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.
Showing posts with label psychoanalysis. Show all posts
Showing posts with label psychoanalysis. Show all posts
Thursday, September 4, 2014
Sunday, August 3, 2014
Jimmy P. - The Psychotherapy of a Plains Indian
Every now and then Netflix surprises me and seems to include come content of interest to psychiatrists. I watch a lot of Netflix basically because I have a WiFi ready TV planted in front of my ergometer. I ride an ergometer at least 4 times a week and as anyone who has ridden indoor cycling trainers can attest, that can be painful activity without some diversion. I had just finished watching a biographical piece about Harry Dean Stanton and found the movie Jimmie P. It starred Benicio Del Toro and I started watching it on that basis rather than the description that had something to do about psychoanalysis. Del Toro stars as Jimmie P. or Jimmie Picard a Blackfoot Indian who also happens to be a returning World War II veteran. We subsequently learn he was a sniper in the war but never shot anyone. We see a scene where he falls out of the back of a transport truck and sustains a severe head injury. It is that head injury that sets the story line for the film, the story develops through flashbacks.
I decided to start watch this film based on two things. The word "psychoanalysis" and the name "Del Toro". I am not a psychoanalyst, but I have been trained in psychotherapy, have done psychotherapy, and have had a great deal of success with psychotherapeutic interventions. At the time I was trained all residents did psychotherapy training and were supervised intensively. One hour of supervision for every hour of patient contact. A lot of that supervision was painstaking. Reviews of audio tapes, video tapes and process notes. I was intensively supervised on 3 extended psychotherapy patients per week so that was 150 hours per year for three years. There were also group seminars, group supervision and seminars that consisted of case discussions. Much of the supervision I had was done by psychoanalysts or psychodynamically oriented psychotherapists. There were also existentialists, cognitive behavioral therapists, and marriage and family therapists. My experience with these supervisors was generally positive, but as you might imagine it was also a grind at times. At times, I felt like I was too physically, mentally, and emotionally drained to go into these sessions, but I made them all. I include this information to illustrate a potential bias in my viewing a psychotherapy movie.
Benicio Del Toro always piques my interest. I don't think there is any other contemporary actor who can play the conflicted bad man as well as he can. He is visually interesting to watch and has huge screen presence. He is one of the few actors that will prompt me to watch a film cold without much knowledge ahead of time. In this film he shows his range in his portrayal of a very real guy coming back from the war. He is a conflicted good man and in fact he is too good at times. When I was a kid growing up there were many uncles who came back from the war, and as I grew up it was common to hear that a particular person was "never the same" after they came back from the war. I am old enough to have observed that effect of war on another three generations. Jimmy P. was one of those guys.
I didn't think of it at the time, but I also have in interest in Native Americans and their culture. I was born and raised between two reservations. I note that some of these reservations have been renamed as tribal homelands. I went to school with folks from these reservations and played sports with them. My uncle and I were fortunate enough to be on a baseball team that was predominately Native American ball players. My grandfather and I fished on the reservation, almost exclusively. Even though those experiences were always positive, the most instructive aspect about knowing about Native Americans and some of their personal situations was the development of biases against them. Over the last thirty years, they have been more assertive and in some cases more successful. They have been granted rights that are viewed as controversial by non-native groups, specifically fishing rights. The backlash has been significant enough to lead any objective observer to conclude that relationships with the native population is actually worse than when I was sitting in a boat on Bad River with my grandfather.
These first four paragraphs are a good indication that there psychodynamic influences in the very decision to select a film. Getting back to the movie - we first see Jimmie P. at his sisters home. He is having difficulty functioning. He is sleeping late, but also has debilitating headaches and a sense of dysequilibrium. At times he collapses with headaches, chest pains and is sweating through his clothing. We learn that he has already been medically assessed and that he has a significant scar on the top of his head. He is eventually admitted to a VA facility that is headed by Karl Menninger. The focus of the admission is to determine whether or not there are any organic factors involved in the presentation or whether a functional illness is present that can be treated with psychotherapy. The diagnostic interventions are vague and understandably crude. For some reason a pneumoencephalogram was postponed until near the end of the film and we learn that the goal was to rule out a cholesteatoma!
At the end of the initial evaluation Dr. Menninger's team is coming up with no medical explanations for Jimmy's symptoms. Dr. Menninger places a call to Georges Devereux, who is identified initially as an anthropologist with a knowledge of Native Americans. He convinces Devereux to come to the hospital and do an assessment on Picard. It was unclear to me about his professional orientation apart from his qualification as an anthropologist but it became apparent that he was also functioning as a psychoanalyst and getting his own analysis from faculty at the hospital. After several interviews he presents his formulation to Menninger and colleagues and they like what they hear. They ask him to stay on and engage Picard in psychotherapy. The bulk of the film is a detailed psychotherapeutic conversation between Devereux and Picard.
That is where the real work for the viewer comes in. My speculation is that whether the viewer does stay engaged depends on their psychological mindedness or ability to stay interested in the narrative. That narrative that is built on Devereux's interpretations and clarifications and flashbacks that are designed to elaborate on what Picard is describing in the sessions. There are several indirect discussions and enactments of transference and countertransference in the film. In one very good scene Picard gets angry with Devereux and they discuss the importance of discussing the anger and associated events with the therapist. There were also many good examples of real situations and how they are handled well but at times imperfectly in therapy sessions. Scenes like this can lead experts to take issue with the way they are portrayed in the cinema. My usual standard for cinema is that it is well executed from a technical cinematic standpoint, that it is entertaining and that I like it as art. It certainly passes that standard. Since we are dealing with just fragments of therapy sessions, any errors are difficult to assess. I found myself thinking about taking too many notes early in the course of therapy as a possible example. Therapy was also portrayed as hard work that results in somewhat erratic progress. The necessary relationship for therapy and a working therapeutic alliance seemed to be emphasized in the film, but over the course of the film it seemed like Devereux became more distant. It may have been written that way to show the effect of termination and possibly supervision on the part of the analyst.
Devereux's personal life is also a focus in the movie. He is having an affair with a married lover Madeleine. Many critics see this a a diversion away from the main text of the film, but I saw it as more important than that. In many ways Madeleine is an idealized lover. She is bright, very attractive, likeable, and at times dotes on Georges. In my observation of Georges, he just does not seem to have a lot going for him. He seems to spend a lot of time on anthropological junkets, is somewhat of a nerd, does not seem emotionally resonant with Madeline, and seems fairly indifferent when it is time for her to leave. Madeline also has a statement and a soliloquy in the film that I saw as critical. One is an overview of how the brain is the central organ in the body and the role of psychoanalysis in psychosomatics. The other has to do with the impact that an idealized lover has on a person, why they do not need to be forgotten, and the ongoing impact on one's life. I think that she also provides contrast between the advice that the analyst gives his patient and how he runs his own life. That is an interesting thought in a movie that includes Karl Menninger. One of Menninger's theories is that there is not much difference between people with mental illness and people who don't have mental illness. Jimmy P. is a great illustration of that idea extended to include the fact that there is really no difference between Native Americans and the rest of us. People seeing this film can probably identify with many of the themes and conflicts that Jimmie P. had to deal with.
I had the usual associations to the film. I have treated many people with psychosomatic problems like Jimmy P. These days most of the work has to go in to the idea that there is not a pill for these problems, but that other strategies can be useful. It is very probable in modern times that the correct treatment of these serious psychosomatic symptoms gets buried under a long series of "medication trials." I could see Jimmy being diagnosed with Post Traumatic Stress Disorder, Panic Disorder, Major Depression, and possibly an alcohol use disorder. I can see all of that happening in one 20 minute session by a nonpsychiatrist. I could see him walking out of that first session with an SSRI, a benzodiazepine, and possibly prazosin - all medications high up on the PTSD algorithm. The issue of diagnosis came up in the last meeting between Picard and Devereux. After discussing the pneumoencephalogram results, Devereux asks whether Picard would like to know his diagnosis. He hands him a piece of paper with the diagnosis "Psychic Trauma".
That's my initial review. There are some addition reference materials I would like to look at including a suggested book and the actual script. A script with dialogue this intensive probably requires an additional read or two. There is a lot of information contained in the dialogue between Picard and Devereux. As far as I know there are no good models or methods for analyzing the information content in therapeutic sessions and how that information is used. I ended up rating the film 5 stars on Netflix. But keep in mind that rating is from a guy who has talked to people at least 6-7 hours per day for the past thirty years.
George Dawson, MD, DFAPA
Matt Zoller Seitz. Jimmy P. This is a good review by a professional reviewer who thought this was a good film and has opinions about it that contrast with mine.
Supplementary 1: Given my comments about psychotherapy and psychopharmacology it is easy to see how those issues can be politicized and how discussions about both of those modalities can be very polarized. The fact that a person with complex problems is more likely to see a psychopharmacologist first should not mean that they are not receiving psychotherapy informed treatment. One of the most striking examples that I can think of is a psychopharmacologist I worked with for many years. He started and ran a psychopharmacology specialty clinic. The people who saw him had a uniformly positive experience based on their relationship with him and what how he discussed problems with them. He was and is certainly an expert in psychopharmacology but he was providing a lot more than that.
I think we are past the time where there needs to be an open discussion and guidelines about psychotherapeutically informed psychopharmacology. That would include a focus on the relationship, a discussion about that fact that there are probably other things that need work in addition to the medication, and a discussion of the meaning of the diagnosis and meaningfulness in general in a persons life.
These ideas have obvious implications for the stilted billing and coding system and the idea that anybody can prescribe psychiatric medications. Expert prescribing requires knowing about what is going on in addition to the diagnostic criteria and algorithms and what else can be done.
I decided to start watch this film based on two things. The word "psychoanalysis" and the name "Del Toro". I am not a psychoanalyst, but I have been trained in psychotherapy, have done psychotherapy, and have had a great deal of success with psychotherapeutic interventions. At the time I was trained all residents did psychotherapy training and were supervised intensively. One hour of supervision for every hour of patient contact. A lot of that supervision was painstaking. Reviews of audio tapes, video tapes and process notes. I was intensively supervised on 3 extended psychotherapy patients per week so that was 150 hours per year for three years. There were also group seminars, group supervision and seminars that consisted of case discussions. Much of the supervision I had was done by psychoanalysts or psychodynamically oriented psychotherapists. There were also existentialists, cognitive behavioral therapists, and marriage and family therapists. My experience with these supervisors was generally positive, but as you might imagine it was also a grind at times. At times, I felt like I was too physically, mentally, and emotionally drained to go into these sessions, but I made them all. I include this information to illustrate a potential bias in my viewing a psychotherapy movie.
Benicio Del Toro always piques my interest. I don't think there is any other contemporary actor who can play the conflicted bad man as well as he can. He is visually interesting to watch and has huge screen presence. He is one of the few actors that will prompt me to watch a film cold without much knowledge ahead of time. In this film he shows his range in his portrayal of a very real guy coming back from the war. He is a conflicted good man and in fact he is too good at times. When I was a kid growing up there were many uncles who came back from the war, and as I grew up it was common to hear that a particular person was "never the same" after they came back from the war. I am old enough to have observed that effect of war on another three generations. Jimmy P. was one of those guys.
I didn't think of it at the time, but I also have in interest in Native Americans and their culture. I was born and raised between two reservations. I note that some of these reservations have been renamed as tribal homelands. I went to school with folks from these reservations and played sports with them. My uncle and I were fortunate enough to be on a baseball team that was predominately Native American ball players. My grandfather and I fished on the reservation, almost exclusively. Even though those experiences were always positive, the most instructive aspect about knowing about Native Americans and some of their personal situations was the development of biases against them. Over the last thirty years, they have been more assertive and in some cases more successful. They have been granted rights that are viewed as controversial by non-native groups, specifically fishing rights. The backlash has been significant enough to lead any objective observer to conclude that relationships with the native population is actually worse than when I was sitting in a boat on Bad River with my grandfather.
These first four paragraphs are a good indication that there psychodynamic influences in the very decision to select a film. Getting back to the movie - we first see Jimmie P. at his sisters home. He is having difficulty functioning. He is sleeping late, but also has debilitating headaches and a sense of dysequilibrium. At times he collapses with headaches, chest pains and is sweating through his clothing. We learn that he has already been medically assessed and that he has a significant scar on the top of his head. He is eventually admitted to a VA facility that is headed by Karl Menninger. The focus of the admission is to determine whether or not there are any organic factors involved in the presentation or whether a functional illness is present that can be treated with psychotherapy. The diagnostic interventions are vague and understandably crude. For some reason a pneumoencephalogram was postponed until near the end of the film and we learn that the goal was to rule out a cholesteatoma!
At the end of the initial evaluation Dr. Menninger's team is coming up with no medical explanations for Jimmy's symptoms. Dr. Menninger places a call to Georges Devereux, who is identified initially as an anthropologist with a knowledge of Native Americans. He convinces Devereux to come to the hospital and do an assessment on Picard. It was unclear to me about his professional orientation apart from his qualification as an anthropologist but it became apparent that he was also functioning as a psychoanalyst and getting his own analysis from faculty at the hospital. After several interviews he presents his formulation to Menninger and colleagues and they like what they hear. They ask him to stay on and engage Picard in psychotherapy. The bulk of the film is a detailed psychotherapeutic conversation between Devereux and Picard.
That is where the real work for the viewer comes in. My speculation is that whether the viewer does stay engaged depends on their psychological mindedness or ability to stay interested in the narrative. That narrative that is built on Devereux's interpretations and clarifications and flashbacks that are designed to elaborate on what Picard is describing in the sessions. There are several indirect discussions and enactments of transference and countertransference in the film. In one very good scene Picard gets angry with Devereux and they discuss the importance of discussing the anger and associated events with the therapist. There were also many good examples of real situations and how they are handled well but at times imperfectly in therapy sessions. Scenes like this can lead experts to take issue with the way they are portrayed in the cinema. My usual standard for cinema is that it is well executed from a technical cinematic standpoint, that it is entertaining and that I like it as art. It certainly passes that standard. Since we are dealing with just fragments of therapy sessions, any errors are difficult to assess. I found myself thinking about taking too many notes early in the course of therapy as a possible example. Therapy was also portrayed as hard work that results in somewhat erratic progress. The necessary relationship for therapy and a working therapeutic alliance seemed to be emphasized in the film, but over the course of the film it seemed like Devereux became more distant. It may have been written that way to show the effect of termination and possibly supervision on the part of the analyst.
Devereux's personal life is also a focus in the movie. He is having an affair with a married lover Madeleine. Many critics see this a a diversion away from the main text of the film, but I saw it as more important than that. In many ways Madeleine is an idealized lover. She is bright, very attractive, likeable, and at times dotes on Georges. In my observation of Georges, he just does not seem to have a lot going for him. He seems to spend a lot of time on anthropological junkets, is somewhat of a nerd, does not seem emotionally resonant with Madeline, and seems fairly indifferent when it is time for her to leave. Madeline also has a statement and a soliloquy in the film that I saw as critical. One is an overview of how the brain is the central organ in the body and the role of psychoanalysis in psychosomatics. The other has to do with the impact that an idealized lover has on a person, why they do not need to be forgotten, and the ongoing impact on one's life. I think that she also provides contrast between the advice that the analyst gives his patient and how he runs his own life. That is an interesting thought in a movie that includes Karl Menninger. One of Menninger's theories is that there is not much difference between people with mental illness and people who don't have mental illness. Jimmy P. is a great illustration of that idea extended to include the fact that there is really no difference between Native Americans and the rest of us. People seeing this film can probably identify with many of the themes and conflicts that Jimmie P. had to deal with.
I had the usual associations to the film. I have treated many people with psychosomatic problems like Jimmy P. These days most of the work has to go in to the idea that there is not a pill for these problems, but that other strategies can be useful. It is very probable in modern times that the correct treatment of these serious psychosomatic symptoms gets buried under a long series of "medication trials." I could see Jimmy being diagnosed with Post Traumatic Stress Disorder, Panic Disorder, Major Depression, and possibly an alcohol use disorder. I can see all of that happening in one 20 minute session by a nonpsychiatrist. I could see him walking out of that first session with an SSRI, a benzodiazepine, and possibly prazosin - all medications high up on the PTSD algorithm. The issue of diagnosis came up in the last meeting between Picard and Devereux. After discussing the pneumoencephalogram results, Devereux asks whether Picard would like to know his diagnosis. He hands him a piece of paper with the diagnosis "Psychic Trauma".
That's my initial review. There are some addition reference materials I would like to look at including a suggested book and the actual script. A script with dialogue this intensive probably requires an additional read or two. There is a lot of information contained in the dialogue between Picard and Devereux. As far as I know there are no good models or methods for analyzing the information content in therapeutic sessions and how that information is used. I ended up rating the film 5 stars on Netflix. But keep in mind that rating is from a guy who has talked to people at least 6-7 hours per day for the past thirty years.
George Dawson, MD, DFAPA
Matt Zoller Seitz. Jimmy P. This is a good review by a professional reviewer who thought this was a good film and has opinions about it that contrast with mine.
Supplementary 1: Given my comments about psychotherapy and psychopharmacology it is easy to see how those issues can be politicized and how discussions about both of those modalities can be very polarized. The fact that a person with complex problems is more likely to see a psychopharmacologist first should not mean that they are not receiving psychotherapy informed treatment. One of the most striking examples that I can think of is a psychopharmacologist I worked with for many years. He started and ran a psychopharmacology specialty clinic. The people who saw him had a uniformly positive experience based on their relationship with him and what how he discussed problems with them. He was and is certainly an expert in psychopharmacology but he was providing a lot more than that.
I think we are past the time where there needs to be an open discussion and guidelines about psychotherapeutically informed psychopharmacology. That would include a focus on the relationship, a discussion about that fact that there are probably other things that need work in addition to the medication, and a discussion of the meaning of the diagnosis and meaningfulness in general in a persons life.
These ideas have obvious implications for the stilted billing and coding system and the idea that anybody can prescribe psychiatric medications. Expert prescribing requires knowing about what is going on in addition to the diagnostic criteria and algorithms and what else can be done.
Sunday, November 17, 2013
Neuron Perspectives in Neuroscience
Eric Kandel's thought, research, and writing have been a major source of inspiration to me ever since I read his neuroscience text and his classic article Psychotherapy and the Single Synapse in the New England Journal of Medicine nearly 34 years ago. I was very pleased to see that he wrote the lead article in Neuron's 25th Anniversary edition entitled "The New Science of the Mind and the Future of Knowledge." I read the article in the same spirit that I read the original NEJM article, guidance from a world class neuroscientist who was also trained as a psychiatrist. At that level the article is quite exciting because somewhere along the line Dr. Kandel has clearly been following concepts that are far removed from the synapse and does a good job of summarizing the major points and the current deficiencies. He also comes back to the idea that psychotherapy is a biological treatment as he proposed in the original 1979 article.
One of the most interesting aspects of the article is that Kandel does not apologize for psychoanalysis. He is also not excessively critical. I read an article about his residency class at Harvard and psychoanalysis was certainly prominent at the time. Although it is fashionable these days to throw Freud under the bus, he points out that Freud and subsequent analysts were right about a number of issues that neuroscience has caught up with including:
1. Unconscious mental processes pervade conscious thought.
2. The importance of unconscious thought in decision making and adaptability.
The probable link here is that Freud, psychoanalysis, and current neuroscience is focused on the mind rather than descriptive psychiatry. At some point the majority of the field got sidetracked on the issue of identifying a small number of pathological conditions by objective criteria. The mind was completely lost in that process and those few psychiatrists who were focused on it were engaged in generating theories. He criticizes the field for a lack of empiricism but recognizes that has changed with clinical trials of psychodynamic psychotherapy and recent interest in testing psychoanalytical theories with the available neuroscience. He also points out that Aaron Beck was a psychoanalyst when he developed cognitive behavior therapy focused on conscious thought processes and became a leading proponent for an evidence based therapy.
It was good to see a discussion of the hard problem of consciousness. I was on the ASSC listserv for many years until it eventually lost a home and was shut down. Many of the experts in consciousness studies posted on that thread but there was very little neuroscience involved but plenty of discussion of the neural correlates of consciousness.
Information flow through the brain has always been one of my interests. The idea that information flows through biological systems at both chemical and electrical levels is a relatively recent concept. At the clinical level behavioral neurologists like Mesulam and Damasio discussed it based on cortical organization and information flow primarily at cortical levels. I taught a course for many years that talked about the basic information flow through primary sensory cortex, association cortex and then heteromodal cortices. The model had good explanatory power for any number of syndromes that impacted on this organizational model. For example, achromatopsia made sense as a lesion in pure sensory cortex and posterior aphasia made sense as a lesion of heteromodal cortex.
Using this model, overall information flow from the sensory to the motor or output side could be conceptualized, but there were plenty of open boxes in the flowchart along the way. The theory of how consciousness is generated from neural substrates was still a problem. Social behavior was another. Despite decades of descriptive psychiatry, the diagnostic criteria for major psychiatric disorders still depended on symptoms. In many cases aberrant social behavior was a big problem and often a more accurate reflection of why patients were disabled, unable to work and had limited social networks. Even though there were scales to rate positive and negative symptoms in schizophrenia, aberrant social behavior cut across a number of major psychiatric disorders. In my first job as a community psychiatrist, we rated social behavior of the people in our community support program and it was a better predictor of disability than diagnosis or ratings of positive symptoms. The neuroscience of social behavior remained resistant to analysis beyond the work done on cortical lesions and obvious comparisons to those syndromes. But people with schizophrenia had no obvious frontal lesions.
Dr. Kandel points out the developments in these areas ranging from de novo point mutations affecting circuitry in the frontal cortex to mirror neurons to the neuroendocrinology and genetics of social behavior. The review of Thomas Insel's work with voles and the extension of that work by Bargmann in C. elegans highlights the importance of specific systems in social behavior and how these systems are preserved across species.
One of the most interesting areas outlined by Dr. Kandel was the issue of art and the neuroscience of its creation and perception. I have just posted on abstract art and was able to locate a quote from Kandinsky:
"The abstract painter derives his "stimulus" not from some part or other of nature, but from nature as a whole, from its multiplicity of manifestations which accumulate within him and led to the work of art. This synthetic basis seeks its most appropriate form of expression which is called "nonobjective". Abstract form is broader, freer, and richer in content than objective [form]." (Kandinsky Complete Writings on Art - p 789)
Kandel develops a narrative based on Viennese art historians and the importance of the aesthetic response to art. That response is an emotional one based on the life experience of the viewer and the neuroscience of that response can be studied. He looks at the inverse optics problem, facial recognition, and comes up with a flow diagram of the processes involved in viewing visual art. I did not realize it until I read this article but he has a new book on the subject and ordered a copy to review at a future date.
Some of the conclusory remarks about neuroscience and what it means to society are the most important. It is easy to be cynical about any scientific endeavor and it is also very easy to be political. Neuroscience has to endure (although to a much lesser degree) than what psychiatry endures. There are people out there commenting on neuroscience who don't seem to know much about it. In many cases they are not scientists. Even in the case of scientists, it is often easy to forget that the public will probably not hear the most objective and the most scientific. They will typically hear from the experts who unambiguously support one side of the scientific argument as opposed to the other. Kandel is cautious in his suggested applications of neuroscience to society. He does not view it as a panacea or an explanation for behavior necessarily. An example:
"Attributing love simply to extra blood flow in a particular part of the brain trivializes both love and the brain. But if we could understand the various aspects of love more fully by seeing how they are manifested in the brain and how they develop over time, then our scientific insights would enrich our understanding of both the brain and love."
Hopefully you will have time to read this paper. I have highlighted a few more based on my reading about neuroscience over the past 20 years or so. I will end with a paragraph on technical expertise.
When I was interviewing for residency positions 30 years ago, one of my questions that drew the strongest emotional reaction was: "Does your program have a reading list for residents?" That question on average elicited shock or at least irritation from the average residency director. The only exception was Johns Hopkins. They handed me a neatly bound list of several hundred references that they considered key references that every psychiatric trainee should read. I should have taken it as a sign and applied there, but my trajectory in life has been more random and circuitous than studied. If I was a current residency director, I would have a list with a neuroscience section and the following articles from this volume of Neuron would be on it. People often recoil when I talk about the technical expertise needed to be a psychiatrist. Technical seems like too harsh a word for most psychiatrists. Most of the media debate after all is essentially rhetorically based political discussions I would say that if you read these articles, you can consider them to be a starting point for what you might need to know about neuroscience and psychiatry in the 21st century.
George Dawson, MD, DFAPA
A reading list for psychiatrists of the future (all available free online at the above link):
One of the most interesting aspects of the article is that Kandel does not apologize for psychoanalysis. He is also not excessively critical. I read an article about his residency class at Harvard and psychoanalysis was certainly prominent at the time. Although it is fashionable these days to throw Freud under the bus, he points out that Freud and subsequent analysts were right about a number of issues that neuroscience has caught up with including:
1. Unconscious mental processes pervade conscious thought.
2. The importance of unconscious thought in decision making and adaptability.
The probable link here is that Freud, psychoanalysis, and current neuroscience is focused on the mind rather than descriptive psychiatry. At some point the majority of the field got sidetracked on the issue of identifying a small number of pathological conditions by objective criteria. The mind was completely lost in that process and those few psychiatrists who were focused on it were engaged in generating theories. He criticizes the field for a lack of empiricism but recognizes that has changed with clinical trials of psychodynamic psychotherapy and recent interest in testing psychoanalytical theories with the available neuroscience. He also points out that Aaron Beck was a psychoanalyst when he developed cognitive behavior therapy focused on conscious thought processes and became a leading proponent for an evidence based therapy.
It was good to see a discussion of the hard problem of consciousness. I was on the ASSC listserv for many years until it eventually lost a home and was shut down. Many of the experts in consciousness studies posted on that thread but there was very little neuroscience involved but plenty of discussion of the neural correlates of consciousness.
Information flow through the brain has always been one of my interests. The idea that information flows through biological systems at both chemical and electrical levels is a relatively recent concept. At the clinical level behavioral neurologists like Mesulam and Damasio discussed it based on cortical organization and information flow primarily at cortical levels. I taught a course for many years that talked about the basic information flow through primary sensory cortex, association cortex and then heteromodal cortices. The model had good explanatory power for any number of syndromes that impacted on this organizational model. For example, achromatopsia made sense as a lesion in pure sensory cortex and posterior aphasia made sense as a lesion of heteromodal cortex.
Using this model, overall information flow from the sensory to the motor or output side could be conceptualized, but there were plenty of open boxes in the flowchart along the way. The theory of how consciousness is generated from neural substrates was still a problem. Social behavior was another. Despite decades of descriptive psychiatry, the diagnostic criteria for major psychiatric disorders still depended on symptoms. In many cases aberrant social behavior was a big problem and often a more accurate reflection of why patients were disabled, unable to work and had limited social networks. Even though there were scales to rate positive and negative symptoms in schizophrenia, aberrant social behavior cut across a number of major psychiatric disorders. In my first job as a community psychiatrist, we rated social behavior of the people in our community support program and it was a better predictor of disability than diagnosis or ratings of positive symptoms. The neuroscience of social behavior remained resistant to analysis beyond the work done on cortical lesions and obvious comparisons to those syndromes. But people with schizophrenia had no obvious frontal lesions.
Dr. Kandel points out the developments in these areas ranging from de novo point mutations affecting circuitry in the frontal cortex to mirror neurons to the neuroendocrinology and genetics of social behavior. The review of Thomas Insel's work with voles and the extension of that work by Bargmann in C. elegans highlights the importance of specific systems in social behavior and how these systems are preserved across species.
One of the most interesting areas outlined by Dr. Kandel was the issue of art and the neuroscience of its creation and perception. I have just posted on abstract art and was able to locate a quote from Kandinsky:
"The abstract painter derives his "stimulus" not from some part or other of nature, but from nature as a whole, from its multiplicity of manifestations which accumulate within him and led to the work of art. This synthetic basis seeks its most appropriate form of expression which is called "nonobjective". Abstract form is broader, freer, and richer in content than objective [form]." (Kandinsky Complete Writings on Art - p 789)
Kandel develops a narrative based on Viennese art historians and the importance of the aesthetic response to art. That response is an emotional one based on the life experience of the viewer and the neuroscience of that response can be studied. He looks at the inverse optics problem, facial recognition, and comes up with a flow diagram of the processes involved in viewing visual art. I did not realize it until I read this article but he has a new book on the subject and ordered a copy to review at a future date.
Some of the conclusory remarks about neuroscience and what it means to society are the most important. It is easy to be cynical about any scientific endeavor and it is also very easy to be political. Neuroscience has to endure (although to a much lesser degree) than what psychiatry endures. There are people out there commenting on neuroscience who don't seem to know much about it. In many cases they are not scientists. Even in the case of scientists, it is often easy to forget that the public will probably not hear the most objective and the most scientific. They will typically hear from the experts who unambiguously support one side of the scientific argument as opposed to the other. Kandel is cautious in his suggested applications of neuroscience to society. He does not view it as a panacea or an explanation for behavior necessarily. An example:
"Attributing love simply to extra blood flow in a particular part of the brain trivializes both love and the brain. But if we could understand the various aspects of love more fully by seeing how they are manifested in the brain and how they develop over time, then our scientific insights would enrich our understanding of both the brain and love."
Hopefully you will have time to read this paper. I have highlighted a few more based on my reading about neuroscience over the past 20 years or so. I will end with a paragraph on technical expertise.
When I was interviewing for residency positions 30 years ago, one of my questions that drew the strongest emotional reaction was: "Does your program have a reading list for residents?" That question on average elicited shock or at least irritation from the average residency director. The only exception was Johns Hopkins. They handed me a neatly bound list of several hundred references that they considered key references that every psychiatric trainee should read. I should have taken it as a sign and applied there, but my trajectory in life has been more random and circuitous than studied. If I was a current residency director, I would have a list with a neuroscience section and the following articles from this volume of Neuron would be on it. People often recoil when I talk about the technical expertise needed to be a psychiatrist. Technical seems like too harsh a word for most psychiatrists. Most of the media debate after all is essentially rhetorically based political discussions I would say that if you read these articles, you can consider them to be a starting point for what you might need to know about neuroscience and psychiatry in the 21st century.
George Dawson, MD, DFAPA
A reading list for psychiatrists of the future (all available free online at the above link):
Kandel, Eric (2013) The New
Science of Mind and the Future of Knowledge.
Neuron 80: 546 – 560
McCarroll Steven A, Hyman Steven E (2013) Progress in
the Genetics of Polygenic Brain Disorders: Significant New Challenges for Neurobiology.
Neuron 80:578-587.
Südhof Thomas C (2013) Neurotransmitter Release: The Last
Millisecond in the Life of a Synaptic Vesicle. Neuron 80:675-690.
Huganir Richard L, Nicoll Roger A (2013) AMPARs and
Synaptic Plasticity: The Last 25 Years. Neuron 80:704-717.
Dudai Y, Morris Richard GM (2013) Memorable Trends. Neuron
80:742-750.
Shadlen Michael N, Kiani R (2013) Decision Making as a Window
on Cognition. Neuron 80:791-806
Buckner Randy L (2013) The Cerebellum and Cognitive Function:
25 Years of Insight from Anatomy and Neuroimaging. Neuron 80:807-815.
Saturday, September 7, 2013
Psychiatry - Science and Pseudoscience
I finished the first chapter in Philosophy of Pseudoscience: Reconsidering the Demarcation Problem by Pigliucci and Boudry. I became aware of Massimo Pigliucci and his work back in 2002 when I read his book on Intelligent Design and since then have discovered his blog Rationally Speaking where he has recently posted his best papers from his careers as a scientist and a philosopher. He writes very clearly on the philosophy of science and has such a command of the field that he can include a history lesson of relevant references. He also does not shy away from controversy or the apparent lack of a clean solution to a problem. One of the central concepts in his chapter is this chart of empirical knowledge versus theoretical understanding. (click to enlarge)
The purpose of this essay is to look at possible boundaries between science and pseudoscience as well as a couple of interesting observations as they apply to psychiatry. One of his key concepts is that the lines of demarcation are not necessarily sharp and the variables are not necessarily linear. He uses the above graph of empirical knowledge versus theoretical understanding as an example. Starting in the upper right corner of the diagram we have hard sciences with particle physics given as the most clear cut hard science. I like to think about my undergraduate chemistry experience as being hard science. Even introductory chemistry exposes the student to an amazing array of facts, observations, and theories that are incredibly accurate. From there, chemistry majors build on their ability to measure specific compounds, synthesize them and study the theory in Physical Chemistry. I don't think that there is any doubt that chemistry as a field is not too far removed from particle physics in terms of empirical knowledge or theoretical understanding. String physics has much theory but is low in terms of empirical support. He refers to evolutionary psychology, scientific history and Search for Extraterrestrial Intelligence (SETI) as a "proto-quasi science" cluster with decreased amounts of theory and empirical support. Other fields like the so-called "soft sciences" of sociology, economics, and psychology have a fair amount of empirical knowledge but less theoretical understanding. The true pseudosciences are in the zone with astrology, HIV denialism, and Intelligent Design. From the history of psychiatry - Freudian psychoanalysis and Adlerian psychology would also be included here but there is also a list of theories from general medicine and surgery that would also qualify.
In psychology and psychiatry a central philosophical problem is the so-called hard problem or the explanatory gap between the neurobiology of conscious states and subjective experience. This is exactly where psychiatry resides. A lot of political criticism of psychiatry involves the ability to parse these states and accurately classify different conscious states. Resolving the hard problem would move psychiatry and psychology firmly to the right in the demarcation diagram but probably not nearly as far as particle physics or maybe not even as far as molecular biology.
The relevant question for me of course is where psychiatry fits on the plane of empirical knowledge x theoretical understanding. What about medicine in general? Could we plot a plane of medical and surgical sub specialties on this plane instead of the hard and soft sciences? Does medicine and surgery have theories or practices end up in the same zone as Freudian psychoanalysis. Of course they do. A great example from my days as a medicine intern was highlighted by Ghaemi as "The cult of the Swan-Ganz catheter." In the places where I trained, anyone with moderately serious cardiopulmonary problems was at risk for placement of a Swan-Ganz catheter. The actual person inserting the catheter could be a medicine resident, a cardiologist, or an anesthesiologist. Since the intern is responsible for doing the initial history and physical exam, I witnessed the placement of a large number of these catheters. Once placed they gave an impressive number of parameters on ICU monitors. We were routinely grilled about the meaning of these parameters by attending physicians on rounds. It all seemed very scientific. The cult of the Swan-Ganz catheter was subsequently disproved by randomized clinical trials. This standard of care from the 1980s and 1990s disappeared much faster than Freud.
The best way to plot medicine and psychiatry on Pigliucci's empirical knowledge versus theoretical understanding plane would be to consider the clinical basic sciences taught in the first two years of medical school. In my experience that was anatomy, neuroanatomy, histology, microbiology, biochemistry/molecular biology, genetics, pathology, physiology, pharmacology, epidemiology, and statistics. Practically all clinical specialties carry these basic sciences forward in one form or another. The research literature in any particular specialty in full of theory and techniques from these basic sciences. The psychiatric literature cuts across all of the basic sciences in the same way as other specialties. At the minimum, some of psychiatry will be at the level of molecular biology on the diagram in some areas and at the level of psychology in others. Hopefully the unscientific theories will be relegated to the lower left hand corner of the diagram as unscientific and not stand the test of time.
I think that Professor Pigliucci's conceptualization is a very useful one. I expect that he will continue to refine these ideas. I think that measurement precision and categorization may be important dimensions to add to these concepts. As Merskey has pointed out both the phone book and the periodic table are much more accurate forms of categorization than any scheme of medical classification. I think that probably says a lot about the underlying scientific dimensions and how measurement is done.
George Dawson, MD, DFAPA
Ghaemi SN. A Clinician's Guide to Statistics and Epidemiology in Mental Health. (2009) Cambridge University Press, Cambridge, UK. p. 91.
The purpose of this essay is to look at possible boundaries between science and pseudoscience as well as a couple of interesting observations as they apply to psychiatry. One of his key concepts is that the lines of demarcation are not necessarily sharp and the variables are not necessarily linear. He uses the above graph of empirical knowledge versus theoretical understanding as an example. Starting in the upper right corner of the diagram we have hard sciences with particle physics given as the most clear cut hard science. I like to think about my undergraduate chemistry experience as being hard science. Even introductory chemistry exposes the student to an amazing array of facts, observations, and theories that are incredibly accurate. From there, chemistry majors build on their ability to measure specific compounds, synthesize them and study the theory in Physical Chemistry. I don't think that there is any doubt that chemistry as a field is not too far removed from particle physics in terms of empirical knowledge or theoretical understanding. String physics has much theory but is low in terms of empirical support. He refers to evolutionary psychology, scientific history and Search for Extraterrestrial Intelligence (SETI) as a "proto-quasi science" cluster with decreased amounts of theory and empirical support. Other fields like the so-called "soft sciences" of sociology, economics, and psychology have a fair amount of empirical knowledge but less theoretical understanding. The true pseudosciences are in the zone with astrology, HIV denialism, and Intelligent Design. From the history of psychiatry - Freudian psychoanalysis and Adlerian psychology would also be included here but there is also a list of theories from general medicine and surgery that would also qualify.
In psychology and psychiatry a central philosophical problem is the so-called hard problem or the explanatory gap between the neurobiology of conscious states and subjective experience. This is exactly where psychiatry resides. A lot of political criticism of psychiatry involves the ability to parse these states and accurately classify different conscious states. Resolving the hard problem would move psychiatry and psychology firmly to the right in the demarcation diagram but probably not nearly as far as particle physics or maybe not even as far as molecular biology.
The relevant question for me of course is where psychiatry fits on the plane of empirical knowledge x theoretical understanding. What about medicine in general? Could we plot a plane of medical and surgical sub specialties on this plane instead of the hard and soft sciences? Does medicine and surgery have theories or practices end up in the same zone as Freudian psychoanalysis. Of course they do. A great example from my days as a medicine intern was highlighted by Ghaemi as "The cult of the Swan-Ganz catheter." In the places where I trained, anyone with moderately serious cardiopulmonary problems was at risk for placement of a Swan-Ganz catheter. The actual person inserting the catheter could be a medicine resident, a cardiologist, or an anesthesiologist. Since the intern is responsible for doing the initial history and physical exam, I witnessed the placement of a large number of these catheters. Once placed they gave an impressive number of parameters on ICU monitors. We were routinely grilled about the meaning of these parameters by attending physicians on rounds. It all seemed very scientific. The cult of the Swan-Ganz catheter was subsequently disproved by randomized clinical trials. This standard of care from the 1980s and 1990s disappeared much faster than Freud.
The best way to plot medicine and psychiatry on Pigliucci's empirical knowledge versus theoretical understanding plane would be to consider the clinical basic sciences taught in the first two years of medical school. In my experience that was anatomy, neuroanatomy, histology, microbiology, biochemistry/molecular biology, genetics, pathology, physiology, pharmacology, epidemiology, and statistics. Practically all clinical specialties carry these basic sciences forward in one form or another. The research literature in any particular specialty in full of theory and techniques from these basic sciences. The psychiatric literature cuts across all of the basic sciences in the same way as other specialties. At the minimum, some of psychiatry will be at the level of molecular biology on the diagram in some areas and at the level of psychology in others. Hopefully the unscientific theories will be relegated to the lower left hand corner of the diagram as unscientific and not stand the test of time.
I think that Professor Pigliucci's conceptualization is a very useful one. I expect that he will continue to refine these ideas. I think that measurement precision and categorization may be important dimensions to add to these concepts. As Merskey has pointed out both the phone book and the periodic table are much more accurate forms of categorization than any scheme of medical classification. I think that probably says a lot about the underlying scientific dimensions and how measurement is done.
George Dawson, MD, DFAPA
Ghaemi SN. A Clinician's Guide to Statistics and Epidemiology in Mental Health. (2009) Cambridge University Press, Cambridge, UK. p. 91.
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