Updated Review of Systems (ROS) for Medical Psychiatrists

The review of systems for psychiatry has changed significantly over the years.  Those changes were due to billing and coding decisions rather than clinical utility.  If you have been practicing long enough you have witnessed the transformation from a document very similar to what primary care physicians use, to one that is more focused on the sleep and appetite disturbances associated with psychiatric disorders. That results in a distinctly different ROS in psychiatry than the rest of medicine.  That puts medically based psychiatrists like myself at a disadvantage because the electronic health record (EHR) templates may not include the physical symptoms that I am most interested in and that requires more documentation. 

These changes are not unique to psychiatry.  Patients find themselves filling out checklists in many clinics that are essentially a surrogate ROS.  Something that your physician used to ask you in person and ask you to elaborate on is now a checklist.  In the modern EHR, the ROS is often just a series of checkboxes.  No elaboration required thank you.  The form that you fill out in the waiting area is incorporated into the physician's note often without reviewing it with the patient.  In some systems employing scribes or persons to do the documentation the scribe will type or dictate this form into the record. There is one additional point where the physician might read any ROS incorporated this way and that is during the read of the final note for signing.  That review is usually cursory because of time constraints - I doubt it is read with any regularity.  There is not enough time to read documentation 2 or 3 times as it is complied, transcribed, and entered into the EHR.

Another EHR strategy that is used from time to time is a statement: "A complete 10-point review of systems was done and it was negative."  Use of that statement depends on the billing, coding, and compliance staff and whether they think it meets the subjective standards of the day to demonstrate to somebody that the work was done. In my experience, unless you are interviewing a very healthy 20 or 30 year old it is unlikely that the ROS is completely negative.

The expanded ROS is more specific to medicine and it assumes that the physician is asking clarificatory questions.  I have found over the years that a very basic structured exercise like the ROS produces very different results depending on asking all of the questions, asking clarificatory questions, and pursuing obvious leads to other sets of questions depending on the patient response. Treating the ROS like it is a static series of yes or no questions is likely to produce the minimum amount of diagnostic information.

As an example consider the following example:

The ROS is being conducted on a 75 year old man.  He is being seen for insomnia.  In taking the medical history he says he was diagnosed with congestive heart failure 2 years earlier. He has impaired physical performance due to CHF and can only walk 100 feet and slowly climb a flight of stairs with great effort. On the ROS he endorses needing to prop himself up to breathe and occasionally wakes up suddenly at night due to shortness of breath.  Those symptoms and additional physical exam findings suggest that CHF is the problem rather than insomnia and the treatment needs to change accordingly. 

A more common example:

The ROS is being conducted on a 50 year old man.  He denies any cardiac or pulmonary symptoms and is only taking an 81 mg aspirin in addition to two different antidepressants. He has a 30 year history of smoking a pack a day of cigarettes.  The interviewer asks: "Have you ever had stress test?"  The patient states he does not know what that is. "You walk on a treadmill and they keep increasing the grade until you have to stop".  The patient replies that he took the test and the Cardiologist came in and sprayed something into his mouth. "Do you think that was nitroglycerin spray?" The patient states that it was and he had an immediate angiography and stent placement. 

Both examples illustrate that the ROS is dynamic and not static.  Filling it out in the waiting room may seem to be efficient, but the amount of information obtained in that setting is likely to be low relative to real medical problems that exist.  The probability of increased information from a more dynamic ROS increases with the age of the patient due to accumulated medical problems with age.

In addition to the list of symptoms in the ROS, additional heuristics at the level of pathological mechanisms can be considered to hone in on a specific syndrome.  The following table illustrates two of them.  For example, the General category in the ROS generally implies some kind of infectious, metabolic or endocrine condition - but it is not enough to make an actual diagnosis without further delineation. ROS categories are supposed to roughly correlate with body systems rather than pathological mechanisms, but many of the symptoms do not have a definable body system.

VINDICATE	VITAMIN D
V – Vascular I – Inflammatory N – Neoplastic D – Degenerative / Deficiency I – Idiopathic, Intoxication C – Congenital A – Autoimmune / Allergic T – Traumatic E –  Endocrine	V – Vascular I – Inflammatory T – Trauma A –  Autoimmune M –  Metabolic I – Iatrogenic N –  Neoplasm D -  Degenerative

If I think the patient has a flu-like illness I ask about specific symptoms of flu-like illness. In addition to fatigue, weight change, fever, chills I might ask about - malaise, cough, rhinorrhea, nasal, congestion headache, sore throat, myalgias, chills, and sneezing.  Positives on several of these symptoms greatly increases the likelihood of a diagnosis of a flu-like illness.  Asking those questions occurs when an infectious etiology is suspected.

The typical review of systems that I used for years is printed below with red highlights for additional points that I ask if there are any markers in the initial history that suggests that they might be positive.  For example, if I am seeing a 50 year old with a long history of stimulant use, on three different antihypertensives and an anti-arrhythmic medication I will generally ask all of the cardiopulmonary symptoms and the additional questions about cardiac testing imaging and diagnoses.  For example: "You mentioned that you have never had a heart attack or a stroke, but has any doctor every told  you that you had cardiomyopathy or a thickened wall of the heart? Do you remember where all of that testing occurred?"

Review of Systems

General:  fatigue, weight change, fever, chills, night sweats

Endocrine: hot or cold intolerance, thyroid problems, hx of neck irradiation

HEENT: decreased visual acuity, hearing loss, tinnitus, vertigo, epistaxis, hoarseness or voice change, sinus/nasal infection or discharge, ear pain, history of ear infections, decreased auditory acuity

Pulmonary: dyspnea, cough, sputum production, chest pain or tightness, hemoptysis, asthma, bronchitis, emphysema, hx pneumonia, hx TB, hx positive/negative PPD, smoking hx

polysomnography, CPAP, APAP, BiPAP, nightmares, night terrors, parasomnia

Cardiovascular: chest pain, palpitations, tachycardia, syncope, edema, orthopnea, paroxysmal nocturnal dyspnea, claudication, phlebitis, hypertension, hx rheumatic heart disease, family hx heart disease

stress test, echocardiogram, angiography, stent placement, congestive heart failure, cardiac ablation, cardiac event monitoring, tilt table testing

Gastrointestinal:  nausea, vomiting, hematemesis, melena, dysphagia, indigestion, heartburn, abdominal pain, abdominal swelling, jaundice, hx hepatitis, hematochezia, diarrhea, constipation, hernia, hemorrhoids, peptic ulcer disease, gallbladder disease, pancreatitis, GI surgery

esophagogastroduodenoscopy, colonscopy, hepatic ultrasound, pancreatitis

Genitourinary: urinary frequency, urgency, dysuria, nocturia, hematuria, hx kidney stones, flank pain, hx STD, genital lesions, testicular mass or pain, sexual dysfunction

Hx acute renal failure

Gynecological: menarche, menopause, last menstrual period, description of menstrual periods, pelvic pain, vaginal discharge or bleeding, sexual dysfunction, breast mass, breast discharge, last breast exam, last mammogram

pregnancy history, hx pre-eclampsia or eclampsia

Skin: mole, other lesion, pruritus, rash, bruises, contusions, lacerations, burns, hx skin cancer

Hematopoietic: excessive bleeding, hx anemia, family history of disorder, lymphadenopathy

Neurological: headaches, migraines, ataxia, incoordination, vertigo, gait problems, falls, loss of consciousness, seizures, head injury, skull fracture, focal weakness, focal sensory change, hx stroke, micropsia, macropsia, metamorphopsia, chronic pain

Brain imaging, EEGs, coma, encephalitis, meningitis, chronic fatigue syndrome, movement disorders

Musculoskeletal:  joint pain, joint stiffness, joint swelling, muscle cramps, muscle pain, muscle wasting, hx fractures

Gout, Lyme Disease, fibromyalgia, rheumatic diseases, treatment by rheumatologist

Allergic/Immunologic: hay fever, rhinitis, seasonal symptoms

Allergy testing, specific allergens, immunotherapy


These are techniques that I have found useful over the years.  In psychiatry, the ROS is useful because I frequently have gotten past the medical history section and inquired about all major surgical and medical diagnoses from the past and the result is surprisingly thin.  More specific prompting about the diagnoses and which physicians the patient has seen in the past can produce much more information in an interview setting.  For psychiatric purposes, the ROS is also included in follow up visits and it seems necessary.  I find it useful for documenting intercurrent illnesses and medication side effects.  

Each class of psychiatric medications has their own relevant ROS that can be recalled with practice.  I might try to type those out at some point in time - but not tonight.  My main point here is that the ROS does have a function above and beyond the psychiatric history for psychiatrists.  People tend to view it as a difference necessary for one billing code or another.

I see it as an opportunity to figure out what is really going on medically with my patient and possibly diagnose another illness. It is also necessary to know that the patient does not have an underlying medical condition or treatment for that condition that contraindicates or necessitates closer monitoring of the proposed psychiatric treatment.

George Dawson, MD, DFAPA


ROS Files:  You can download the ROS files used for this post at the following links as Word documents.  Any suggestions for further modification appreciated:

ROS modified 

ROS standard

Additional Fact: 

A poster on Twitter [Alasdair Forrest @alasdairforrest] let me know that the ROS in the UK is called "systemic enquiry".

Sex Scandals - Human Sexual Consciousness and Prevention

Over the past three weeks the country has been rocked by another entertainment business sex scandal.  An endless series of actresses describing very similar inappropriate behaviors and in some cases sexual assault.  The allegations alone at this point have led to major disruptions in family life, businesses, and professional recognition and honors.  Women have been encouraged to come forward and report these incidents and there is a movement to spark a sea change in the culture that lead to the problem of the sexual exploitation of women in the entertainment industry.   In some cases men have come forward. There are also claims that the specifics of child sexual exploitation in Hollywood will soon become public.   This seems to be a familiar scenario that unfolds from time to time, but never before at this scale.  What are the implications?

Looking at the epidemiology of sexual harassment leads to a wide range of statistics.  The first reliable medical reference that I could find was in the American Journal of Psychiatry from 1994. That article was a review of existing literature showing that sexual harassment was commonplace with estimates varying from 42-73% of women and 15-22% of men in occupational and medical educational settings and that a small percentage of the people affected (1-7%) file formal complaints.  The Equal Employment Opportunity Commission (EEOC) is the federal agency that monitors and enforces civil rights in the work place and one of those rights is not to be sexually harassed.  The agency has very little useful information on their web site in terms of epidemiology, primarily looking at enforcement data. Since this represents a minority of incidents and there is overlap from year to year depending on when the claim is settled it has limited utility in determining the scope of the problem.  As far as I can tell there are no definitive studies done with similar definitions across a representative population, but all of the subgroup studies indicate it is an ongoing significant problem despite legislation and the EEOC.

Inappropriate sexual behavior has been a significant focus of every educational and employment situation that I have been in over the course of my career.  The approaches have varied widely from stating rules and implying what was unacceptable right up to prohibitions of behaviors and the fact that violations could lead to reprimands or immediate termination.  The unacceptable behaviors included a wide range of unwanted approaches or statements, suggestive humor, inappropriate touching, and included dating subordinate employees.  There were comprehensive approaches that explained the rationale for all of these rules.  In other cases there were not.  In psychiatry, the boundaries have become even more clear in terms of dating former patients and supervisees.  It is no longer considered appropriate for a psychiatrist to ever date or have a sexual relationship with a former patient. In some places where I have worked with other disciplines - I noticed that there is a time frame where such behavior is allowed for non-psychiatrists.  As far as I can tell - there are no uniform approaches that seem to apply to all employees and all disciplines.

Apart from employment expectations when working in health care environment, sexual trauma is overrepresented in people  being treated in psychiatric settings.  There are high rates of depression, post traumatic stress disorder, suicide attempts, and suicide.  The World Health Organization has several resources on the available statistics for violence toward children and adults and sexual maltreatment and violence.  They classify sexual harassment as a form of sexual violence against women.  Their definition of sexual violence is:

 "any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work." 

The available estimates are high.  In the US, 14.8% of women  over the age of 17 report that they have been raped and an additional 2.8% have been subjected to attempted rape. The WHO report documents other forms of sexual assault but had no clear data on sexual harassment.

The WHO report is interesting because it has some suggested strategies for prevention.  They begin by discussing secondary prevention for both the victims and perpetrators of sexual violence.  An educational and developmental model was discussed that includes discussion of a sexual aggression and setting boundaries for appropriate sexual relationships.  Improved health care interventions for victims of sexual violence is another WHO priority ranging from forensic evaluations to the prevention of sexually transmitted diseases.  Legal reform is also suggested as necessary particularly in the areas of legal definitions of sex crimes and the court processes that are used for these cases.  Child marriage is a variation of sexual abuse that continues to exist world wide. In the US, like elsewhere the practice is culturally based (2) and even though there are generally minimum ages for marriage in some states the courts can grant exceptions.  These exceptions allowed children between the ages of 10 and 15 to get married in the US.  The WHO report has a few paragraphs on primary prevention of stopping sexual violence before it occurs.  Most of that is directed at educational programs that target changing cultural and individual attitudes about sexual behavior.

I found a recent paper on a specific subculture (anthropological fieldwork) (3) that was studied by anthropologists. This paper looked at the issue of sexual harassment in the context the expectations of that subculture.  The authors found that when there were clear rules in the workplace and an expectation that they would be enforced - the field experience was more productive and there were far fewer reports of harassing behaviors.  The authors included discriminatory behavior along with harassment and assault.     

I included some of the additional information on sexual violence to show that is only slightly more studied than sexual harassment.  From the descriptions of recent victims, there is a clear association between sexual harassment and sexual violence.   It is apparent to me that the scientific study of problematic human sexual behavior at the levels of epidemiology and causation is primitive to non-existent.   Society seems to depend on a legal model including civil and criminal penalties as potential corrective factors - but there is no evidence that has had much impact.  Society might also be a bit too self congratulatory on attitudes about human sexual behavior. Tolerance for nudity and pornography has not translated into less victimization.  Neither has widespread exposure to detailed information on the mechanics of sexual behavior.

The brain has been left out of the discussion, specifically human sexual consciousness and why there are people who can routinely negotiate this most sensitive aspect of interpersonal relationships, while others leave a number of traumatized victims in their wake.  Retrospective analysis and armchair psychoanalysis is always easy after the fact.  I have seen many of these men referred to as sociopaths, psychopaths, or narcissists.  The perpetrators themselves often claim "sex addiction" as a problem and go to a rehabilitation facility to treat the problem.  Social etiologies are also part of these analyses, especially the idea that most perpetrators are likely victims of sexual abuse.  All of these diagnoses seem to be a function of the crisis situation rather than any useful diagnosis that results in treatment and life change.  The diagnoses also seem to be based on a very simplified model of how the mind/brain work.  The models typically included cognitive, behavioral, moral and social elements that do not produce a viable theory to produce much treatment or prevention.  The models also do not explain individual variation, but generally look at class variation (men versus women).  More biological based models of sexual differences (4) look at imaging studies, limited cognitive tests, and functional imaging and differences are typically minimal.

A consciousness based approach may be more useful to look at real differences between men and women.  The focus of these studies would be to look at the conscious states associated with sexual behavior and what actually happens in the optimal and sub-optimal or abusive states.  Any  study of these conscious states typically begins with phenomenology and in addition to epidemiology - it is lacking in this area.  The largest literature continues to be psychodynamic and psychoanalytical that has produced non-falsifiable theories based case reports and experience with individual cases.  That same literature is also limited by the theories and interpretations of the authors.  A phenomenology of sexual consciousness needs to take a look at the current theories of consciousness and how they might apply to very specific situations.  In a previous post I quoted Tononi and Koch speculating about the complex that occurs when they see a particular actress in a movie.  They focus a lot on the neural correlates associated with the visual representation but also the neurons that are associated with higher order concepts.  What are the specific complexes generated when people meet?  We currently do not know what they are.  There seems to be a broad idea that every person has an internalized moral code or set of rules that comes into play, but is that a realistic way to view the process or any associated problems.  Consciousness researchers seem more focused on ideas about machine intelligence and possible machine consciousness these days than the issue of sexual consciousness.

For now, there does appear to be a societal approach to minimize sexual harassment and abuse, but it is limited by self report.  It depends on transparency and enforcement that is spotty at best. The strong wave of advocacy that we have seen originating in the entertainment industry is a potential positive force - but we have seen these waves in the past lose momentum.  Like many readers of this post, I hope that does not happen.  In the meantime, a focus on sexual consciousness may lead to important ideas about how to address inappropriate sexual behavior and it will lead to a more complete science of human sexual biology.     

 George Dawson, MD, DFAPA


References:

1: Charney DA, Russell RC. An overview of sexual harassment. Am J Psychiatry. 1994 Jan;151(1):10-7. Review. PubMed PMID: 8267106.

2:  Diane Cole.  Children Get Married In The US, Too: 15 Girls   http://www.npr.org/sections/goatsandsoda/2015/10/28/452540839/children-get-married-in-the-u-s-too-15girls

3:  Nelson, R. G., Rutherford, J. N., Hinde, K. and Clancy, K. B. H. (2017), Signaling Safety: Characterizing Fieldwork Experiences and Their Implications for Career Trajectories. American Anthropologist. doi:10.1111/aman.12929

4: Mueller SC, De Cuypere G, T'Sjoen G. Transgender Research in the 21st Century:A Selective Critical Review From a Neurocognitive Perspective. Am J Psychiatry. 2017 Oct 20:appiajp201717060626. doi: 10.1176/appi.ajp.2017.17060626. [Epub ahead of print] PubMed PMID: 29050504.

5: Centers for Disease Control and Prevention.  A Guide to Taking A Sexual History. Link.

I included this document to illustrate where the focus is on sexual behaviors - in this case detecting sexually transmitted diseases.

Blade Runner 2049

In keeping with the previous two posts - I did get out to see Blade Runner 2049 last Saturday.  It was clearly a first rate science fiction film and I guess some viewers not used to the genre might also call it a thriller.  Visually I thought it was less stunning that the first due to the lack of street level scenes and the hectic activity on the street.  It has critical acclaim but because of the high cost is being described by some critics as a "box office bomb".  In this film replicants (bioengineered androids) have become Blade Runners.  In some reviews of the film they are referred to as bioengineered humans and that is not a trivial difference since the main plot theme is whether or not the androids can reproduce.  The focus is on K (Ryan Gosling) who is the main protagonist.   We seem him interacting with and dispatching another replicant in the initial scene.  That replicant asks for mercy on the basis that they "are the same kind" and that there is a higher calling based on the miracle that he has witnessed.  When K returns to the station (LAPD) he undergoes a rapid debriefing protocol, test questions with monitoring of various anthropometric and physiological parameters.  The meaning of the test questions is not clear but the implication is that it determines if he has stayed at his baseline or his status had been perturbed in some way.   The test is also being administered for a very different reason than the Voight-Kampff protocol since the test subject is a known replicant.

There are three generations of replicants in the film starting with K - a Nexus 9 series, to the Nexus 8 replicant he retires in the original scene, the the Nexus 7 series that dates back to Rachael in the original Blade Runner film.  Over the course of that time frame the replicant population has become less subservient and more interested in equality or autonomy.  There is a rebellious faction.  We learn later in the film based on a series of events that the common "miracle" that the replicant population refers to is the birth of a child by Rachael in the original film.  In that film in the final scene she was leaving with Deckard (Harrison Ford).  There were implications that Rachael was a specially modified replicant and in retrospect the question is whether she was modified to reproduce.   

The competing forces in the film were threefold.  First, the LAPD is invoked as the police force determined to suppress any replicant rebellion.  K is a detective for the LAPD and after discovering Rachael's remains buried at the site where he encounters the initial replicant and there is evidence that she gave birth to a child..  Second, Tyrell corporation has been replaced by the potentially more evil Wallace Corporation header by Niander Wallace.  Wallace is very explicit about the need for replicant reproduction since he does not believe that manufacturing capacity can ever meet the need for replicants in service of his corporation and its off world needs.  And finally there is the role of K as a free agent in all of this.  Does he do the bidding of his boss at LAPD or not?  His boss emphasizes the importance of killing any story that replicants have reproduced - she sees it as a game changer for civilization as they know it.  She assigns him to find and kill the child.  He is later assigned to kill Deckard for the same reason.

I will leave the plot specifics to the various reviews and descriptions already out there and concentrate on the main issues that have to do with consciousness in the film.  At one point K is asked about childhood memories and recalls being bullied by a group of boys who wanted a small hand carved horse that he was carrying.  We see him escaping the boys and burying the toy in a pile of ashes in the bottom of an old furnace.  Later he consults with an expert to determine if the memory is real or not.  She confirms that it is a real memory and that leads him to believe he may be the child of Deckard and Rachael.  I asked myself at that point if K's interest in the memory was even possible if he was a replicant.  By definition in Tononi Koch theory, this experience requires consciousness and even perfectly engineered system mimicking the human brain could not generate the human experience associated with the memory much less the integrated emotions associated with this scene.  When K finally finds Deckard he is in a state of emotional turmoil related to information that Deckard provides him about his origins.  In a shootout Deckard is captured by Wallace Corp and is in the process of being tortured to find out information about the location of his and Rachael's child.  He is both rescued by K and united with his child by K.  In both Blade Runner movies Deckard is rescued in the end by a replicant.

My summary may not match up well with other reviews about specifics.  I did not view the protocol being given to K as the Voight-Kampff protocol, since it did not seem like it was an updated version.  Keeping Tononi Koch theory in mind it would be totally unnecessary even if he was really a highly sophisticated bioengineered replicant.  It would only be necessary to place a transcranial magnetic stimulation (TMS) coil close to his brain and observe the high density electroencephalogram (EEG) pattern.  If consciousness exists the theory predicts a pattern of widespread activation and deactivation.  It should also be possible to observe the characteristic sleep EEG pattern of transitioning from consciousness to unconscious dreamless sleep and back.  Of course these androids would need to be flawlessly engineered to protect circuitry from magnetic and electrical fields that occur with these measurements. 

In summary, I thought that Blade Runner 2049 was an excellent film just based on the plot and artistry.  I can always see the distinction between real science and science fiction.  If Tononi Koch theory is accurate, it is hard to imagine that a replicant would not be obvious to conscious humans.  I guess we will need to either wait until that day comes or until the theory has more widespread acceptance and proof.  The other parallel aspect of this film is bioengineered human reproduction.  It is difficult to see how that could ever be done, especially through human sexual contact with machines.  Sexual contact with bioengineered androids is a more frequent science fiction theme these days than in the past.  It is probably easier to see how that might happen from the human side.

There is currently not enough information about human sexual consciousness to imagine how it could be built or programmed into an android.     


George Dawson, MD, DFAPA               

Tononi Koch Test for Machine Consciousness

In follow up to my previous post and before I saw Blade Runner 2049, I wanted to post a more modern take on the Turing Test based on a coherent theory of consciousness  by Tononi and Koch - both experts in the neuroscience of consciousness.  Their theory is the Integrated information Theory (IIT) of consciousness.  I have included the reference (1) and a graphic from their public access paper on the theory and there are also several very useful videos available to listen to the verbal descriptions of the theory.  I have been following consciousness research for at least the past 20 years including the two main listservs on this topic until they shut them down.  When a topic is so specialized, barring any breakthroughs the arguments become repetitive and a lot of time is spent bringing novices up to speed.  The videos fill a useful gap that these listservs previously addressed although I must admit  that I am always biased toward the written rather than the spoken word because it is a much more efficient information transfer for me.  The videos listed at the bottom of this page also serve another useful purpose.  The viewer is able to see how researchers in this area define consciousness and describe their theories.  I think that it is possible to notice that some of the definitions and descriptions are so vague as to have limited utility.

That is one of the reasons that I like the approach by Koch and Tonini.  I will also also say from the outset that I am not sure whether they view the theory as a joint venture or not.  As an example of what I mean looking at this specific search on consciousness finds that Tononi has been working in this area for at least 20 years.  A similar search on Koch goes back even 8 years earlier.  I don't know either of the authors but based on reading this paper it seems like a joint effort and that seems to come across in  the available videos of their presentations. (see addendum).

In the paper, that authors outline phenomenological definitions that are more exacting than any that I have seen in the past from other authors.  They are also neuroscience based and that makes a difference to me.  In various venues people often faintly praise but then lament psychiatry's emphasis on biology.  That is obviously not true or at least without reason and it also illustrates the lack of research that people do when it comes to critiquing psychiatry.  Psychiatrists have actively researched practically all forms of social, psychological, and biological etiologies of mental illness since the specialty was founded.  Any cursory review of a general psychiatric text illustrates that point.  So if a psychiatrist is focused on brain biology, it is certainly not without reason.  I previously posted a breakfast that I had with a mentor and after a long career as a psychiatrist he summed it up the way a lot of psychiatrists do: "It is all about the biology."  Critics take that to mean some kind of medical intervention.  They are certainly studied, but every other non-medical intervention has been studied as well.  It is common to read about non-medical interventions (psychotherapy, meditation, etc) altering the brain in some way.  In psychiatry that has been known within the field for at least 70 years.

There are two levels to study the work of Tononi and Koch.  The first is at the purely descriptive level.  That is the level that you will find in the first reference.  The second level is at the level of neuroscience and mathematical theory.  The authors have produced this work as well and reference it in this paper, but for the purpose of this post I am going to stay at the descriptive level and possibly post a more technical article on the advanced theory at a later date.  I will add that there are several competing theories of consciousness that I am not going to mention here.  I have studied several of them and think that they have less to offer than the Integrated information Theory (IIT) of consciousness.  I am admittedly a reductionist seeking to close the explanatory gap between brain biology and how conscious states are generated.  In some of the videos available online where there are panel discussions it is clear that the proponents of the other theories think that their own theories are correct and IIT is wrong. I have been down the rabbit hole with a few of those theories and don't want to take time to criticize them.  Feel free to look them up and form your own opinion.  For now I will focus on IIT.   

If you have never heard of Tononi, Koch, or IIT the first task is to read the paper.  I found it to be very clear in terms of definitions, postulates, and a clearly stated theory.  They point out that every experience will have an associate neural correlate of consciousness (NCC). There is currently an explanatory gap at the level of how conscious experiences are actually produced by the NCC.  They discuss the axioms necessary for a coherent phenomenology of consciousness.  From there they move on to the postulates.  Eventually they discuss how a conceptual structure that is maximally irreducible conceptual structure occurs in the brain.  These states are also known as quale.

They give a couple of examples about how conscious states occur within their theory.  They provide and example of how to calculate the quality and consciousness given a particular state containing elements (Figure 4).  They provide a clear example of the physical substrate of experience (complex), and a set of maximally irreducible cause-effect repertoires (concept), and a maximally irreducible "cause -effect structure in cause-effect space made of concepts..." or conceptual structure (quale)(p. 12).  The quantity of experience or consciousness is specified as Φ^max.  The quality of experience is the form or shape of the conceptual structure. Distinct shapes occur with different experiences.

A more accessible example is discussed on page 9 and that is seeing Jennifer Aniston in a movie.  In that case, the complexes at the neuronal level affects the probability of past and future states. Consistent with neuroanatomy many specialized neurons are firing or not firing in the visual system that are associated with Jennifer Aniston as an invariant concept.  Other neurons are associated with other invariant concepts that allow for a fuller description in terms of appearance, age, etc.  All of the elements of the complex are intrinsic information and do not depend on visual inputs for example if dreaming or imagining the actress.

The authors also briefly review some of the experimental evidence that is consistent with the theory. They find that the theory is predictive in number of experimental paradigms. Transcranial magnetic stimulation (TMS) can be applied to to conscious individuals and unconscious (dreamless sleep, general anesthesia) individuals. In the conscious state there is a widespread pattern of activation and deactivation noted with high density EEG.  In the unconscious state cortical response is local or global and stereotypical - integration and information are lost.  A metric called the perturbation complexity index (PCI) a measure of the EEG compressibility from TMS stimulation can be used consciousness and it decreases in states that lack it.   

Tonini has been very explicit about the issue of machine consciousness - it doesn't exist no matter how sophisticated the machine is.  Any machine recognizing inputs that the human nervous system would recognize and producing identical outputs, even if that machine duplicates the structure and function of the human brain - is not conscious.  Tononi uses the consciousness science term zombie to characterize such machines.  By definition a zombie system is one that lacks consciousness and they are described as being subsystems in humans (2) when they are active outside the sphere of conscious recognition.

That brings us back to the ability to detect machines from humans.  If a machine is a perfect human zombie in terms of its input and output, we would not expect an empathy or Turing test to throw it off.   IIT theory acknowledges that what appears to be human input and output can be perfectly simulated.  The original Blade Runner protocol seems more than an empathy test. Specific questions about past memories illustrate an attempt determine if there is continuity between any current and past experiences, even though in the case of Rachael - the memories are false and implanted.

That being said IIT states there there is no Turing test for consciousness.  By now it does seem that fairly basic programs (like self learning neural nets) can replicate a narrowly defined human skill. In that case many people speculate that there is an intelligence or even human consciousness behind it.  On the other hand the perturbation complexity index (PCI) seems like a potentially useful test based on current results.



George Dawson, MD, DFAPA


References:

1: Tononi G, Koch C. Consciousness: here, there and everywhere?  Philos Trans R Soc Lond B Biol Sci. 2015 May 19;370(1668). pii: 20140167. doi: 10.1098/rstb.2014.0167. Review. PubMed PMID: 25823865; PubMed Central PMCID: PMC4387509.

2:  Koch C, Crick F. The zombie within. Nature. 2001 Jun 21;411(6840):893. PubMed
PMID: 11418835.

Addendum:

I read Christof Koch's book Consciousness - Confessions of a Romantic Reductionist a couple of months after this post.  In it he credits Tononi for Integrated Information Theory:

..."The theory of integrated information, developed by the neuroscientist and psychiatrist Giulio Tononi, starts with two basic axioms and proceeds to account for the phenomenal in the world." (p. 6)


     

Blade Runner and Tests of Consciousness

There is an event happening tomorrow that has philosophical, biological and engineering implications and the respective definitions of the conscious state in humans.  That even is the opening of Blade Runner 2049.  This film is the highly anticipated sequel of Blade Runner - a 1982 science fiction film starring Harrison Ford as Deckard - a former cop and Blade Runner who is recruited back into active service as the latter.  Blade Runners are assigned to hunt down and terminate replicants or bioengineered androids.  These androids are the product of Tyrell Corporation and the plot of the first film involves Deckard needing to track down and terminate 6 replicants, including 4 who escaped form a mining colony.  Replicants are engineered to be similar to humans in basic appearance, behavior and social interaction but many have superior strength, intelligence, and speed.  That part of the plot would seem to be enough, except that Blade Runners need a specific skill to detect replicants from humans.  They need to be able to administer a test with the Voight-Kampff machine to determine if the test subject is human or a replicant.  A series of test questions of visual stimuli are administered and pupillary response, typical polygraphic measures like respiratory and heart rate, and particles emitted from the skin are measured.  The test questions themselves are designed to detect empathic responses in the subject suggesting that they are human.  The replicants in question are programmed to die in 4 years to prevent them from acquiring empathy and becoming undetectable. 

Early in the original film there are two of these interviews.  In the first, what appears to be a routine interview of an employee goes bad.  He is asked for a response to what he would do if he saw a tortoise in the desert laying on its back, struggling in the sun and not able to right itself.  The second interview is more critical because Deckard travels to the Tyrell Corporation where he meets Dr. Eldon Tyrell and Rachael who appears to be his assistant.  Dr. Tyrell is interested in both the V-K machine and the Blade Runner protocol for detecting replicants.  Rachael asks if there are any false positives from the procedure: "Have you ever retired a human by mistake?"  Eventually Tyrell asks Deckard to administer the protocol to Rachael. When he is done he and Deckard discuss the results.  Here is their exchange after Tyrell interrupts the questioning (2):

Deckard: One more question. You're watching a stage play. A banquet is in progress. The guests are enjoying an appetizer of raw oysters. The entree consists of boiled dog.
Tyrell: Would you step out for a few moments, Rachael -- Thank you.
Deckard: She's a replicant, isn't she?
Tyrell: I'm impressed. How many questions does it usually take to spot them?
Deckard: I don't get it Tyrell.
Tyrell: How many questions?
Deckard: Twenty, thirty, cross-referenced.
Tyrell: It took more than a hundred for Rachael, didn't it?
Deckard: She doesn't know?!
Tyrell: She's beginning to suspect, I think.
Deckard: Suspect? How can it not know what it is?......

The imagery in the film is outstanding.  The acting is good.  These opening scenes set the stage for most sci-fi fans to recognize that Blade Runners are used in the future (originally November 2019) to terminate replicants and they also detect them through a specific augmented interview protocol.  As the action starts to unfold there are additional philosophical questions that arise but these opening scenes are basic to my post.

The concept that there is some kind of procedure that can detect deception has been with us for some time.  The most recognizable form is the polygraph - the basis of which the V-K machine and the interview protocol based upon.  Polygraphic research illustrates that it has "extremely serious limitations for use in security screening" and that the rationale for such a device is weak (1).  Despite those findings and inadmissibility in court the polygraph continues to be used for both security screenings and informal screening of criminal suspects as though it works.  Would an emotional or more correctly psychophysiological response to questions about empathy yield any better predictive response patterns?  Probably not, but we need to keep in mind this was the author's idea about screening machine consciousness and not humans.

Although the viewer is not aware of all of the questions asked in a typical protocol with a compliant replicant, the ones asked are not impressive in terms of empathy.  Empathy as a conscious quality has varying definitions.  Empathy the technical skill is probably a more rigorous definition than what is applied in the screenplay.  A more common definition of empathy is the ability to understand another person's subjective state.  The word empathy is used only once by Dr. Tyrell who asks if the interview with the V-K machine is an "empathy test".  The initial questions that Deckard asks seem to be focused more on ethical behavior or societal standards. Later Deckard breaks protocol with Rachael and suggests that her memories are implanted from others - not really her own.

Apart from the action sequences, the important aspect of the original Blade Runner was the whole idea that there may be a unique human conscious state differentiated from machine consciousness - even in the most sophisticated machines.  The test for consciousness was a subjective interview protocol combined with physiological measures that were supposed to be an enhancement.  The main metric was empathy.  The measures were purely qualitative and their ability to distinguish the differences in empathy between different humans was not discussed but should be suspect.  If the V-K protocol was a valid test - it is conceivable that humans with the least empathy could be confused with a replicant. This problem in consciousness has been the subject of debate for decades - including any specific test to distinguish humans from machines trying to emulate humans.

Before I take a look at any specific test - it is always a good idea to look at the problem of defining consciousness.  Practically any paper that is focused on consciousness discusses the problem of definition at the outset.  From a medical perspective the term is probably even less certain because of its application in neurology and in contrast to subjects who have no discernible neurological problem.  Classic texts like Plum and Posner's Diagnosis of Stupor and Coma (4) discuss consciousness as awareness of self and awareness of the environment.  Consciousness is also viewed as being determined by level of arousal and the content of consciousness defined as the sum of all cognitive, affective, and experiential products of the brain. Fractional loss of consciousness is discussed as being possible when specific neuronal functions are lost.  They differentiate acute states (eg. delirium, stupor, coma) from subacute or chronic states (eg. dementia) and discuss how they are determined clinically.  These states are studied primarily neurologists along with other clearly altered states of consciousness like sleep and general anesthesia.

Assuming no major disruptions in neuroanatomy or physiology, the definition of a baseline conscious state also lacks precision.  There is a general agreement that the person needs a level of awareness and experience.  They are able to experience sensory phenomenon, thoughts, and emotions.  Some authors break that down into standard components of the mental status exam but it it much more than that.  In normal life, we routinely lose consciousness during non-REM sleep and regain it during periods of REM sleep.    Today we know the situation is even more complex because there appears to be a posterior cortical zone that correlates with dreaming experience (DE) or no-dreaming experience (NE) in both REM and non-REM sleep (5).  On of the unique aspects of brain complexity and human experience is that it generates a unique conscious state for individuals.  That makes it impossible to fully appreciate the specific conscious experience of another person.  We generally infer that they are conscious by their typical behaviors.

One of the critical factors in the study of consciousness, especially if we are stepping away from real discontinuities like the loss of consciousness is how we define it.  Most clinicians will say that "we know it when we see it" - but rigorous research definitions are lacking.  At the level of thought experiments things get even more confusing.           

Consider one of the original tests invented by Alan Turing.  His published paper on the subject is available free online (6).  Turing's paper is interesting from a number of perspectives not the least of which is that he predicted in 1950 that "in 50 years time" there would be digital computers that could fool humans at least 30% of the time in what he called the Imitation Game.  The game is played by asking a machine (computer) a series of question to determine if it is human or a machine.  He details this test protocol in the original paper.  He suggests the communication be accomplished with a teletype machine.  The goal of the test is to fool a human judge into believing that the machine is human.  In rereading the original paper it is clear that his focus is on machine thinking rather that the machine's conscious state.  In the paper he debunks what he refers to as "The Argument from Consciousness " by saying this about the need for emotion and self awareness - specifically recognizing that the machine knows what it has done:

"This argument appears to be a denial of the validity of our test. According to the most extreme form of this view the only way by which one could be sure that machine thinks is to be the machine and to feel oneself thinking. One could then describe these feelings to the world, but of course no one would be justified in taking any notice. Likewise according to this view the only way to know that a man thinks is to be that particular man."

This is of course a property of conscious states and he appears to take it to at least as an extreme as the philosophy professor who proposes the original argument that more is needed than the Imitation Game to show that a machine thinks.  It also sets up the question: "Is there any difference between thinking and consciousnesses?"

Turing also predicts that at some point in time, it may be possible to cover a computer with synthetic human tissue and make the identification even more difficult.  He considers and rejects various counterarguments for eventual machine intelligence in this article.

The relationship between consciousness and intelligence is complex.  Practically all of the AI that is written about involves restricted task domains (playing games (chess, poker, Go), verbal chats, or some specific pattern recognition.  One thought about intelligence is that it is context sensitive and needed to complex tasks that cannot be broken down into smaller single domain tasks.  According to one expert (Tononi - see reference 8) "That kind of intelligence is consciousness".  I think that it is fairly easy to look back at the Turing Test and see what Tononi is referring to.  On the face of it - this task of producing a typed transcript appears to be a single domain task.  But behind that there needs to be an intelligent structure that is able to play a game that involves making a human judge believe that the transcript is being produced by a human rather than a machine. While Turing refers almost exclusively to intelligence or thinking in this case it can be considered consciousness.     

The reality of testing replicants is that it is a lot less complicated than suggested by Deckard's interviewing technique with the V-K device.  All you would have to do is polysomnography.  One of the clear cut conscious states is REM sleep.  You could make the argument that a bioengineered android could be set up to fake a sleep EEG, but my guess is that would be a very costly procedure and as Dr. Tyrell says in the original film commerce is the goal of the corporation and spending a lot of money on faking a sleep EEG would hardly be cost effective.  Some AI philosophers might suggest that at some point the machines might learn it on their own if it was advantageous in their competition with humans.  It would take a lot more than learning.  It would take a lot of engineering to produce the necessary electric potentials under standard EEG electrodes inside an artificial skull even if it was covered with cloned human tissue.  We can say at least that the vision in the film cannot be realized anytime soon.

 On the issue of a verbal test for humanness, that is slightly more complicated but not out of the question even at this point in time.  The first time, that I heard that a computer may have "passed" the Turing Test was when a chess player stated that when he was playing an IBM computer it seemed like he was playing a real human.  That is a very restricted task domain paradigm and outside of that I doubt that same computer could have been mistaken as being conscious.  The official milestone of a computer program passing the Turing Test occurred on Saturday June 7, 2014 at an annual competition held by the Royal Society.  Obviously a blinded test of a robot conversing does probably not represent much of a recognizable conscious state.  AI experts are currently working on more rigorous test of machine consciousnesses including interactions in other sensory modalities in order to improve the level of AI.

As I thought about related issues to this post, testing AI for conscious states may come down to determining the manufacturer.  From a theoretical standpoint - perfecting AI performance on future tests of consciousness looks like a trend in the future.  The current AI trends are bound to leave traces of algorithms and an imprint of the management biases in that company.  There are just too many degrees of freedom in conscious systems to not leave a mark.

There are a list of associated issues having to do with identity and implanted memories in machines hoping to emulate humans that I hope to consider in the future.  Consider this mention of Blade Runner a jumping off point.


George Dawson, MD, DFAPA



References:

1:  National Research Council (2003). Polygraph and Lie Detection.  Committee to Review the Scientific Evidence on the Polygraph.  Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

2:  Hampton Fancher, David Peoples.  Blade Runner. Screenplay.

3:  Philip K. Dick. Do Androids Dream Of Electric Sheep? New York; Ballantine Books: 1968.

4:  Posner JB, Saper CB, Schiff ND, Plum F.  Plum and Posner's Diagnosis of Stupor and Coma.  Fourth Edition.  Oxford University Press. New York, 2007.  p 6-37.

5:  Siclari F, Baird B, Perogamvros L, Bernardi G, LaRocque JJ, Riedner B, Boly M,Postle BR, Tononi G. The neural correlates of dreaming. Nat Neurosci. 2017 Jun;20(6):872-878. doi: 10.1038/nn.4545. Epub 2017 Apr 10. PubMed PMID: 28394322; PubMed Central PMCID: PMC5462120

6:  Turing AM.  Computing machinery and intelligence. Mind 49: 1959: 433-460. Link to full text

7: Lorraine Boissoneault.  Are Blade Runner’s Replicants “Human”? Descartes and Locke Have Some Thoughts.  Smithsonian.  October 3, 2017. Link to full text.

8: Consciousness and Intelligence:

MIT150 Symposium: Brains, Minds and Machines Moderator: Shimon Ullman PhD '77, Samy and Ruth Cohn Professor of Computer Science, Department of Computer Science and Applied Mathematics, Weizmann Institute of Science Panel: Ned Block, Silver Professor of Philosophy, Psychology, and Neural Science, Department of Philosophy, New York University Christof Koch, Lois and Victor Troendle Professor of Cognitive and Behavioral Biology, California Institute of Technology; Chief Scientific Officer, Allen Institute for Brain Science, Seattle, WA Giulio Tononi, David P. White Chair in Sleep Medicine; Distinguished Chair in Consciousness Science; School of Medicine, Department of Psychiatry, University of Wisconsin, Madison


Attribution:

Graphic credit is: Shutterstock Stock illustration ID: 561497119 "old street in the futuristic city at night with colorful light,sci-fi concept,illustration painting By Tithi Luadthong".

Mass Shootings in America - Why They Are not Terrorism

You will find more statistics at Statista

American media is so used to mass shootings that many are set up to reflexively release provocative and often poorly thought out theories after the incident.  The fact that there is rarely much more information about the shooter's motive reinforces this process.  The tragic event in Las Vegas is no exception.  It is currently the worst mass shooting incident in the USA and here is a link to the previous two.  There is the usual gun debate and public relations maneuvers by wide gun access advocates.  There are the rational responses by citizens calling for some measure of gun control.  I say rational because there is excellent evidence (1) that stricter gun laws enacted after a mass shooting incident, prevent further mass shooting incidents.  In the media coverage after this incident and on various social media cites there appears to be some confusion over whether American mass shooters are terrorists or not.

Before I go on, I have noticed that in social media many people are posting state statutes that equate terrorism with acts of violence.  The US Code defines both international and domestic terrorism as intimidation or coercion on a domestic population in order to influence the conduct or policy of the government.  I would take it a step further in that there needs to be an ideological message.  All of the news about who takes "credit" for these incidents implies this is a critical dynamic along with all of the publicity generated by many of these groups with very explicit messages.

For all of these reasons, typical mass shooters in the United States are not terrorists.  There is no ideology, no message, and no attempt to influence the government.  There certainly may be mental illness, but that alone is insufficient to produce a typical mass shooter.  There are many more mass shooters that are not technically mentally ill than those who are, but I will admit that the methodology for studying the problem is inadequate since many of these perpetrators are dead or unwilling/unable to produce a coherent story.  I will also be the first to admit that this is my impression, because the data on mass shooters is large and I have no access to all of that data.  For example, the NY Times came out with a graphic showing that in the past 477  days in the US there were 521 mass shootings (2).  They use the criteria of 4 or more people killed or injured qualifying as a mass shooting.  I have no access to that data.  There have been attempts to look at the data according to specific types of mass shooters like rampage killings.  The most recent FBI study looked at where the events occurred, if there was any connection between the shooter and the location.  It did not focus on the potential motivations of the shooters despite having access to all of the data:

Though this study did not focus on the motivation of the shooters, the study did identify some shooter characteristics. In all but 2 of the incidents, the shooter chose to act alone. Only 6 female shooters were identified. Shooter ages as a whole showed no pattern. However, some patterns were seen in incident sub-groups. For example, 12 of 14 shooters in high school shootings were students at the schools, and 5 of the 6 shooters at middle schools were students at the schools. (p. 20).
  
It did look at some specific locations and the relationship of the shooter (employee, family member)  to that location.  The critical analysis of this report was that it appeared that although mass shootings have occurred a long time in the United States - they appeared to be increasing in rate and lethality as indicated by the following graphic from that report:

The graphic points out that not only is the general problem of mass shooting being ignored from  policy perspective, the increasing rate and lethality of these incidents is being ignored.  From the FBI report some of the motivations clearly involve enraged employees or former employees.  Mental illness was omitted as a possible motivation.  All of the vignettes of each incident are attached to the end of the report.

My views on mass shootings, violence prevention, and even homicide prevention have not changed from my previous posts in this area.  I will add one more dimension to the issue and that is the cultural meme of the mass shooter in America.  Granted there are various etiologies that can produce a mass shooter, but after terrorism has been  eliminated there is a prominent cultural meme present in the USA and that is - if I feel like I have been wronged - I can pick up a gun and and make things right (at least in my own mind).  Americans are oblivious  to the presence of this thought pattern in our culture and what it implies.  The most significant implication is that reality is suspended if I merely feel like I have been wronged.  The reality of why I was fired, divorced, arrested is secondary to my thoughts on the matter.  Most adults in this country have had experience dealing with somebody who had this pattern of thinking.  To some extent most people with some level of self awareness can catch themselves in the process of making the same errors - most frequently when angry or emotionally upset.  Varying degrees of road rage is a classic example.  There is an anthropological argument that violence, aggression, and homicide are age old solutions to often minor disagreements.  In many cases the aggression spreads to a  larger number of targets than were involved in the original conflict.

There is the issue of violent and homicidal fantasy being common in both normative and violent criminal populations (4).  Various theories about the function of these homicidal fantasies exist.  Some homicidal fantasies seem higher risk than others but the study of fantasy per se, is limited by inadequate methodology including degree of self disclosure and lack of long term follow up.  Much of the work is anecdotal.
   
At the cultural level is there a larger problem in America?  American culture unquestionably has viewed firearms as tools for settling disputes.  That plays out time and time again in various movies and to varying degrees in American subcultures where being capable of violence and aggression is synonymous with being respected. To be very clear most people can tell the difference, but cultural influences can have a powerful effect.

No matter what the intrapsychic or cultural ground for gun violence, one thing is obvious if a firearm is available it is more likely to be used in both incidents of suicide and homicide.  We currently have a Congress and various political factions that are in denial of that basic fact.  Unless there is a radical change in that political approach and/or a concerted effort toward violence and homicide prevention reversing the trend in the FBI graph is unlikely.


George Dawson, MD, DFAPA




References: 

1:  Chapman S, Alpers P, Agho K, Jones M. Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev. 2015 Oct;21(5):355-62. doi: 10.1136/ip.2006.013714rep. PubMed PMID: 26396147.

2:  The Editorial Board.  477 Days. 521 Mass Shootings. Zero Action From Congress. New York Times; October 2, 2017.

3:   Blair, J. Pete, and Schweit, Katherine W. (2014). A Study of Active Shooter Incidents, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. 2014.

4: Gellerman DM, Suddath R. Violent fantasy, dangerousness, and the duty to warn and protect. J Am Acad Psychiatry Law. 2005;33(4):484-95. PubMed PMID: 16394225

Treatment Setting Mismatches - The Implications

Most physicians first experience with treatment setting mismatches occur when they are medical students and residents.  The ethos of medical training fosters an attitude of being put upon by the trainees - partly because they are or at least they were.  There was a history in American medicine as using the trainees in particular as inexpensive labor - doing all of the admissions to training hospitals and staffing them all night long.  In many if not most cases that meant long hours and minimal staff supervision.  The staff typically would hear about late night admissions only if they gave their resident team specific parameters to call them.

That work flow created tension in the system of care.  Depending on the institution teams could negotiate for admissions but typical the emergency department (ED) physicians had veto power in getting people in the hospital.  They were in the highest risk situation because they were responsible for what happened with discharges from the ED and they were responsible for getting patients out of the ED in a timely manner.  This led medical and surgical teams to view some of the admissions pejoratively as weak or dumps.  Many of these admissions were discharged as soon as possible - partly due to circumstances and partly self-fulfilling prophecy.  The treatment setting mismatches in these case could occur in both the ED and the hospital if the patient did not need to be there.  These problems has bee addressed over the part 15 years with the advent of hospitalists.  Hospitalists have a more enduring relationship with their colleagues in the ED.  There is more consensus on admissions and hospitals are staffed 24/7 by hospitalists rather than trainees.  That does not mean that the treatment setting mismatch has been solved.  You start to notice the issues involved with treatment setting mismatches after you are practicing medicine and you are no longer a trainee.  A few examples will illustrate this point.    


Hospital to Home

A 75 year old woman with diabetes mellitus Type 2, hypertension, and new onset atrial fibrillation is discharged home after two days in the hospital. She came in taking 5 medications but is leaving with 8.  She lives alone and during the nursing review at the time of discharge she knows how to set up the medications out of the bottles every day and the basics of what she needs to avoid in her diet.  There are some red flags with her medications in terms of potential interactions and symptoms that she needs to quickly report to her physician.  She currently has no primary care physician.  Her physician quit the practice and moved to a different clinic.  She tried making appointments with the other physicians in the clinic and had the feeling that "none of them like old people".  She is discharged with a bundle of medication side effect sheets highlighted by the nursing staff.  She is advised to review the highlights and report those symptoms to the clinic. 

Hospital to Facility

An 82 year old man with dementia and agitation is admitted to an acute care psychiatric unit.  He comes in with the message that his current facility will not take him back because he is too aggressive.  The initial assessment shows that he is barely mobile due to osteoarthritis but that he requires intensive nursing care for diabetes mellitus Type 2, wound care for foot ulcers, nebulizer treatments for asthma/COPD, and careful attention to his input and output each day because of moderate renal failure and a tendency to take inadequate amounts of fluids.  After two weeks of working with medical consultants, the attending psychiatrist realizes that there is no Skilled Nursing Facilities where the patient will get the level of care he is currently getting.  Without that level of care the patient will be dead in a few months. 

ED to Home

Patient X is a 50 year old man with alcoholism, alcoholic liver disease, and mild emphysema.  For the past three months he has been drinking 750 ml of vodka per day.  After an intervention with his friends and family he was referred to a substance use treatment facility.  The family was told at that time that he should be admitted to a detox facility because detox was not available at the treatment facility.  The patient decided to go to the ED.  He was given IV fluids and discharged 3 hours later with a prescription for lorazepam and told to go home and detoxify himself of go directly to the treatment setting.  He took all of the lorazepam on the first day and resumed drinking vodka.  He tried to get in to the original treatment facility and was turned down again because he still needed detox.

ED to Treatment Facility

The patient is at a local drug and alcohol treatment facility when he experiences a sudden acute mental status change.  He is confused and starts to experience auditory hallucinations part way through a detoxification protocol.  He asks to leave the treatment facility.  The facility and the patient's family convince him to go to the ED.  While there the staff treat him with benzodiazepines and IV fluids and tell him to return to treatment.  He tries that but the treatment facility disagrees with the ED and see his mental status and being too compromised to participate in treat.  He goes home and resumes drinking instead.

Hospital/ED to Jail

Patient Y a 29 year old man is detained by the police in a local shopping mall for creating a public disturbance.  He was panhandling. When none of the shoppers responded favorably he got very close to them and made loud threatening noises until the police were called.  When the police asked him to leave the mall, he shouted at them and threatened to kill them.  He was arrested but because the police suspected a mental illness he was taken to the emergency department for evaluation.  The arresting officers were hoping he would be admitted for further observation and treatment.  After the ED evaluation was completed as social worker came out and asked about what would happened if the patient was discharged to the street.  The officers responded that he would be arrested and taken to the local county jail.  At that point the patient was released on the basis that he was not dangerous and transported to county jail.   

These scenarios are all hypotheticals based on my experience.  Any physician with similar experience can cite hundreds of these examples and many, many catastrophic endings.  The common biases are that alcohol is not that much of a problem and that most people with chronic mental health and medical problems can continue to plug along with minimal assistance.  The error is to ignore the real dangers and not be focused on quality care that by definition solves and addresses clear health problems.

These scenarios all have some common dimensions.  First, the receiving setting is easily exceeded by the patient's medical needs.  In some cases the receiving setting is not medical oriented at all and is ill equipped to address medical problems.  Obvious examples are people who are discharged to jail or care facilities that are funded on the basis that they provide little to no medical care.  The scenario where the man with chronic (or in some cases acute) mental illness being sent to jail rather than hospitalized for effective treatment is one of the reasons why county jails have become the largest psychiatric hospitals in the USA.  It is one thing to recognize that fact but it is another to think about how that is happening.  In most cases hospitals have little to no bed capacity for psychiatric patients.  If they do - they are inadequately funded to provide complex care with inadequate staffing, length of stay, and in some cases inadequate medical and psychiatric coverage. At some point the politicians and bureaucrats decided to align the incentives so that level of care would be best provided in jail. 

Second, the discharge to inadequate facilities are driven by rationing of acute care facilities as "expensive and possibly unnecessary facilities".   That determination is complicated by the fact that receiving facilities have also been depleted by the same rationing mechanisms.  The reality of American healthcare at this point is that it is almost all rationed by a middleman who are incentivized to make as much profit as possible by rationing.  A great example is detoxification from drugs and alcohol.  Despite the fact that this process is potentially life threatening, at the minimum is associated with a high degree of distress, has significant psychiatric morbidity including suicide risk, and needs to be properly done in order to facilitate sobriety very few people in the USA are admitted for appropriate detoxification.  Like people with severe mental illnesses they are mostly sent home or to a facility with minimal to no medical coverage and then sent home.  In cases where a person is incarcerated they often go through acute detoxification with no medical assistance.  In many cases they suddenly stop opioids, benzodiazepines, or opioid agonist treatment (methadone or buprenorphine) and go through severe withdrawal in jail. 

Third, leaving a medical facility where there is intensive nursing care is like falling off a cliff for a lot of people.  There is no transition or assurance that many people can manage their own care in their own homes.  There used to be more options.  Public health nursing comes to mind.  Twenty years ago the attending physician could write an order and a public health nurse would see the patient in their own home and make sure that the transition was occurring properly and if not stay in contact with the patient and provide ongoing assistance.  That service was eliminated along time ago in order to reduce costs.

Fourth, an entire system of shadow care has evolved to make it seem like care is being provided when it is not.  Typical examples include health club discounts or a life style coach that calls you up on the phone and encourages you to be more physically active or eat less.  The ultimate advertising these days is a plan where you get a very modest health insurance discount through your employer if you sign up for one of these options and demonstrate compliance.  It makes it seem like both your employer and your health plan care about your health.  In the larger scope of things, it is nothing compared to the lack of care that happens in the above scenarios.

The final point to be made here is the irony of spending more money on health care than any other country in the world and having a large portion of it go up in smoke.  The source of that smoke is the huge administrative costs and profits of rationing health care under the guise that it is more "cost effective" or "efficient".

There is nothing cost effective or efficient about rationing poor quality care to patients.  The best evidence is during care transitions and the resulting treatment setting mismatches.


George Dawson, MD, DFAPA

Whatever Happened to IPT?

I  first read about the Interpersonal Psychotherapy of Depression when the book came out in 1984.  The origins were there for quite a while before the book.  Gerald Klerman, MD and Myrna Weissman, PhD were prominent in developing a model that depended heavily on psychoanalysis and previous interpersonal theorists like Harry Stack Sullivan and John Bowlby.  The theory rests on a fairly basic assumption and that is that depressions can have an interpersonal etiology as well as social and biological ones.  At the time the book came out, manualized psychotherapies were starting to peak.  A few years earlier I requested a copy of the research manual from Marsha Linehan, PhD and she sent it to me.  That original manual is quite different from the way that (dialectical behavior therapy) DBT is practiced today as a general group behavior therapy.  Beck, Ellis, and Meichenbaum were focused on cognitive-behavioral therapy or CBT at about the same time.  These authors produced texts and manuals on how to perform these therapies.  The driving force for the manuals was psychotherapy research.  A standard research protocol in any therapy was to produce a manualized version, train the research therapists in the therapy, and then monitor them at various points in the therapy to assure that they were performing the therapy according to the manual.

Clinical training at the time was not nearly as standardized. It is fair to say that the predominate training model for psychiatrists was psychoanalytically based psychodynamic psychotherapy.  The main subdivisions were insight oriented psychodynamic psychotherapy and supportive psychotherapy.  Supportive psychotherapy avoided confrontation of the patient's defenses and the therapist used many of the techniques used in CBT.  There were also some brief forms of psychodynamically based psychotherapy.  Viedermann wrote about a psychodynamic life narrative model of crisis intervention for college students in crisis.  It was designed to be delivered in just a few sessions.  The approach was interesting because it had interpersonal psychodynamic interpretations rather than transference based or interpretations based on unconscious mechanisms.

Depression is a very heterogeneous category of disorders.  The interpersonal context remains the same and it is up to the clinician to figure out what might be relevant - what might have personal meaning.   The four areas of focus noted int he above diagram can be historically recorded in just about anyone's life - but are they the cause of depression?  IPT answers the second half of that question - what can be done about it?

A good illustration is the case of the depressed person who has sustained a significant personal loss that they have not recovered from.  In clinical practice it is common to see people who are depressed and  date the onset of that depression to a point in time when a significant figure in their life died. Whether that happened 10 or 20 years ago - they have not recovered despite antidepressant maintenance or multiple antidepressant trials.  The goal for the IPT therapist is to discover of the depression is due to the loss of the meaning of the loss and facilitate completing the grief process.  In today's world, many patients with grief are referred to Eye Movement Desensitization and Reprocessing (EMDR) therapists for presumptive post traumatic stress disorder (PTSD).  I have certainly encountered people who were traumatized by the manner in which their significant other died.  The most common scenario is a surviving spouse or parent.  In the majority of cases, the patient is experiencing grief and they have not been able to complete that process.  The IPT therapist is able to recognize and treat that problem.            

There is plenty of evidence that IPT is an effective form of psychotherapy if you really need evidence.  Medline searches yield a total of 4590 references for interpersonal psychotherapy 786 reviews in that category.  For interpersonal psychotherapy depression there are a total of 1548 articles and 327 reviews.  A recent brief and excellent review article was written by Markowitz and Weissman.   It contained this description of Gerald Klerman's orientation during the initial discussions of this psychotherapy:

"Although Klerman, a psychiatrist, saw depression as basically a biological illness, he was impressed by how social and interpersonal stress exacerbated onset and relapse. Noting that ‘one of the great features of the brain is that it responds to its environment’, he felt that the interpersonal context of the onset of a depressive episode might be a target for psychotherapy." 

I would add that at the time there was active conflict between academic psychiatrists who considered themselves to be biological psychiatrists and a group who considered themselves to be psychotherapists.  Eclectic psychiatrists like Klerman existed in every department but they tended to be the silent majority.  Psychiatrists like me were fortunate to be trained by them.

There are several reasons why knowing about IPT - in addition to other psychotherapy paradigms can be useful to any psychiatrist:

1.  It is easy to learn -

There have certainly been other manualized versions of psychodynamically based psychotherapy.  The authors here have really streamlined the process and generally provide a level of analysis based on social roles/behaviors and discuss specific strategies to address problems.

2.  It facilitates thinking about a formulation (if you do that) - 

When it comes to assessment and diagnosis - I have a lot of details on this blog supporting the basic framework that a psychiatric diagnosis is really not enough when it comes to a psychiatric assessment.  There needs to be an overall formulation of what the patient's problems are and how they came about.  A diagnosis or diagnostic code is a poor substitute.  Considering two 50 year old men with severe depression - it probably matters if one of them got depressed as a result of being fired and the other became spontaneously depressed and could not work because of that disability.  That fact alone creates more relevant information for the diagnosis and treatment planning that all of the diagnostic codes and modifiers.

3.  The therapy can be delivered rapidly in the context of psychiatric appointments -

Once the formulation is in your notes, you can pull it up at subsequent visits and discuss what is relevant to the patient.  Many of the interventions are very focused and can be discussed over the span of 15 or 20 minutes.  Instead of just reviewing medication related symptoms and side effects, the discussion can include a therapy that is effective for depression and may either enhance or replace the medication effects.

4.  It provides a formulation that the patient understands and improves empathic communication - 

I have had people ask me at the end of the interview to "Tell me what you think the problem is." They may add other sentences for emphasis like: "I've done all of the talking here - you're the doctor - tell me what the problem is."  Listening for a thread in addition to the usual description of symptoms allows for a formulation based on interpersonal of social contexts and how that relates to diagnosis and treatment.  It should not be too hard to believe that most people find that a DSM atheoretical formulation falls flat.

5.  IPT can reveal unaddressed problems - 

If the IPT therapist is talking with a patient who dates their depression back to the loss of someone who they were emotionally attached to and that has never been addressed, that provides some diagnostic and therapeutic insight in the same session.  In some cases it can also lead to cost effective therapy for the patient if there are grief counseling clinics or a clergy person who does grief counseling.  One of the glaring errors I have noticed with a lot of current therapy is that it is trauma based.  To me that means that a person has experienced trauma at the level that it could cause post traumatic stress disorder or similar problems.  I see many people with grief diagnosed as having a trauma disorder and treated with exposure therapy for grief.  Grief counseling or an IPT approach is a preferable option.  

6.  IPT adds a needed non-medicine dimension to psychiatric treatment - 

The term psychopharmacologist is often mentioned by people who I assess.  I ask myself what does a psychopharmacologist do when the patient is experiencing a chronic stressor that is either environmental of interpersonal in nature.  Does the medication just go up to the point that the person is numb to the stress?  As a psychopharmacologist myself, there is an obligation to let people know that at some point - the stressors in life will overcome the effects of medicine and that there is no medicine that will overcome chronic stress - at least without sedating them to the point that it will be difficult to function.  At that point the therapeutic alliance needs to focus on resolving the environmental or interpersonal stress.  It is extremely important at that point in time to be able to associate the patients problem with the therapy models and discuss these paradigms as a way to resolve the problem.  In this case - hopefully all psychiatrists have been trained in the non-medicine dimension before they start seeing patients.  

Those are some of my thoughts about IPT.  I have always considered it to be an effective and pragmatic form of psychotherapy.  Back when I was learning about psychotherapy, I had supervisors of every stripe ranging from Rogerian therapy to psychodynamic to existential psychotherapy.  The paradoxical  aspect of my psychotherapy supervision was that they all advocated for picking one style of therapy and sticking to it.

I really don't think that is a good idea.  Strictly in terms of psychodynamic therapy, one of the key aspects of the assessment was to determine if the patient was psychologically minded enough to engage in the constant clarification, confrontation, and interpretation that goes on in that format.  If not they were considered candidates for supportive psychotherapy.  To someone trained in my era, CBT, IPT, and DBT and their equivalents would all be considered supportive psychotherapies.

I think that provides a good rationale for knowing these therapies and being able to apply them to situations where they might be the best approach.    



George Dawson, MD, DFAPA


References:

1: Viederman M. The Psychodynamic Life Narrative. Psychiatry. 1983 Aug;46(3):236-246. PubMed PMID: 27719516.

2:  Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES.  Interpersonal Psychotherapy of Depression.  Basic Books, Inc; New York; 1984: 255 pp.

3: Markowitz JC, Weissman MM. Interpersonal psychotherapy: past, present and future. Clin Psychol Psychother. 2012 Mar-Apr;19(2):99-105. doi: 10.1002/cpp.1774. Epub 2012 Feb 14. PubMed PMID: 22331561.

4:  Holly A Swartz.  Interpersonal Psychotherapy (IPT) for depressed adults: Indications, theoretical foundation, general concepts, and efficacy. In: UpToDate, Roy-Byrne P (Ed), UpToDate, Waltham, MA, 2018.  Accessed February 17, 2018. Link