrists could make this process explicit, discuss the cognitive aspects of pattern matching and completion necessary for generating hypotheses in the differential diagnosis, the differences between differential diagnosis and comorbidity, and probabilistic considerations in selecting the preferred diagnosis. It would potentially have training implications because in order to optimize the pattern matching required - adequate training experiences need to be supplied to develop those skills. 

A DSM for psychiatrists needs to be much more information intensive in terms of research on validators, psychiatric genetics, multiomics, endophenotyping, drug mechanisms of action, and biological markers for each category.  A typical response to that suggestion is "Well there are no biological markers, labs tests, etc."  I don't find that to be a compelling argument when I think about what is currently being ignored.  We are on the cusp where more of that information is becoming relevant and we are past the point where much relevant information can just be dismissed. Any concern about cost of a more extensive manual can be dealt with by placing it online for subscribers. This may seem like a significant task given the accumulating information, but it is time the APA and research leaders in psychiatry to realize that the task has changed.  Psychiatrists are different from other physicians and other mental health professionals.  Psychiatrists need the technical information to provide quality care and compete against other systems that claim to know more about psychiatry and medicine than they do. Time to adjust to that reality and have the necessary internal debates first.

That concludes my suggestion for a DSM for psychiatrists, but I am open to more suggestions.  And for the record I am suggesting two different publications instead of a general manual full of qualifiers about expertise.  We need a manual for experts and another one like the current version - for everybody else.

 

George Dawson, MD, DFAPA

References:

1:  Horwitz, A.V. (2014). DSM - I and DSM - II . In The Encyclopedia of Clinical Psychology (eds R.L. Cautin and S.O. Lilienfeld). https://doi.org/10.1002/9781118625392.wbecp012

2:  Kim YK, Park SC. Classification of Psychiatric Disorders. Adv Exp Med Biol. 2019;1192:17-25. doi: 10.1007/978-981-32-9721-0_2. PMID: 31705488.

3:  Cooper R, Blashfield RK. Re-evaluating DSM-I. Psychol Med. 2016 Feb;46(3):449-56. doi: 10.1017/S0033291715002093. Epub 2015 Oct 16. PMID: 26470724.

4:  Shorter E. The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders. Dialogues Clin Neurosci. 2015 Mar;17(1):59-67. doi: 10.31887/DCNS.2015.17.1/eshorter. PMID: 25987864; PMCID: PMC4421901.

5:  Blashfield RK, Keeley JW, Flanagan EH, Miles SR. The cycle of classification: DSM-I through DSM-5. Annu Rev Clin Psychol. 2014;10:25-51. doi: 10.1146/annurev-clinpsy-032813-153639. PMID: 24679178.

6:  Grob GN. Origins of DSM-I: a study in appearance and reality. Am J Psychiatry. 1991 Apr;148(4):421-31. doi: 10.1176/ajp.148.4.421. PMID: 2006685.

Supplementary:

It has been suggested that a hierarchical approach informs the usual differential diagnosis exercise but it may be the application of the parsimony principle. To me there is an open question about how well parsimony works for complex biological systems.

Photo Credit:  Eduardo Colon, MD

 

 

They Don't Even Know What They Are Seeing.......

I was walking back from a meeting with a psychiatric colleague the other day.  There was the usual grousing about the practice environment and miscommunication and she made the following observation about why physicians and psychiatrists don't get the information they need.  She pointed out that in many cases the nonphysician  observers: "Don't even know what they are seeing."  If you are counting on people for observational data and that is true - that is a setup up for suboptimal care at the minimum and a catastrophe at the worst.

Take the case of a very basic measurement - blood pressure and pulse.  Anyone taking those measurements should be aware of the guidelines and whether or not the patient has a baseline abnormality, condition that can affect either, or medication effect that leads to changes in the vital signs.  They should also be aware of the limitations of measurement.  All of the automatic blood pressure machines in the world will not be able to assess and treat the patient unless the operators know what the numbers mean.  They also need to know that one of the problems with single operator and strictly machine operated approaches is that arrhythmias are problematic even if the blood pressure is fine.  There have been situations where I had to put together a continuing education course on blood pressure and pulse and the correct assessment of both.  That was a long time before the recent article on common mistakes made by medical students in these measurements.

If measurements that are considered routine and done hundreds of times a day are problematic what about observations that occur on the other end of the spectrum.  A common health care myth today is: "If I have a checklist and check off all of the boxes on that list that will lead me to some kind of diagnosis."   That is probably a minimization of the myth.  In the case of psychiatry, the myth is more: "If I convert a standard psychiatric assessment into a form (or a checklist) - the ultimate product of going through that list will basically be a psychiatric evaluation and diagnosis."  Systems of care who use this approach can deny these myths as much as they want but I see this happening every day. Organized psychiatry and the DSM approach to diagnostic criteria is partially responsible, although the manual does say that it can't be used by anybody.  It doesn't say who specifically should use it and it does not suggest (like Kendler) that it is an indexing approach.

Looking at the graphic at the top of the page illustrates why a form or a checklist does not suffice.  The observer/psychiatrist in the drawing is doing more than asking the subject a series of yes or no questions.  The psychiatrist is looking for patterns in symptoms (medical and psychiatric), what is happening in relationships with the person (including the relationship to the psychiatrist), and the person's conscious state - specifically whether there has been a departure from baseline.  There is often a balance between historical detail, phenomenology, the person's ability to describe what has happened and a plausible scenario based on probability estimates from the psychiatrist's previous experience.  Any psychiatrist who has been trained in many presentations of complex psychiatric illness is more likely to see those patterns than somebody who has not been.

To illustrate some of these concepts I will describe several cases that are all what non-psychiatrists (nonphysicians and other physicians) called hysteria. Hysteria is an old word that dies hard.  The DSM equivalent is histrionic personality disorder.  The generic use of the term suggests a person who is overly emotional, dramatic and attention seeking but there are 8 diagnostic criteria that are unchanged between DSM-IV and DSM-5.  Many clinicians opt for the term Cluster B - a DSM-IV originated term that grouped personality disorders in groups according to some common diagnostic features.  The Cluster B group included individuals that often appear dramatic, emotional, or erratic.  Those personality disorder diagnoses include antisocial, histrionic, narcissistic, and borderline.

The rule-in criteria (significant impact on life circumstances and onset when you expect a personality disorder to occur) and the rule-out criteria (not due to another mental or physical disorder) are predictable for any causal reader of a DSM and could be included on any checklist or form.  How does all of that play out?  Well here are a few examples:

Hysterical patient #1:   A 30 year old woman presents for a therapy intake.  She is mumbling and laughing.  The therapist describes her as "odd and having an odd affect."  She alludes to some suicidal behavior in the past but is smiling and joking about it.  The therapist has the impression that she is manipulative and overly dramatic.  He contacts the clinic psychiatrist and says that she is histrionic but he is concerned about her suicide potential.  The psychiatrist sees her that day and makes a diagnosis of bipolar disorder-mixed type with psychotic features.  The patient is eventually stabilized on lithium and an atypical antipsychotic.

Hysterical patient #2:  A 25 year old woman is being treated on a general medicine ward for dehydration from a respiratory infection.  She suddenly gets tearful and agitated.  Family members visiting have to physically restrain her when when she tries to get out of bed.  She starts to make very loud high pitched vocalizations.  A psychiatrist is called to go in to assess hysteria and possibly sedate the patient.  The psychiatrist sees an agitated young woman who is not able to respond coherently to any examination questions.  Brief neurological examination suggests increased intracranial pressure is the problem and the patient requires immediate transfer to a neurological intensive care unit. 

Hysterical patient #3:  A 58 year old man is referred acutely from a therapist for acute panic attacks and "probable Cluster B" personality traits.  He has recently retired due to osteoarthritis of the knees.  He had no earlier history of panic attacks but the therapist thought that he was overly dramatic at the initial session 2 days earlier when he was unable to relax and breathe normally with behavioral techniques that are usually effective.  The psychiatrist gets a history of the patient needing to abort an exercise stress test two weeks earlier due to the arthritis and having  a prolonged period of immobility at home due to sore knees. During that time he developed acute shortness of breath.  The episodes of anxiety that he described were secondary to shortness of breath and not panic attacks.  The psychiatrist sends the patient to the emergency department where an acute pulmonary embolism is diagnosed and he is admitted to the ICU.     

These are just a few examples restricted to one collection of psychiatric symptoms that illustrates what my colleague was referring to.  The value of psychiatric training goes far beyond what is in the DSM and what checklists and templates can be extracted from it.  I have never really met a psychiatrist who was focused on the DSM probably because it is implicitly evident to us that it is an index more than a diagnostic manual. We are focused on what is not in the DSM and as far as I know that is not well documented in many places.  Those are the patterns associated with clinical practice and that should have been gleaned along the way with medical training.  The DSM doesn't tell you how a pulmonary embolism presents. It is possible that you night have never seen one. But in medical training I can guarantee that it was discussed somewhere along the line in the differential diagnosis of dyspnea.  I can guarantee that one of those attendings discussed the phenomenon of the healthy young adult immobilized by air travel who gets off at their destination and suddenly has an acute pulmonary embolism. All of those features and urgencies should be in a physicians conscious state when they are seeing the whole patient and not some DSM/checklist version of a patient.

This brief post also illustrates the biasing effects of language.  What  does "Cluster B" really mean?  Aren't people who are acutely medically (or psychiatrically) ill dramatic, emotional, or erratic?  Hysteria is an extremely biasing term that over the centuries has been applied selectively to women rather than men.   The examples above illustrate that point.  If you are seeing the world through DSM language and that is your only lens - you are by definition not seeing the whole patient.  The list of possible errors in that landscape is very large.

There are a number of constraints that will get  in the way of a trained psychiatrist trying to see the whole patient.  Inadequate time is one, but time frames vary significantly.  Diagnosing a life threatening medical problem upon seeing a patient may take a matter of minutes and is clearly the most important diagnosis.  Seeing a long series of new patients briefly to prescribe treatment will necessarily mean that certain features in the above diagram will be missed.  So-called measurement based care depending on a large number of checklists to "quantitate" affects or other psychiatric states makes the same mistake.  Collaborative care where a psychiatrist looks at these rating scales and recommends treatments makes the same mistake.

The best assurance that the critical aspects of care will not be missed is to be sitting across the room from someone who has been taught all of the critical aspects of care.  That process is complex and as far as I know has never been adequately described.  A first approximation is whether that person knows what they are seeing and how to respond.

George Dawson, MD, DFAPA     

Delirium Reinvented

One of my colleagues posted an article from the The Atlantic on delirium to her Facebook feed a few days ago.  Most of my colleagues in that venue are hospital, consultation-liaison, addiction or geriatric psychiatrists and we diagnose a lot of delirium.  Entitled the Overlooked Danger of Delirium in Hospitals it makes it seem like this is some kind of new and strange diagnostic category.  The article talks about the prevalence, the association with critical illness and advanced age, and the diagnostic overlap of dementia and delirium.  We hear from an Internal Medicine specialist Sharon Inouye, MD about the need to correctly diagnose and prevent delirium.  She mentions that as opposed to a decade ago, physician and nurses are all taught about delirium.  There is mention of the CAM (Confusion Assessment Method) that Inouye developed.  Like all health care articles there are estimates of the massive cost of delirium as well some prevention techniques.  There is also political concern that Medicare will declare delirium a "never" event with penalties for any hospital with cases of delirium.  That would be unfortunate because it makes a mistake that also seems to be made in this article - that delirium is a manifestation of many illnesses, especially the kind of illnesses that patient's are hospitalized for.

The article seemed odd to me because it was written from the perspective that delirium is an iatrogenic preventable event!  Certainly that can be the case. Delirium is a primary feature of hundreds of different disorders and recognizing delirium and those etiologies is potentially life saving.  Delirium can mimic psychiatric conditions due to the presence of hallucinations and delusional thinking.  For example, it is entirely possible to see a patient in the emergency department with apparent paranoid delusions and miss the fact that they happen to be delirious.  Sometimes the only sign is that the patient is inattentive and when vital signs are checked they have an elevated temperature.  This can be a common presentation of viral encephalitis in younger patients or urinary tract infections in the elderly.  It is bad form to miss either of those diagnoses and attribute the symptoms to a psychiatric disorder.  Another common form of delirium that is missed is drug or alcohol intoxication or withdrawal states.  Some intoxicants will render the patient totally unable to care for themselves until they are detoxified.  Other deliriums from alcohol or sedative withdrawal are life threatening and can be associated with seizures and other life-threatening states.  An acute change in a person's mental state resulting in delirium needs to be recognized and assessed as a medical emergency.    

One of the first cases of delirium that I ran into after residency was a case of cerebral edema that I was consulted on because of "hysterical behavior".  After that, I worked in and eventually ran a Geriatric Psychiatry and Memory Disorders Clinic for about 8 years.  The majority of people coming to that clinic had dementia of some sort.  They would see me and a neurologist.  We started out with an internist who was also a geriatric specialist, but that turned out to be overkill in terms of the number of medical specialists seeing each person in an outpatient clinic.  We eventually opted for records from the patient's primary care physician.  One of the most valuable functions of that clinic was our ability to follow people with prolonged deliriums.  Once a delirium has been established by a disease state and that state has resolved the delirium can persist for months.  Some of the outliers in that clinic took up to 6 months to clear.  We found that in many cases, the patients were extensively tested for intellectual ability and functional capacity when they were in the delirious state and told that they had dementia.  It was always instructive for the patient and family to get the testing repeated when we were sure the delirium had resolved and find that they had been restored to baseline.  Many people know their full scale IQ score and were relieved to see that they were back to that level of functioning.

A valuable lesson from working in that clinic and in hospital settings was the use of the electroencephalogram (EEG) as a possible test for delirium.   EEGs are commonly viewed as diagnostic tools to determine if a person is having seizures, but they also contain a lot of information about brain metabolism.  EEGs can be difficult to interpret especially if the patient is on a number of medications that affects cerebral metabolism. There are two broad categories of EEG patterns for delirium: one with a predominance of slow frequencies (designated theta and delta) and one with faster frequencies (designated beta).  We found a number of people with very significant cognitive impairment that was thought to be either a psychiatric disorder or a dementia but with a profound degree of slowing more consistent with a delirium.    

Delirium is an augenblick diagnosis for most psychiatrists.  The patient could appear disinterested, apathetic, agitated, or overtly confused.  It occurs in situations where brain physiology is compromised such as post surgical/anaesthesia states, drug intoxication states, drug reaction states, or possible physical illness delirium should be high on the differential diagnosis.  The Atlantic article makes it seem like knowledge about delirium is something very recent, but psychiatrists have been focused on it for a long time.  In the first two iterations of the DSM, delirium was subsumed under the categories of acute and chronic brain syndromes (DSM-I 1952) and organic brain syndromes (DSM-II 1968).  The current diagnostic code and name has been with us since the DSM III in 1980.  One of the early experts in delirium was Zbigniew J. Lipowski, MD, FRCP(C) - a Professor of Psychiatry from the University of Toronto.  His first text on the condition was Delirium: Acute Brain Failure in Man published in 1980.  That was followed by his classic text,  Delirium: Acute Confusional States published in 1990.  A comparable text from a neurological standpoint was Arieff and Griggs Metabolic Brain Dysfunction in Systemic Disorders published in 1992.

Any psychiatrist trained in the past 30 years should be able to diagnose delirium and come up with a differential diagnosis and monitoring or treatment plan.  A significant number of people can be followed on an outpatient basis as long as they are in a safe environment with the appropriate level of assistance.  The main goal of treatment is to make sure that the primary medical illness that led to the problem has been treated.  There are no known medications that will accelerate the resolution of these symptoms and medical management usually involves getting rid of medications that can lead to cognitive problems.  That can include benzodiazepines, antidepressants and antipsychotics but also more common medications like antihistamines and anticholinergic medications that are used for various purposes.  Like most psychiatric interventions in our health care system, clinics with staff interested in doing this work are few and far between generally because they are rationed resources.

There is a current movement underway to train Family Physicians and Internists (like Dr. Inouye) to recognize and prevent delirium.  In the minority of hospitals where psychiatrists work they are also a clear resource.  A delirium in a previously healthy person should signal a fairly comprehensive evaluation to figure out what happened.

And whenever there is a question of whether a person has a delirium or a psychiatric disorder - call a psychiatrist.  Psychiatrists know a lot about delirium and have for decades.



George Dawson, MD, DFAPA



Reference:

Sandra G. Boodman.  Overlooked Danger of Delirium in Hospitals.  The Atlantic.  June 7, 2015.


Supplementary 1:  The graphic is a standard EEG.  I tried to post a slowed EEG seen in delirium, but the publisher wanted what I consider to be an exorbitant fee for a non-commercial blog.  If anyone has a slow anonymous EEG laying around, send me a copy and I will post it.

A Few Words About Sex

Sex remains a poorly studied and controversial topic.  It is a powerful interpersonal and cultural force.   Many ideas that originated with Freud are considered outmoded and yet when I have attended seminars that I thought might lead to ways to advance my knowledge in this area, they seemed like a dead end.  In fact, at the last seminar I attended I asked the speaker about experts in sexual consciousness he referred me to a psychoanalyst who I had corresponded with but who had since died.  The only real innovation in the area has been sexual compulsivity or sexual addiction.  Several authors write about this as though it is an actual disorder.  There have been the compulsory brain imaging studies showing activation of the reward center.  I have reservations about defining an addiction when so little is known about the baseline sexual consciousness of men and women.  It is against that backdrop that I watched two films by von Trier - both of them with the title Nymphomaniac.

After some deliberation let me say that I am not recommending that anyone watch these films.  At the very minimum they are highly controversial and they contain images that will be regarded as highly offensive or disturbing to many if not most people.  The point of this post is to illustrate how the basic storyline of these films brought me back to an issue that I have been pointing out for years, that psychiatry is no longer focused on this area of human experience even though we diagnose and treat these problems all of the time.  In many ways reading Kandel's book The Age of Insight highlights how there were more enlightened conversations about these issues in early 20th century Vienna, than I have seen anywhere during my professional career.   The public discourse is abysmal.

I was familiar with von Trier's work from an earlier film Antichrist, a film that I suppose in a very basic way was a psychotic repudiation of genital sex.  Like most things it popped up on my Netflix screen as I was getting ready to cycle.  Let me preface this post by saying that this is not a review of these films.  From what I can tell the film has been exhaustively reviewed.  The Netflix rating was a meager 2.9 stars.  Even informal reviews usually adhere to a thumbs up/thumbs down convention.  This is one of those films that is not conventional in that sense.  There are few people that would be very enthusiastic about this film based solely on content.   It is difficult to watch.  It is depressing, desolate, and in some cases violent.  It is a film that you would not necessarily recommend or even say that you had watched because it would invite inferences about your character or taste.  It may be an ideal backdrop for the trajectory of the main character and her sexual experiences in the  film.

The storyline is basic enough.  A middle aged man finds a woman who was apparently beaten up and left in an alleyway.  It is night time and lightly snowing at the time.  The alleyway is surrounded by brick walls and there is an impression that it is an impoverished part of the city.  The man offers to call for medical help but she declines.  She accepts his offer to go back to his apartment.  When she is more comfortable, she relates her history of compulsive sexual behavior in a series of eight vignettes with titles that seem interwoven with observations and stories from the man who appears to be helping her.  These stories are the main content of both films.

The stories all have the common elements of compulsive sexual behavior.  We start to learn that the chief protagonist Joe (Charlotte Gainsborough), made a conscious decision about this lifestyle at an early age.  We get to known her parents, her interactions with them and witness her father's death.  We see her embark on a vigorous program of engaging as many sexual partners per day as possible.  I think the number over much of the film that could have covered 15-20 years of her life was 8-10 men per day.  We witness some of the logistics when some of these men meet in her apartment and a scene where one of the men leaves his wife and his wife shows up at Joe's apartment with her children and is very agitated.  She angrily details the cost of  extramarital sex for the family.  Practically all of these scenes are difficult to watch.  We observe Joe over time as she becomes exhausted and eventually physically ill and debilitated, presumably from the excessive sexual behavior.  Whether or not she contracts sexually transmitted diseases is never made explicit, but we see rashes that do not heal and she describes bleeding from the genital area.  We also see her physically injured as a result of sadomasochistic behavior.  We watch her struggle emotionally.  The basic idea at the outset was not to develop any emotional attachments and to have as much sexual intercourse as possible.  Sex strictly for the sake of sex.  There are critical times during her life when that does not happen and attachments, jealousy, and envy happens and we see how she deals with these developments.  Near the end she is psychologically devastated, trapped and alone because of the sexual compulsion.  At the end, we have come full circle and realize how one of these emotional involvements has resulted in her being beaten and left in the alley.   There is additional drama at the end that I will not disclose.  If you can watch the entire sequence of these films, you deserve to discover that for yourself.

Films like Nymphomaniac are thought provoking and if you like your thoughts provoked that could lead you to give it a thumbs ups.  I have already listed my criteria for cinema as good entertainment and good acting and the film meets some of those standards.  As I thought about the content, my first thought had to do with the fact that this film was written by a man, so it is really a man's estimate of the sexual consciousness of a woman.  Strictly speaking, it is impossible for any one of us to understand the conscious state of another human being.  The thought experiment from consciousness researchers is typically, my experience of the color red is not your experience of the color red.  It is interesting to contemplate whether there might be a larger gap in understanding the sexual experience of the opposite sex.  People may argue that observations of dating and sexual behavior, anatomy and fairly crude mental and physiological data allow us to make reasonable estimates, but I would say this is more likely conjecture than the reconstruction of an actual conscious experience.  Since there is so little scientific evidence about this, the area is highly politicized.  Experts frequently talk about stereotypes of sexual behavior and the theories about why they occur.  Any attempts at discussion may break down to personal anecdotes supporting these political approaches that nobody wants to hear.   There are probably any number of reviews available online that will examine Joe's behavior from these perspectives.  Many of these arguments can come down to existential and moral dilemmas and what side of these arguments an observer happens to take.  And there is always the artistic argument that reality is relevant insofar as it may be part of the beholder's experience (see Kandel).

We get to know the man who seems to have saved Joe.  His name is Seligman (Stellan Skarsgård).  He is a self-described asexual man who gives the impression that he is an ascetic with far too much time on his hands.  His associations to some of Joe's stories often has a level of analysis that you could only get in a college classroom by a professor who is an acknowledged expert in his field. That level of sterile intellectual analysis seems consistent with his self described asceticism.   He seems to be different from the numbers of other men that Joe has encountered.  A key question is whether or not Seligman can interact with Joe in a non-sexual manner, although the obvious question is whether that can occur if a man is calmly listening to the sexual history of a self professed nymphomaniac for a number of hours.  That issue does not get resolved until the final moments of the film and I am sure that many film goers will find it controversial and suggestive of motivations on the part of the director and writer.

As as psychiatrist and a physician I naturally think about the implications of this movie.  Have I seen people with this problem?  Do I think this problem exists?  Have I been able to help people with all of the variations in between?  Are there implications for the training of psychiatrists and physicians?  As a first year medical student, I was exposed to a course that was described as cutting edge at the time.  It was devised and taught by a psychiatrist who had been brought  to my medical school expressly to teach this course.   It consisted of a surprisingly dry curriculum about the importance of taking a sexual history, videos of sexual behavior with group discussions, and lectures on how to address some very basic sexual problems.  It always struck me as the "birds and the bees" talk that your parents gave you at the end of elementary school but with better audiovisuals.  It seemed shockingly unsophisticated relative to some of the theories of the day.  The timing was also wrong.  Taking 30 minutes to do a detailed sexual history is not going to work when you start rotating through acute care medical and surgical settings.  Knowing enough medicine and psychiatry and practicing in an ambulatory care setting seem like better prerequisites.  A course like that is inadequate preparation for what occurs in those clinic settings.  The mechanics are irrelevant.  The focus is all intrapsychic and interpersonal, helping the person process that information and adapt.  A focus on the mechanics of sex,  either in the sexual history or sexual education in school really seems to miss the mark.  All of the discussion of mechanics even with the recent details of how the ventral striatum is activated during sexual behavior seems to marginalize the meaning of sexual behavior and how it influences the entire conscious state of a person.  Whether Joe's story is accurate or not, the common experience of sexual behavior organizing one's conscious state probably makes this story believable for most people.

The issue of whether of not nymphomaniacs exist is certainly another issue for psychiatry.  The diagnostic manual lists no similar term and no reference to the equivalent condition in the film - sexual addiction.  In some circles, sexual addiction is seen as a behavioral equivalent of substance use disorders.   The existing sexual dysfunctions available for diagnosis include problems with hypoactive sexual desire, arousal and orgasms.  Hypersexual disorder is not an option and Grant and Black explain:

"During DSM-5 deliberations, there was some controversy about the possibility of including hypersexual disorder, which is characterized by sexual behavior that is excessive or poorly controlled (commonly referred to as either "sex addiction" or "compulsive sexual behavior") and paraphilic coercive disorder, which consists of a sexual preference for coerced sexual activity (i.e. rape).  After considerable discussion and input from fellow APA members, the decision was made not to include these disorders in DSM-5." (p. 274)

A current Medline review shows that the research in this area is thin considering that there are experts out there who are treating sexual addiction or sexual compulsivity and there are several instruments that are designed to gather that data.   I also can't help but think that there are more cases that are under the epidemiological radar.  By that I mean the cases that present to psychoanalysts.  Some of the most fascinating areas that I studied as a resident were the different approaches to psychoanalysis, particularly the differences between Kohut and Kernberg.  Kohut's paper called "The Two Analyses of Mr Z." was particularly interesting because the presenting symptom was compulsive sexual behavior.  The symptom did not respond to traditional psychoanalysis but required Kohut to modify the technique and he used this as an example of his new self-psychology approach in psychoanalysis.  So a question for the analysts out there, I know that many analysts treat focal sexual symptomatology out there and eschew the DSM categorical approach to sexual behavior.  Are there psychoanalytical papers written about hypersexuality in general and is it a problem frequently seen in psychoanalytic practice?  The Psychodynamic Diagnostic Manual has the following commentary on the subject of the categorical (DSM) classification of sexual disorders:

"Sexual inclinations and experiences are sufficiently diverse among human beings that we urge caution in diagnosis.  In this area we are particularly uncomfortable with the categorical depiction of "disorders" in the DSM.  Especially in the area of paraphilias, it becomes easy to pathologize behavior that may simply be idiosyncratic.  In contrast to categorizing specific acts as inherently pathological irrespective of context and meaning, we recommend a thoughtful assessment of subjective factors, meanings, and contexts of variant sexualities...." (p. 126)

The diagnosis of Hypersexual Disorder was listed in the online proposed DSM-5 as a paraphilic disorder but it did not make the final cut.   There was a note posted that it would be included in "Section III" conditions for further study, but in the final version it was not listed there either.  It would appear that there is little guidance from either the DSM or PDM camp on this disorder.

I had originally planned to include a new graphic here summarizing the imaging results from studies of human behavior, but I am having some difficulty getting the original papers and images.  For anyone interested in that list of references you can find them here.  A recent paper in Science, raises some serious questions about what reward center activation really means (see Donoso, et al).  In this paper the authors demonstrate that reward center activation can occur with a purely cognitive task and seems to function in a way to continue to make correct choices.  That raises some questions about conventional approaches to reward center activation and what it means in the study of human sexual behavior but also addictions of all types.  How much reward center activation is purely due to making a "correct" choice and what does that mean in the case of an addiction or in the cases of normal function like eating, drinking, or sexual behavior?

In terms of clinical practice, I have treated hundreds of people with hypersexuality, socially inappropriate sexual behavior, and victims of sexual assault.  They were almost all due to mood disorders (mostly mania), neurocognitive disorders, chronic intoxication states associated with addictions, medication side effects (primarily medications used to treat Parkinson's Disease), or the effects of various forms of sexual violence.  I have fielded a lot of questions on the whole notion of sexual addiction, especially in chemical dependency treatment settings where compulsive behaviors are viewed as behavioral addictions.  I have never really encountered anyone describing a problem similar to what is portrayed in Nymphomaniac.   There is always a strong selection bias in clinical practice and for a long time, I assessed and treated people with severe mental illnesses and addictions.   The hypersexuality in these cases usually had causes that any psychiatrist could diagnose and hopefully treat.   My read of the psychoanalytic and family therapy literature suggests that there are cases that are independent of the etiologies that I have seen and many of them have intrapsychic/interpersonal and social etiologies.  Apart from individual case presentations by psychoanalysts and psychotherapists it is very difficult to see this as a widespread problem.  That seems to happen in other areas like Intermittent Explosive Disorder.  I have not seen a single case in 28 years and yet there it sits in the DSM-5.

This is probably another area in psychiatry that will require a lot of data and more research to resolve.  People often take offense to the idea of more research as a standard answer, but it should be clear that when it comes to sex, the approaches are largely anecdotal and it seems like an area that most people avoid thinking about in any scientific manner.



George Dawson, MD, DFAPA


Black DW, Grant JE.  DSM-5 Guidebook - The Essential Companion To The Diagnostic and Statistical Manual of Mental Disorders.  American Psychiatric Publishing, Washington, DC.  2014.  p.274.

Kafka MP.  Hypersexual Disorder: A Proposed Diagnosis for DSM-5.  Arch Sex Behav (2010) 39: 377–400.

"There are significant gaps in the current scientific knowledge base regarding the clinical course, developmental risk factors, family history, neurobiology, and neuropsychology of Hypersexual Disorder.  Empirically based knowledge of Hypersexual Disorder in females is lacking in particular."

Kandel ER.  The Age of Insight - The Quest to Understand the Unconscious in Art, Mind, and Brain.  Random House, New York, 2012. p. 394.

Kohut H. The two analyses of Mr. Z.  Int J Psychoanal. 1979;60(1):3-27. PubMed PMID: 457340.

PDM Task Force.  Psychodynamic Diagnostic Manual.  Alliance of Psychoanalytical Organizations.  Silver Spring, MD.  2006. p. 126

Donoso M, Collins AG, Koechlin E. Human cognition. Foundations of human reasoning in the prefrontal cortex. Science. 2014 Jun 27;344(6191):1481-6. doi: 10.1126/science.1252254. Epub 2014 May 29. PubMed PMID: 24876345.



Supplementary1:  This post may be modified as more data becomes available.  I just had to move on.

Supplementary 2:  Since there are apparently no conferences I had this idea for a conference based on this post to put sex back into psychiatry.  The conference would consist of the following elements:

1.  Update on the current epidemiology of sexual behavior.
2.  Review of the physiology and neuroendocrinology of sexual behavior.
3.  The neurobiology of the human sexual response.
4.  Brain imaging of the human sexual response.
5.  The sexual consciousness of men and women.
6.  An approach to useful clinical classifications across the DSM-PDM spectrum.
7.  Clinical approaches to identifying sexual problems and normal sexual function.
8.  Approaches to treatment across the DSM-PDM spectrum: disorders to focal problems.

Let me know if you can think of other topics, I am trying to get people interested in putting this conference together right now.