The Insurrection

This has been an historic week in the United States. On January 6, 2021, President Donald Trump and several of his supporters incited a large group to attack and invade the Capitol Building as Congress was in the process of certifying the electoral college vote – the last official but routine step for Joe Biden to become the duly elected President of the United States.  During the riot, Capitol police were assaulted and one of them was killed. A rioter was shot and killed.  Three people died of medical emergencies due to poor access at the scene. There were scores of people injured, many serious.

Police and the National Guard eventually regained control and Congress was able to reconvene and certify the electoral college vote.  The challenges to the votes in several states were overwhelmingly rejected.  The President had also suggested that the Vice President Mike Pence could decide to not accept the votes and nullify the election, but the Vice President was very explicit about his Constitutional duties and knew that was outside of his scope of power. He kept the process going and brought it to appropriate closure declaring that Biden-Harris were the winners.

The aftermath of this event has produced a little certainty but not much.  As I write this late on a Saturday night, all that we know for sure is that Joe Biden is the certified winner of the election and that he will be inaugurated on January 20^th.  President Trump’s supporters from the recertification debacle are in disarray.  Press reports quote them as lashing out at the expected fall out from their efforts and the insurrection at the Capitol. At least one has lost a book deal and in other cases constituents are calling for their resignation.  Since the official vote was preceded by the insurrection and violence, some of the people who were expected to object to the certifications from specific states did not. Other Republicans were outspoken against the process from the outset since it was clear that the President had repeatedly lied about the election being stolen and there was no factual basis for any objections. Republicans adopting those positions were subjected to derision and threats from Republicans who supported Trump.

On the night of the insurrection, there were rumors that Trump’s cabinet may be considering invoking the 25^th Amendment and removing the President from power based on his incapacity to do the job. Inciting an insurrection against the government and Constitution that he was sworn to uphold would seem like a sure way to get anyone fired.  The other logical question is, if a person can make such a drastic error in judgment – does it imply that they will continue to make further drastic errors?  In other words is their judgment compromised even beyond the crisis they have created?  I am not talking about a diagnosis of mental illness. I am an adherent of the Goldwater Rule and don’t believe that psychiatrists should speculate about the mental health of a public figure without doing a thorough personal assessment and then disclosing the result of that assessment only with the consent of that individual.

That does not mean that professional organizations should abdicate their roles in advocating for science, social justice and correcting disparities related issues, and most of all advocating for a practice environment that allows physicians to provide high quality health care to our patients who need it the most. Health care professional organizations have not done a very good job on these issues largely because they have been completely ineffective against the business takeover of health care. 

With the recent events the American Psychiatric Association came out with a statement on January 7, 2021 entitled: APA Statement on Yesterday’s Violence in Washington.  It seemed to be overly reactive to me and it carried the usual generic conclusions – if you are having problems see someone. It would have more authority if there had been statements at every stage of the President’s escalating rhetoric.  Where was the APA for example when the President attacked science, the CDC and its scientists, and Dr. Fauci?  Where was the APA when the President attacked Black Lives Matter and showed support for white supremacists? Where was the APA when the President trivialized the COVID-19 epidemic, politicized the treatment and endangered lives, and spread misinformation about the origins of the virus and how it spreads. There is no authority when you sweep in at the very end when conditions are dire and seek to correct what you did not comment on in the previous 10 months. Real time commentary on political action that is detrimental to the social fabric of the country is necessary from professional organizations, especially one whose members assess the impact of that social fabric on every patient they see.

But there is more blame to go around – especially when it comes to social media companies.  Facebook, Twitter, and Google all seem to be very confused about how they are used for propaganda purposes. Misinformation is a euphemism for propaganda these days and there has never been a more powerful amplifier of propaganda than American social media. To be clear, propaganda is an intentional lie that is repeated over and over again until a certain segment believes it to be true and starts to react emotionally to it. This behavior was clearly visible from people at the Trump rally and people who invaded the Capitol building. People clearly agitated about the election being “stolen”, socialists taking over, the country turning to socialism, personal freedoms being impinged upon.  Image after image of people in the media who were obvious Trump supporters who were agitated about what are essentially non-issues. The clearest non-issue was the election being stolen.  Trump himself keeps repeating this despite the clear facts that the elections are much more well run that when Al Gore was defeated by hanging cardboard chads in the 2000 election that was decided by a Supreme Court decision and a 271 to 267 electoral college vote. In fact, the score card about election fraud shows that there is a complete lack of evidence of significant “fraud” or stolen elections.  The major social media players finally came around and banned Trump and his accounts, but even as I type this he is vowing to get more media access and continue his divisive propaganda campaign.

In the big picture, the Trump propaganda is much more than a curiosity at this point.  In addition to the insurrection at the Capitol, Trump followers have threatened violence against the families of both Democrat and Republican elected officials largely as a way to support Trump.  These coercive tactics have no place in a functional democracy and at the individual level should be considered terroristic threats by local police. The insurrection has provided a blueprint for both foreign and domestic enemies of the United States who seek to disrupt the functions of our government and the security of our citizens. The disruptive effect that the Trump administration has had on our military, intelligence community, allies and leadership role in the world adds greatly to the insecurity of the republic. President Trump and his administration should be considered a case study of incompetent leadership and suggest pathways to competency that future leaders should be assessed by.

I started to write this with some suggestions about what needs to happen over the next 10 days to get the country back on track and correct some of the current glaring deficits:

1:  President Trump: the people on the ground specifically his Cabinet and leaders in Congress need to make an assessment acutely about whether he lacks the current capacity to function in his role as President. The insurrection is strong evidence.  His lack of commentary of a major Russian government hack that has been occurring for months (the extent of which is not currently known) is another.  There is speculation that some of his cabinet members are contemplating this but there have been resignations and temporary appointments.  There is a question about how fragmented the Cabinet is and whether that would hinder the process.  Members of Congress are apparently considering impeachment, but that is a long process.  There are platitudes about how impeachment would not “heal the divisiveness” that are more than a little ironic considering the people making these statements. I have heard that two impeachments of any President rules out any future candidacy and if that is true – it is a very good reason for proceeding with impeachment.

There are still some mental health professionals out there who think a psychiatric emergency is a better response. I routinely did psychiatric emergencies for 22 years and I can say without a doubt that there is no court judge that I know of who would detain President Trump on an emergency basis for hearing or schedule a hearing for guardianship or conservatorship on the basis of a mental illness. Media reports are full armchair diagnoses of narcissistic personality disorder or malignant narcissism (not an actual diagnosis) and even if these diagnoses were accurate – they are not diagnoses that result in court action.  Those diagnoses are typically statutorily defined severe mental illness.  The legal criteria in the 25th Amendment is much clearer: unable to discharge the powers and duties of his office. The only problem is that it is interpreted by lawyers and politicians and not everyone will agree with that interpretation.

Another feature of the legal versus psychiatric intervention is that the decisions can be made right now, by people who have been working with the President in some cases for 4 years.  That constitutes a larger amount of information and a much shorter timeline for action than is possible in any psychiatric scenario. 

2:  The security issue:  The Capitol and any place there are elected officials doing the work of the US Government needs to be very secure. That means there needs to be an adequate force and clear rules of engagement.  Right now there are people threatening the inauguration process and there must be very thorough plans to prevent that from happening.  The FBI is apparently trying to identify as many people as possible from the original insurrection and the message is out there that they will be prosecuted.

The larger security issue is starting to counteract the propaganda about stolen elections, fake pandemics, fake news, and freedom being under attack. I am confident that clearer messaging from the White House and members of Congress will be useful as well as integration back into the international community.

3:  The potential for Civil War:  Not my idea.  About 3-4 months ago I was contacted by people who knew that I was a bit of a survivalist.  Their concerns ranged from civil unrest disrupting the food and power supply as well as access to medical treatment to outright armed conflict between warring factions  Their specific questions were about what they should acquire now to protect themselves and their family if the Trump induced negative reverberations through society continue and worsen.  I am not a historian and wonder if an attempted coup by an autocrat who refuses to accept or even acknowledge 200 years of democracy qualifies as a civil war?  The autocracies in my lifetime including Hitler, Stalin, Mussolini, Pol Pot and many others extending right up to modern times do not seem to be the products of civil war.  Many occurred as the result of internal political turmoil often fomented by propaganda.  Many of these propaganda techniques were codified by the Nazis such as the Big Lie propaganda technique.  

The transition from ordered to disordered society is never clear. No American anticipated the rise of a disruptive autocrat and the impact that he could have on ordinary citizens.  In many ways it reminds me of Robert J. Lifton's interviews in The Nazi Doctors and how the transition to state sanctioned medical killing occurred during the Holocaust.  On page 13 he quotes a French speaking eastern European physician on whether what happened can be understood from a psychology viewpoint:

"The professor would like to understand what is not understandable. We ourselves who were there, and who have always asked ourselves the question and will ask it to the end of our lives , we will never understand it because it cannot be understood."    

I think there may be some insights from the anthropology of warfare.  Keeley gathered anthropological evidence of ancient conflicts between tribes, towns, and eventually cities.  He concluded that there were no peaceful primitive people. The settlement of disputes between neighboring tribes or city states have always been violent with a significant toll on the losing population.  That theme is obviously extended to current times where there is an uneasy peace based on nuclear deterrence but a quarter million people lose their lives each year due to small arms fire.  Peace does not seem to be the interest of many nations even though there are clear cut advantages.  The human propensity for violent dispute resolution is not reassuring in a heavily armed nation and an angry faction who show up on government property holding assault rifles.  Interestingly one of the features of society that Keeley considered protective against war was an active trading and economic relationship with rivals.  That is another area where President Trump has not done well. 

4:  The propaganda at the individual level:  Many people ask me why so many people buy into obvious propaganda like the stolen election lie.  It turns out this recipe for influencing large groups of people politically has been around for decades.  The general message is to keep repeating the lie and at some point people start to emotionally react to it and that reinforces it.  From a neuroscience perspective there have been some imaging studies that claim to be able to detect Democrats from Republicans but I question those results.  Some suggest the problem is a lack of critical thinking, but I know a lot of professionals who have accepted Trump’s stolen election lie as a fact and their critical reasoning capabilities in all other areas seem to be intact.  One of my colleagues proposed an evolutionary social theory that seems to have some plausibility – as humans we are socialized to follow charismatic leaders whether they are right or wrong.  There seems to be a lot of historical data to back that up.

I would suggest a complementary hypothesis and that is the emotional inputs for day-today decision making.  Some time ago on this blog I discussed some of the groundbreaking work of Antoine Bechara, MD, PhD and his work on why emotional input is critical for human decision making. He demonstrated that without it – subjects with normal intelligence is unable to function.  We also know that an excess of emotion can adversely affect decision making and lead to errors both acutely and on an ongoing basis.

Propaganda has both a cognitive component (the lie) and a strong associated emotional component.  Supporters of the stolen election lie are clearly angry about getting a raw deal, about their rights being impinged up, about needing to take the law into their own hands, about someone treating them (or their candidate) unfairly, the list is quite lengthy but the emotion is always anger.

I don’t claim to know how to reverse that process.  I did take a course in how to deprogram cult members at one point and the main intervention was to get them away from the people influencing them.  Removing the continuous inaccurate social media messaging may be useful in that regard. An improvement in the general tone of the media may also be helpful.  Since the insurrection, the mainstream media seems a lot more willing to make determinations of what is accurate and what is a lie.  One lesson appears to be that even if the propaganda lie is labeled as misinformation that is probably not enough.  It will still be altered in a positive way and propagated for propaganda use.  Propaganda needs to be eliminated when there is obvious overwhelming evidence against it.

There also have to be organizations that are willing to step up and make a stand for accuracy to correct political misinformation.  Both Science and Nature the major general scientific publications have been doing that on an increasing basis.

And finally, there is the appeal to the individual. In some of my earlier writing on this blog about firearm violence I suggested that people self-monitor for violent or aggressive thinking and seek out help if they noticed this. My thoughts related this insurrection are no different.  Nobody should be thinking that American elections are rigged or that they need to take the country back from someone.  We all know how this democracy works and it has been working well for 200+ years.  It works well because of the concept of peaceful transfer of power and the associated traditions. In other words, it is about what is good for the country and its people and not an individual official.  The President is the President for all of the people and not half of the people and he or she serves at the will of the majority.

Let that sink in……

 

 George Dawson, MD, DFAPA

Supplementary 1:  A poster on Twitter pointed out the rationale for the suspension of Trump's account.  The rationale is listed in this blog post.  Pay particular attention to the last 5 bullet points, especially bullet point 5:

"Plans for future armed protests have already begun proliferating on and off-Twitter, including a proposed secondary attack on the US Capitol and state capitol buildings on January 17, 2021."

I am hoping that there will be more than a few hundred National Guard troops present at the Inauguration and that Governors take these threats seriously, especially in states where gun advocates have succeeded in getting laws passed to carry firearms on state government property. I would suggest going as far as a temporary order to suspend firearms in proximity to the state capitols in addition to an adequate show of force to deter further antigovernment activity. 

Supplementary 2:  For anyone confused about what happened at the Capitol building it comes down to this:

References:

1:  Lawrence H. Keeley.  War Before Civilization. Oxford University Press, New York 1996.

2:  Robert Jay Lifton.  The Nazi Doctors. Basic Books, New York 1986: p 13.

Image Credit:  This is an image from the Capitol Building on Jan 6, 2021 from Shutterstock per their standard agreement.

Layered Psychiatry

 

I had this idea about how to present the complexity of the psychiatric diagnostic and treatment process.  After putting up a couple of diagrams for comment, I went ahead with a PowerPoint. For about 15 years I taught a course in how not to mistake a medical diagnosis for a psychiatric diagnosis.  My audience at the time was 3rd and 4th year medical students.  The lecture included a discussion of the research at the time in pattern matching and pattern completion, heuristics and common biases, Bayesian considerations, and inductive reasoning. It was generally well received but really cannot be appreciated until you are a senior clinician.  Over the time since I taught that course there also seems to be a distinct bias toward considering DSM criteria to be the basis for psychiatric diagnosis and decision making – and that is clearly a mistake.

The very first time I really became aware of the importance of pattern matching occurred when I was a fourth-year medical student.  I was on an Infectious Disease rotation and my job was to get the consults for the day, go out and see the patients we would be rounding on, do my basic compulsive medical student work up and present the findings and my ideas about the case to the attending physicians. ID docs are very bright people and like most impressive rotations I contemplated becoming an ID specialist for a while.  My patient that day had spontaneous bacterial peritonitis and the question for us was: “Do you agree with the diagnosis and current antibiotic treatment?”  I met with the patient, took a complete history, did a physical exam, reviewed the hospital course and labs, and had time for a little research. At the time I was carrying a copy of Phantom Notes for Medicine – basically an outline of the major medicine text of the day. I looked up the differential diagnosis.  I was also carrying a copy of Sanford’s guide to antibacterial therapy – the 1982 version and looked up the recommended antibiotics for peritonitis.  I was all set for rounds at that point.

Both of our ID attendings were very serious physicians. There was not a lot of banter or joking.  I anticipated presenting all of the dry facts and either getting a brief agreement, some questioning until I could no longer answer, or a long discussion of the diagnosis and treatment.  In this case the attending came into the patient’s room. He was 15 feet away from the patient and he said: “What am I seeing from right here that is a potential problem?”  Our team consisting of the ID fellow, two Internal Medicine residents, and myself – stopped in our tracks.  Nobody had an answer.  Weren’t we here for peritonitis?  How can you diagnose that from across the room?

“What is wrong with the patient’s shin?” Dr. R stated looking as serious as usual.  Sure enough there was a light pink confluent rash covering about 10 square inches of the patient’s left shin area. Dr. R happened to be an expert in streptococcal infections. He rattled off the type of strep he expected and suggested that we get a culture and send it to his lab for confirmation. I completed my presentation.  The primary diagnosis and treatment by the medicine team did not change, but now there was a new diagnosis and treatment that depended on Dr. R’s ability to recognize the pattern of this rash and make a rapid diagnosis – even though he was not expecting it.  But beyond that – we all saw the rash (although we had to be prompted to see it). Dr. R not only saw it, he processed it as a unique rash, and then a rash most likely caused by a specific kind of streptococcal bacteria. And over the next several days he was proven correct by the culture result.

Pattern matching and pattern completion are critical skills acquired by clinicians over the course of their training and careers that allows for not only more rapid diagnosis and treatment but also more accuracy in classifying ambiguous cases. Some of the examples I used in my course included ophthalmologists compared with primary care physicians diagnosing diabetic retinopathy and dermatologists compared with primary care physicians across a series of rashes.  In both cases the specialists had a higher degree of accuracy and were better at diagnosing ambiguous cases.

Cognitive neuroscience encompasses a broad range of perceptual studies starting with the early studies of visual processing by Hubel and Wiesel to more recent studies that look at the encoding that occurs in perceptual systems and what level of processing occurs at the level of primary sensory and association cortices, what the higher-level cortical structures may be, and whether or not top down processing influences perception. According to Superior Pattern Processing (SPP) theory (3), both perceived and mentally constructed patterns are processed by encoding and integration and at that point can be used for decision making or transferring approximations to other individuals.  In my example, Dr. R not only sees the pattern of the rash, but it is integrated into a feature set that has a time, visuospatial, social, and emotional context that makes it more likely that he will make a correct diagnosis. Experimental data suggests that he is not seeing the rash like any other person in the room – largely as a function of top-down control of his perceptual process.  The actual transfer of this pattern to his junior colleagues is limited because they see the rash as being a universal truth – that is they just “missed it” and therefore need to memorize what this rash looks like and not let it happen again.  They are also unaware of the processes involved in pattern matching or processing or they might have asked him about it.  For example, a logical question would have been: “What features of this rash do you notice that are suggestive of strep or a specific kind of strep?”

The question of what represents a pattern is critical to the idea of pattern recognition and processing.  There is a natural tendency to associate the term with visual or auditory stimuli, but without too much imagining patterns can clearly exist in any sensory modality and often involves the integration of multiple sensory inputs.  Cortical organization generally reflects primary sensory input to the cortex with adjacent sensory association areas and further information flow to heteromodal areas in the frontal and temporal cortex where additional integration occurs. Patterns can be sensed, encoded, recognized encoded and processed across theses systems.  The resulting integration yields a very complex array of patterns that are not intuitive.  For example, Mattson suggests that pattern processing in the human brain forms the basis of human intellect including problem solving, language and abstract thought and that it includes fabricated patterns.  Those fabricated patterns allow vicarious problems solving without having to conduct real world experiments.  The recent cognitive neuroscience of pattern processing is a significant advance compared with the old diagnostic paradigms I taught 20 years ago.  Those old experiments were basically a comparison of a non-expert to an expert diagnostician focused on a relatively basic clinical problem like a pathology slide, x-ray, ECG, or physical finding and the results were not a surprise – the experts typically prevailed in both accuracy and speed.  The sheer amount of information in a clinical encounter looks at what is essentially an infinite array of patterns, including patterns that are generally not even mentioned as being clinically relevant.

In considering what kind of patterns that need to be recognized and processed by a psychiatrist – the patterns that exist in clinical practice are a starting point.  These patterns and the associated phenomenology have been grossly oversimplified by an overemphasis on nosology. I talk with far too many people who see psychiatric diagnoses as phrases on a page in the DSM. I cringe when I hear: “The patient does or does not meet criteria for (DSM diagnosis x)”.  Kendler was correct when he referred to the DSM approach as an indexing system.  It gets people into the same ballpark, but it is not be very useful for predicting response to treatment or that specific person’s response to being ill.  It is also based on a fraction of the information collected in a psychiatric evaluation. When I consider the feature sets that psychiatrists are considering in evaluations it may look something the graphic below.  Of course, these features sets are simplified for the purpose of making a useful graphic. They will vary with the individual, their experience, social context, and culture. They will also be blended across space and have their own individual levels of integration and patterning.  Let me provide a couple of examples to illustrate these points.

Consider the above diagram as representing the possible features that must be recognized in order to assess a patient presenting to a psychiatrist and formulating and optimal diagnostic and treatment plan. My overriding concern in the first few minutes of the evaluation is whether this person really has a psychiatric disorder or a misdiagnosed medical problem and as a corollary - are they medically stable? That sounds like a basic consideration but prioritizing it is not listed anywhere in the DSM or any medical text that I know about. It does involve rapid recognition of patterns of acute medical illness particularly the most likely patterns to be misdiagnosed as psychiatric disorders and what I am seeing in real time.  It also involves pattern recognition of the thousands of psychiatric presentations that I have see that were really medical disorders.  Real life examples have included an almost immediate recognition that the patient had a stroke (many cases), seizures (many cases), meningitis, encephalitis, cerebral edema, serotonin syndrome, and neuroleptic malignant syndrome.  These rapid diagnoses were all predicated on experience-based pattern recognition rather than written criteria and these diagnoses had nothing to do with the DSM at the time.

A more cross-cutting feature in the diagram would be transference issues and defenses that can arise as soon as the initial evaluation or be indirectly evident by the patients historical description of their relationships with important people in their life.  These patterns will involve several layers in the above diagram and most importantly may suggest a psychotherapeutic intervention that can be implemented as early as the original assessment.  A similar process occurs if the patient is describing features of a major medication responsive illness.  In that situation, features from multiple layers result in a pattern that may be recognizable to the psychiatrist in terms of specific medical treatments or the urgency of those treatments.

And finally - what might the graphical representations of these pattern matching processes be?  Here are a few examples.  In the case of psychotherapeutic examples, it will depend on the exposure to specific therapies in training and practice. Each therapy has a specific pattern or series of patterns that the therapy depends up as well as patterns more specific to the conduct of therapy.  These graphics contain critical books from my library shelves with those elements.  In the case of the diagnostic and treatment process - the school of therapy and potential application are important patterns to recognize in the initial assessment.

All of these books contain symbolic representations of clinical patterns in the form of vignettes designed to assist the student of psychotherapy in learning techniques. They also contain information about the patterns of intervention that are relevant for a specific therapy and in some cases the common factors required in all successful therapies. I have graphically represented what happens in pattern processing once a theme is noted in the clinical assessment of the patient.  Clinical teaching of this process is often problem identification followed by an algorithm of features that might predict a successful course of therapy or limitations in therapy based on the students knowledge level at the time. As is true for most pattern matching and processing, the more extensive a physician's previous pattern exposure - the more likely they are to match the optimal intervention to the problem. 

I will resist making this first post of the New Year too long and wrap it up at this point with a diagram that I think pulls it all together (see below).  Each layer of this diagram consists of patterns and all of the associated pattern processing that leads to psychiatric diagnosis, formulation and treatment.  A few of the key features include the fact that diagnosis and treatment are interchangeable processes.  There will be times even during the initial information gathering that a verbal treatment intervention needs to occur and the entire interview occurs in the context of empathy and what Ghaemi, et al (4) have described as an existential psychotherapy based encounter – even if the administrative focus is on pharmacology. A second feature is that the information exchange is necessarily large if the psychiatrist and the patient are capable of it. There has been no research that I am aware of on the optimal amount of information that is required, but there are many limitations.  The advent of the electronic health record for example has led to the universal use of templates that are very restrictive in terms of information, typically dichotomous responses. A third implicit feature is the concept of patterns, what they imply for diagnosis and decision making and how there is almost a complete lack of discussion about this process in an era where diagnoses seem to have collapsed to a brief list of bullet points.  Cognitive neuroscience is a critical area of research focused these processes that I first became aware of when reading Kandel’s book “The Age of Insight” (5).  It is an area that does not typically get a lot of attention from psychiatrists, but it is a logical extension of the work done by behavioral neurologists from 20 years ago.  If we really want to focus on how psychiatrists think about diagnosis and treatment – we need to study this field, especially as the experiments get more complex.

I will wrap up this post at this point with the hope that 2021 is a much better year and that mankind is able to put this pandemic virus behind us by the summer and approach future pandemics with more science and wisdom.

 

Happy New Year!

George Dawson, MD, DFAPA

 

References:

1:  Constantine-Paton M. Pioneers of cortical plasticity: six classic papers by Wiesel and Hubel. J Neurophysiol. 2008 Jun;99(6):2741-4. doi: 10.1152/jn.00061.2008. Epub 2008 Jan 23. PMID: 18216235.

2: Poirier CC, De Volder AG, Tranduy D, Scheiber C. Neural changes in the ventral and dorsal visual streams during pattern recognition learning. Neurobiol Learn Mem. 2006 Jan;85(1):36-43. doi: 10.1016/j.nlm.2005.08.006. Epub 2005 Sep 22. PMID: 16183306.

3:  Mattson MP. Superior pattern processing is the essence of the evolved human brain. Front Neurosci. 2014 Aug 22;8:265. doi: 10.3389/fnins.2014.00265. PMID: 25202234; PMCID: PMC4141622.

4:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the "Med Check". J Clin Psychiatry. 2018 Apr 24;79(4):18ac12177. doi: 10.4088/JCP.18ac12177. PMID: 29701934.

5:  Kandel ER.  The Age of Insight. Random House, New York, 2012.

Graphics:

All generated by me for a PowerPoint presentation by the same name.  The photo at the top are two pamphlets that I carried as a med student along with a copy of Phantom Notes.  I was carrying them when I was in the room with Dr. R as he made the diagnosis described above.  I would not trade my medical school experience for anything. 

The Bureaucratic Takeover of American Psychiatry

 

This interview was posted on the Psychiatric Times web site today.  It contains bit and pieces from blog posts here over the past 8 years. It is a rare opportunity for people to see what is wrong with American psychiatry and that is - it is not run by American psychiatrists. It is run by managed care companies, pharmaceutical benefit managers, and government bureaucrats who all have the common goals of restricting access to psychiatric services.  And by psychiatric services, I am including substance use disorders and their treatment as well as the considerable amount of treatment of organic brain disorders that is provided by psychiatrists. 

I expect that some people will say: "What is special about psychiatry? Aren't these same rationing techniques applied to all of medicine?"  To a certain extent that is true.  Primary care physicians, medical specialists, and surgical specialists have to contend with similar rationing techniques.  It is however a question of scale.  I have talked with physicians who were around when the psychiatric rationing started and psychiatric services were chosen as the target of the express purpose of elevating the stock price of a company.  I was there when the Hay Report was released in the 1990s showing disproportionate rationing of psychiatric services relative to any other specialty.  I saw the original figures released in 2002 showing that Cardiology services were reimbursed at a 20% premium, while psychiatric inpatient services were discounted by 60%.  That led to some immediate closures of psychiatric hospitals and a continued trend of lower and lower bed availability.   There are endless examples of this disproportionate rationing on this blog and as I point out in the interview it is one of many reasons I write this blog.

One of the key questions that any observer of psychiatry should ask themselves is: "Why is George Dawson the only guy writing about this issue?"  Apart from the fact that this rationing has impacted my care of patients nearly every day of my professional life there are some obvious considerations.

1.  The people who self identify as the critics of psychiatry - clearly know very little about the practice environment or its constraints. I have seen two articles now that use the same example that psychiatrists believe that every mental disorder should be treated with a medication and that this is biological psychiatry.  The model of care they are referring to is not how psychiatrists are trained (see the above figure).  It represents a blended government and managed care model of how patients are scheduled, seen, and billed.  That bureaucratic model at one point employed an M code meaning a 5-10 minute visit with a psychiatrist.

2.  The critics similarly ignore highly innovative and individualized therapies that were invented by psychiatrists such as the Assertive Community Treatment  model that I mentioned in this interview as well as the myriad ways that psychiatrists have figured out how to talk in therapeutic ways with patients in rationed time slots and how those relationships result in recovery.

3.  The critics systematically ignore the lack of infrastructure to support psychiatric treatment.  There are very few inpatient units in each state that allow for the treatment of people with severe mental illnesses. By contrast, there appears to be no shortage of state-of-the-art facilities to treat heart disease, cancer, and gastrointestinal problems.  There is no shortage of state-of-the-art surgical facilities to treat any condition where surgery may be indicated.  In the mean time, mental illness and substance use disorders are the number 1 debilitating disease condition in the United States.  Rather than invest in the necessary infrastructure to provide an equivalent level of care, people with severe mental illnesses are incarcerated instead.  Rather than reversing that trend, several Sheriffs in the country propose designated parts of county jails as psychiatric hospitals and treating people in jail who should not have been incarcerated in the first place. 

I could keep going with additional points like I have in the past, but at this point would encourage any interested reader to take a look at the interview at this link.  Then take a look at the summary at the top of this post and consider my point. Psychiatrists are well trained to do a lot for people with mental illnesses and substance use disorders. We want our patients and their families to have access to the same amount of resources that other medical or surgical specialists have. Don't accept any criticism of psychiatry that does not address these basic points.  

George Dawson, MD, DFAPA 

Reference:

Awais Aftab, MD.  The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA
Psychiatric Times.  November 13, 2020    Link

Supplementary 1:

Dr. Allen's comment made me realize a critical deficiency in my graphic and also the interview and that is impact on the academic environment. One of the most exciting aspects of medical school and residency was learning to understand the medical literature and apply it to patient care. I met hundreds of physicians and colleagues with their own unique approaches. In training environments in the 1980s and early 1990s the expectation was that you were researching and reading about your patient's problems and diagnoses and were prepared to intelligently discuss it.  As an attending you had to keep on top of the literature to be a competent teacher and also as a marker of professional competence. Teaching rounds, grand rounds and other teaching based meetings were the most exciting aspects of going to work each day.  I modified my managed care timeline to illustrate the impact on the academic side of the work environment.  

Book Review of The Great Pretender by Susannah Cahalan

 

 This is the second book review of this book on my blog.  I was asked by the editor of The Philosophy Special Interest Group of the Royal College of Psychiatrists - Dr. Abdi Sanati to write another review for this newsletter.  I looked at it as an opportunity to cover some things I may have missed in the first review.  I agreed to not put it on my blog until the newsletter came out.  The latest review follows:

The Great Pretender (1) is written as an exposé of a famous experiment conducted by Rosenhan (2) that purported to discredit psychiatric diagnoses.  The original article was published in in the journal Science in 1973.  Whether you we aware of the original article or not depended on when you were trained and the extent to which you followed that literature. I was just finishing my undergraduate degree at that point and did not complete psychiatric training until 1986.  We had a community psychiatry seminar for 6 months during my last year that was taught by some of the innovators in the field.  It was common to analyze and discuss controversial papers of the day.  A good example would have been the paper that suggested that people with schizophrenia had a much better outcome in the developing countries (3).  At no point did we hear about or discuss the Rosenhan paper.  In fact, for the next 24 years the paper never came across my desk. It was only when I started writing a psychiatry blog that I realized it played a major role in psychiatric criticism and antipsychiatry rhetoric.  At that point, I read the paper and the associated criticism and concluded independently that the methodology was extremely weak and that pseudopatients were not really a good test of medical or psychiatric diagnoses.  I thought it would just fade away on that basis.

I was as surprised as anyone when I heard that investigative reporter Susannah Cahalan had written a book about this experiment, the author, and the methods used.  The investigation begins with a visit to one of Rosenhan’s former colleagues. This colleague shows her a stack of anti-psychiatry books that he thinks “were the key to his thinking”. There is also a file labeled “pseudopatients” that contain the names of all eight pseudopatients and details surrounding their hospitalizations. All the names or aliases and the hospital names had also been changed.

Cahalan’s approach is to write about three parallel subjects.  The most thorough and objective analysis is about the pseudopatient experiment. She covers everything from the available remaining data and the problems with it to the likelihood that the experiment actually occurred the way it was described in the Science paper.  The second broad subject was a character study of Rosenhan.  How did people describe him?  What was he like? Did people especially his colleagues believe that he conducted the experiment.  And finally, the book is a vehicle for Cahalan to comment on psychiatry.  She comes to this work with the direct experience of having experienced autoimmune encephalitis and writing about that experience in the book Brain on Fire.

Reading the original paper is a good starting point for understanding the book.  If you do pull up that article, a few details are immediately evident. The author begins the introduction using the terms “sane” and “insane” as though this is technical language used by psychiatrists. That use of language is interesting because he is listed as a professor of both psychology and law at Stanford.  Since the days of my training, insanity is a strictly legal term and it is without meaning in psychiatry.  The use of these legal terms allows him to point out the unreliability of the “sane”-“insane” dichotomy based on expert witnesses disagreeing in adversarial court hearings.  That has nothing to do with the clinical diagnoses in psychiatry. To what extent were formal diagnoses used in 1973? Rosenhan refers to the Diagnostic and Statistical Manual in the body of his paper.  Interestingly, the authors of my community psychiatry paper (3) reported on the 2-year follow-up of patients from the International Pilot Study of Schizophrenia (1973) and concluded that schizophrenia could be reliably diagnosed so that international comparisons and follow up were possible.  A sanity metric during the same time frame is crude by comparison. There are many additional examples of a lack of objectivity toward the issue of psychiatric diagnosis in the introductory section of the paper (paragraphs 4-7) and the discussion. Excellent critiques of the scientific merit of the paper were available at the time most notably by Robert Spitzer. 

The author describes his pseudopatient experiment as consisting of 8 people – three women and four men of various occupations. Cahalan identifies Rosenhan as pseudopatient number 1.  Twelve hospitals in various locations were chosen.  One was a private hospital.  Pseudopatients were supposed to call the hospital, present for an intake appointment, and then complain that they were hearing voices. When asked to elaborate they were supposed to say the voices were unclear except for the words “empty”, “hollow”, and “thud”.  Rosenhan provides a rationalization for this symptom choice about how on the one hand these symptoms were supposed to have existential meaning and yet there was not a single report of existential psychosis in the literature. Once admitted, the patient was supposed to cease simulating any symptoms and give their actual social history and behave “normally”. They were to take notes and be as cooperative as possible to get discharged. The length of stay was 7-52 days with an average of 19 days. 

Rosenhan also claims in the body of this paper that a second experiment occurred at a “research and teaching hospital” where the staff were informed ahead of time that pseudopatients were going to seek admission during a 3-month period.  Staff were asked to rate whether a patient was a pseudopatient or not.  Of 193 admissions during that time 41 were ranked as likely being a pseudopatient. In this case, Rosenhan did not send any pseudopatients to the facility and claims this false experiment represents “massive errors”.  

One of the elements of the paper that is really never discussed is it structure. The primary data points were eight pseudopatients were admitted and discharged from psychiatric hospitals without being discovered. The secondary data points were a series of observations of the staff that is largely unstructured, highly anecdotal, and contrasted with other situations that seem to lack relevance. The bulk of Rosenhan’s discussion is judgmental and there is no discussion of the limitations of the experimental design or data. Instead the author leaps to clear-cut conclusions that are in some cases only peripherally connected to the data.

Cahalan expends a lot of effort to try to identify and find the pseudopatients and ask them what their experience was like. She locates the records of Rosenhan’s own admission as a pseudopatient. The first real sign of a departure from the research protocol described in Science, occurs in Rosenhan’s recorded admission interview. He recited the voices script and said the symptoms had been going on for four months. He was admitted on an involuntary commitment and discharged nine days later. The hospitalization ended in 1969 - four years before the article came out. The first major sign that the experiment described in Science was not quite the way it was described in the paper occurs when Cahalan looks at the record of the admission interview. In addition to the vague description of hallucinations, Rosenhan states that he believes he can “hear what people are thinking”, that he has tried to “insulate out the noises by putting copper over my ears”, and that he has “suicidal thoughts”. These are all more serious psychiatric symptoms than factitious “existential hallucinations”. Rosenhan also altered his occupational history during one assessment to say that his psychiatric illness led him to give up a job in economics 10 years earlier. At one point he stated that his wife is probably unaware of how useless he felt and that “everyone would be better off if he was not around”.  Considering the seriousness of his fake history, I was surprised that he was discharged in 9 days.

What about the other 8 pseudopatients?  Cahalan was able to locate two – only one of whom was part of the research protocol and shared Rosenhan’s experience. The second patient started out as a psychologist and co-authored a couple of papers with Rosenhan. The author was surprised at how little preparation went into the pseudopatient role. Patient 2 was taught to cheek medications and spit them out. He was reassured by Rosenhan that he had filed a writ of habeus corpus to get him out of the hospital at any time.  When Cahalan tracked down that attorney who said the writs had been discussed but never prepared and that he did not consider himself to be “on call” to get pseudopatients immediately released. Patient 2 was also in the hospital for 9 days and basically released upon his request.  There was no reason for discharge given on the official form but he recalled a psychiatrist approaching him prior to discharge and making remarks to suggest that there was still some concern that he may still be suicidal. Despite that concern there was apparently no discharge plan.

The third pseudopatient discovered by Cahalan was interesting in that he was eliminated from the original protocol and not counted by Rosenhan.  Cahalan discovered that the ninth uncounted pseudopatient was a research psychologist named Harry Lando.  Dr. Lando is well represented in the smoking cessation literature and had published an article in the Professional Psychologist (4) stressing the positive aspects of his pseudopatient experience.  His observations were in direct contrast to Rosenhan and he states as much in the observation: “My overall impressions of the hospital are overwhelmingly positive. The powerlessness and depersonalization of patients so strongly emphasized by Rosenhan simply did not exist in this setting.” He goes on to suggest that using better hospitals as models may be a way to improve the quality of care.  He also questions the ethics of placing pseudopatients in “already overcrowded and understaffed institutions”.  Lando does express a concern about the diagnostic process since all three pseudopatients received diagnoses of schizophrenia.

The key question about why the data of the ninth pseudopatient was omitted from the original paper is answered as a footnote number 6 on page 258 of the original paper:

“Data from a ninth pseudopatient are not included in this study because although his sanity went undetected, he falsified aspects of his personal history. Including marital status and parental relationships. His experimental behaviors therefore were not identical to the other pseudopatients.” 

That footnote is exactly what Rosenhan did when he was admitted as pseudopatient 1 as documented in the existing medical record.  Rosenhan’s lapses were discovered and discussed by Cahalan and are included in the following table.

 

Rosenhan’s Lapses

1.  Data was improperly recorded. The two pseudo-patients interviewed by Cahalan pointed out that their durations of stay in the hospital were not correctly recorded.

2.  His private notes indicated strong influence by Szasz and Laing. Prior to the pseudopatient experiment he assigned work to his students describing psychiatric hospitals as “authoritarian”, “degrading”, and “illness-maintaining”.

3.  He told a pseudopatient that a writ of habeas corpus was prepared and an attorney was on call to get them out of the hospital if necessary. That was not true.

4.  Professional and possibly “unethical” mistakes (p. 173) about length of stay in pseudopatient number two (7 days versus 8) and pseudopatient number 9 (26 days versus 9 days), patient population in the hospital 8,000 vs 1,510), the specific discharge diagnoses of pseudopatients 2 and 9, and details of staff behavior on the ward.

5.  Sending a pseudo-patient into a hospital that was in disarray because it was closing.

6.  Rosenhan at one point lied in correspondence to Spitzer about his stay in the hospital and said it was part of a “teaching exercise” that had nothing to do with research(p. 180). Cahalan describes this as “an outright lie”.

7.  During his admission Rosenhan “goes off script” and gives far more fabricated symptoms and history than the “empty, hollow, thud” existential hallucinations he described in the protocol. Additional symptoms suggest a significant psychiatric disorder. He describes suicidal ideation and significant conflict with his employer – the same falsification of personal history that led him to eliminate the data of the ninth pseudopatient.

8.  Rosenhan fabricated an excerpted portion of the medical record and both the original record and the excerpt are published for A - B comparison on page 190. Cahalan concludes that the facts “were distorted intentionally by Rosenhan himself.”

9.  Inadequate preparation of the research subjects. Patient 2 ended up taking a dose of chlorpromazine and patient 9 was given liquid chlorpromazine so it could not be cheeked as instructed.  Pseudopatient 9 estimated the preparation time for hospital admission by Rosenhan was about 15 minutes.

10.  When patient 9 was eliminated from the study none of the data about pills dispensed or staff contact time in the paper was changed.

11.  In an National Public Radio program that aired before the publication of his paper (December 14, 1972) he misstated his time in the hospital as a pseudopatient (several weeks versus 9 days) and the amount of medications dispensed to pseudopatients (5,000 pills versus 2,000 pills) while building to the conclusion that psychiatric hospitals are non-therapeutic and should be closed (p.234)

12.  Pseudopatient 9 commented that what Rosenhan had written about him in the experiment was “total fiction” (p.269)

13.  Rosenhan did not complete a book about the pseudopatient experience, despite an advance from the publisher, a subsequent lawsuit from the publisher and what is described as plenty of publicity around the time the paper came out in Science. He also never published on the topic again (p. 295).

 

Rosenhan did continue to publish a description and discussion of his study in the text Abnormal Psychology (5). The discussion emphasized that the simple hallucinations described with nothing else being unusual would have been detected outside of a hospital. In the context dependent setting it was not.  In other words – he maintained one of the same themes as in the original paper.

One of the areas that really piqued my interest was why Science published this paper in the first place.  Cahalan got the opinion from an academic psychologist that the peer review in a non-psychology journal would be less rigorous.  When she approached the journal she was told that records were confidential and that they were not kept back that far.  Accessing Retraction Watch (6) demonstrated that there has been a total of 120 papers retracted from Science since 1963. The reasons for the retractions are given as data errors, errors in methods, result errors, errors in conclusions, errors due to contaminated experiments, falsification/fabrication of data, irreproducible results, misconduct by the author, ethical violations by the author, investigation by a company, institution, or third-party.  Only three of these papers had anything to do with psychiatry and those papers were primarily about the neurobiology of the brain. Cahalan’s investigation suggests that several of the reasons for retraction have been met.

Apart from the details of the Science paper, Cahalan also does a character study of Rosenhan. We learned that his brother had bipolar disorder and did well on lithium. It was suggested that was why he became interested in psychology. He was described as bright and charismatic. He was clearly influenced by the work of anti-psychiatrists and assigned work to his students that “describe psychiatric hospitals as authoritarian, degrading, and illness maintaining among other terms”. (p 73).  The title of the book highlights Rosenhan’s characteristics as a raconteur who would occasionally pretend to be someone who he was not. His son described an incident in New York City where he introduced himself as a professor of engineering at Stanford in order to get a tour of an interesting construction site with his son. In another scene he is joking about the wig he wore to get into the psychiatric hospital.  Cahalan finds the admission photo showing that he is bald without a wig. The people who knew him the best – acknowledge the he was difficult to know and just like Rosenhan’s arguments about psychiatric diagnoses being context dependent – his personality was as well.   

Apart from academic books about the history of psychiatry – most books review sensational history and arguments that by their very nature diminish the field.  This book is intermediate in that tone with those arguments interspersed through the investigative journalism about Rosenhan. They touch on the familiar themes of biological reductionism as opposed to a clinical psychiatry where patients are actually listened to with no reference to how clinical psychiatrists really practice every day. Some psychiatrists end up being caricatured and some are acknowledged as being highly motivated and humanistic. I am probably far too invested in clinical psychiatry and the good I have seen done to tolerate a journalist’s approach to the field.  I give Cahalan credit for touching on the current situation that has resulted in severely rationed care and the transinstitutionalization of patients in jails.  The overall concept that psychiatrists have little to do with the systems of care that are controlled by businesses and governments is not emphasized even though it was recognized as a problem by two of the pseudopatients.  She also points out that the pseudopatient experiment is irrelevant to psychiatric practice today but her resounding theme throughout the book was that it was extremely relevant irrespective of what actually happened.  The book also gives Rosenhan too much credit for psychiatric criticism. Like many books of this nature – there is little to no evidence that psychiatrists might be their own best critics or that outrage might be a legitimate reaction to outrageous criticism rather than defensiveness.

 In conclusion The Great Pretender identifies very specific problems with the original Rosenhan paper that have been listed in the narrative and table in this report. He gained initial celebrity status from the study and signed a book contract. Even though he was given an advance on the book and wrote a manuscript he never produced a book.  The author suggests that may have been due to the fact that Robert Spitzer was aware of Rosenhan’s nonadherence to the research protocol during his admission. As Rosenhan withdrew from the pseudopatient limelight he also stated that none of his research should lead to the conclusion that psychiatric hospitals were unnecessary and that represented a complete turnaround form earlier statements.

The controversy, the original paper and the book could be the subject of seminars in the history or philosophical aspects of psychiatry. It touches on a number of themes primarily the ethics of research and how it should be conducted. It also touches on psychiatric criticism and may be useful in discussing how future generations of psychiatrists can prepare to deal with it. 

 

George Dawson, MD, DFAPA

 

References:

 

1: Susannah Cahalan.  The Great Pretender. Grand Central Publishing. New York, 2019. 382 p.

2: Rosenhan DL. On being sane in insane places. Science 1973 Jan 19;179(4070):250-258.

3: Sartorius N, Jablensky A, Shapiro R. Cross-cultural differences in the short-term prognosis of schizophrenic psychoses. Schizophr Bull. 1978;4(1):102‐113. doi:10.1093/schbul/4.1.102

4: Lando, H. A. (1976). On being sane in insane places: A supplemental report. Professional Psychology, 7(1), 47–52. https://doi.org/10.1037/0735-7028.7.1.47

5: David E. Rosenhan, Martin E.P. Seligman. Abnormal Psychology- 2^nd Ed. WW Norton and Company, New York City, 1984, 1989; p 181-183.

6: Retraction Watch: Retractions from Science.  Accessed on May 22, 2020: http://retractiondatabase.org/RetractionSearch.aspx#?jou%3dScience

7:  Gaudino M, Robinson NB, Audisio K, et al. Trends and Characteristics of Retracted Articles in the Biomedical Literature, 1971 to 2020. JAMA Intern Med. Published online May 10, 2021. doi:10.1001/jamainternmed.2021.1807

The authors cite retracted literature (5209 papers) back to the year 1923. Scientific misconduct like fabrication of data was cited as the most common reason.  

Supplementary:

The review was written for Philosophy Special Interest Group of the Royal College of Psychiatrists September 2020 newsletter and it can be found starting on page 8.

Additional Reference posted on July 17, 2021:

Justman, Stewart, "Below the Line: Misrepresented Sources in the Rosenhan Hoax" (2021). Global Humanities and Religions Faculty Publications. 13. https://scholarworks.umt.edu/libstudies_pubs/13

This author fact checks Rosenhan's references and footnotes and finds they do not support his points.