Psychiatry - Science and Pseudoscience

I finished the first chapter in Philosophy of Pseudoscience: Reconsidering the Demarcation Problem by Pigliucci and Boudry.  I became aware of Massimo Pigliucci and his work back in 2002 when I read his book on Intelligent Design and since then have discovered his blog Rationally Speaking where he has recently posted his best papers from his careers as a scientist and a philosopher.  He writes very clearly on the philosophy of science and has such a command of the field that he can include a history lesson of relevant references.  He also does not shy away from controversy or the apparent lack of a clean solution to a problem.  One of the central concepts in his chapter is this chart of empirical knowledge versus theoretical understanding. (click to enlarge)

The purpose of this essay is to look at possible boundaries between science and pseudoscience as well as a couple of interesting observations as they apply to psychiatry.  One of his key concepts is that the lines of demarcation are not necessarily sharp and the variables are not necessarily linear.  He uses the above graph of empirical knowledge versus theoretical understanding as an example.   Starting in the upper right corner of the diagram we have hard sciences with particle physics given as the most clear cut hard science.  I like to think about my undergraduate chemistry experience as being hard science.  Even introductory chemistry exposes the student to an amazing array of facts, observations, and theories that are incredibly accurate.  From there, chemistry majors build on their ability to measure specific compounds, synthesize them and study the theory in Physical Chemistry.   I don't think that there is any doubt that chemistry as a field is not too far removed from particle physics in terms of empirical knowledge or theoretical understanding.  String physics has much theory but is low in terms of empirical support.  He refers to evolutionary psychology,  scientific history and Search for Extraterrestrial Intelligence (SETI) as a "proto-quasi science" cluster with decreased amounts of theory and empirical support.  Other fields like the so-called "soft sciences" of sociology, economics, and psychology have a fair amount of empirical knowledge but less theoretical understanding.  The true pseudosciences are in the zone with astrology, HIV denialism, and Intelligent Design.  From the history of psychiatry - Freudian psychoanalysis and Adlerian psychology would also be included here but there is also a list of theories from general medicine and surgery that would also qualify.

In psychology and psychiatry a central philosophical problem is the so-called hard problem or the explanatory gap between the neurobiology of conscious states and subjective experience.  This is exactly where psychiatry resides.  A lot of political criticism of psychiatry involves the ability to parse these states and accurately classify different conscious states.  Resolving the hard problem would move psychiatry and psychology firmly to the right in the demarcation diagram but probably not nearly as far as particle physics or maybe not even as far as molecular biology.

The relevant question for me of course is where psychiatry fits on the plane of empirical knowledge x theoretical understanding.  What about medicine in general?  Could we plot a plane of medical and surgical sub specialties on this plane instead of the hard and soft sciences?  Does medicine and surgery have theories or practices end up in the same zone as Freudian psychoanalysis.  Of course they do.  A great example from my days as a medicine intern was highlighted by Ghaemi as "The cult of the Swan-Ganz catheter."  In the places where I trained, anyone with moderately serious cardiopulmonary problems was at risk for placement of a Swan-Ganz catheter.  The actual person inserting the catheter could be a medicine resident, a cardiologist, or an anesthesiologist.  Since the intern is responsible for doing the initial history and physical exam, I witnessed the placement of a large number of these catheters.  Once placed they gave an impressive number of parameters on ICU monitors.  We were routinely grilled about the meaning of these parameters by attending physicians on rounds.  It all seemed very scientific.  The cult of the Swan-Ganz catheter was subsequently disproved by randomized clinical trials.  This standard of care from the 1980s and 1990s disappeared much faster than Freud.

The best way to plot medicine and psychiatry on Pigliucci's empirical knowledge versus theoretical understanding plane would be to consider the clinical basic sciences taught in the first two years of medical school.  In my experience that was anatomy, neuroanatomy, histology, microbiology, biochemistry/molecular biology, genetics, pathology, physiology, pharmacology, epidemiology, and statistics.  Practically all clinical specialties carry these basic sciences forward in one form or another.  The research literature in any particular specialty in full of theory and techniques from these basic sciences.  The psychiatric literature cuts across all of the basic sciences in the same way as other specialties.  At the minimum, some of psychiatry will be at the level of molecular biology on the diagram in some areas and at the level of psychology in others.  Hopefully the unscientific theories will be relegated to the lower left hand corner of the diagram as unscientific and not stand the test of time.

I think that Professor Pigliucci's conceptualization is a very useful one.  I expect that he will continue to refine these ideas.  I think that measurement precision and categorization may be important dimensions to add to these concepts.  As Merskey has pointed out both the phone book and the periodic table are much more accurate forms of categorization than any scheme of medical classification.  I think that probably says a lot about the underlying scientific dimensions and how measurement is done.


George Dawson, MD, DFAPA

Ghaemi SN.  A Clinician's Guide to Statistics and Epidemiology in Mental Health.  (2009) Cambridge University Press, Cambridge, UK.  p. 91.

First Episode Psychosis

There is an interesting study in the July JAMA Psychiatry on the treatment of first episode psychosis (FEP).  The authors conclude that this is the first study that shows major advantages of an antipsychotic discontinuation strategy over maintenance therapy.  FEP has always been a topic of interest to me because for 22 years I ran an inpatient unit and about 10% - 20% of the admission were patients with FEP.  For the purposes of the study FEP encompassed the diagnoses of schizophrenia, schizophreniform   disorder, schizoaffective disorder, brief reactive psychosis, delusional disorder and psychotic disorder not otherwise specified (NOS).  There were no diagnoses of mood disorders or organic disorder with psychotic symptoms.  Thirty six percent had a comorbid alcohol or substance use disorder.  In the original study 7 years earlier, 128 patients were randomized into a DR (dose reduction/discontinuation) and MT(maintenance treatment) arms.  A few things are striking as I look at this study.  The first is the relatively small N of patient in the study and the diagnostic heterogeneity.  In the subgroup analysis at 7 years (Figure 3.) there were a total of 5, 6, 8, and 14 patients in the subgroups.  Some of the diagnostic categories imply more chronicity than others.  

From an experimental standpoint I have concerns about the addition of that last three categories - delusional disorder, brief psychotic disorder, and psychotic disorder-NOS.  In my experience, delusional disorder is often not associated with much functional impairment and patients often do not benefit from or want to take any medications.  They can be engaged in psychotherapy but maintaining them in therapy is often problematic unless there is an associated crisis in their lives.   Brief psychotic disorders also have a good prognosis.  I recall presenting data to families concerned about this problem based on a review of what was primarily Scandinavian literature from the 1980s suggesting that up to 50% of patients with a diagnosis of "brief reactive psychosis" experienced remissions.  Schizoaffective disorder has similar problems with the manic subtype having a course and prognosis similar to bipolar disorder and the depressive subtype having a course and prognosis similar to schizophrenia.  In clinical practice it is extremely common to see bipolar patients misdiagnosed with schizoaffective disorder and I have always wondered how that impacts on the studies of course and prognosis.  At any rate, adding these diagnostic categories (31% of the total sample) biases this study toward better outcomes.

The dose of haloperidol is interesting.  I started to practice inpatient psychiatry in an era of very high dose antipsychotic medication.  It did not take long to figure out that this was a bad idea.  It also did not take long to look at the basic science behind antipsychotic medication dosing.  A key figure in the early days of dopamine receptor pharmacology was Phillip Seeman, PhD who wrote an excellent review in American College of Neuropsychopharmacology's The Fourth Generation of Progress.  His graph of D2 receptor dissociation constants versus free neuroleptic in plasma water correlated well with antipsychotic dose provided a sound rationale for lower doses and also monitoring plasma levels of antipsychotics.  In my experience the only people who need higher doses of antipsychotics are rapid metabolizers of a particular drug with lower than expected levels.  With haloperidol that usually translates to a dose of 2-4 mg/day.  That is consistent with the dose ranges in the diagram in Figure 2 of this paper.  There is also a distinct group of people who have such neurotoxicity from antipsychotic medications that they should probably never take them.  That is also why I am member of the Movement Disorder Society.

Another interesting aspect of this paper is the psychopathology ratings.  When I noticed the diagnostic heterogeneity and the likelihood of remission, the logical question is what the ratings show.  In this study the  Positive and Negative Syndrome Scale (PANSS).  I had experience   with the brief versions of these scales.  Each dimension is rated on a 7 point Likert scale from 1 (normal) to 7 (extremely severe).  The PANSS is widely accepted as being psychometrically valid.  There is not a consensus on the interpretation of scoring and what might mean remission.  In this study we have to track back to the original description of the sample (3) and we observe the average baseline PANSS P score as 9.9 for the DR groups and 10.7 for the MT group.  The average PANSS N score was 13.1 for the DR group and 14.0 for the MT group.  For the purpose of contrast, the authors of this article expressed their concern about the interpretation of PANSS scores illustrate their concern by presenting ratings for an agitated patient with schizophrenia and paranoia.  The PANSS P score of 28 had improved to 24 by the end of the study and the PANSS N score was unchanged at 22.  

The overall context for the references here are important to keep in mind.  The authors original experiment (3) was an 18 month follow up of FEP following 6 months of remission of positive symptoms according to the PANNS.  It basically showed at that point that only 20% of patients can discontinue medications in the acute phase and that the relapse rate was twice as high with the DR than the MT strategy (43 versus 21%).  The current article (2) recruited members of the original trial and did the same intervention after 6 months of remission and assigned them to DR and MT groups and showed that the DR patients had twice the symptomatic and functional recovery rate than the MT patients (40.4 vs. 17.6%).  Looking at the baseline and study completion PANNS score for both studies yields the following:

All PANNS scores are  mean(SD)	Study 1				Study 2
	Baseline		End of Trial		Baseline		End of Trial
	DR	MT	DR	MT	DR	MT	DR	MT
PANNS P	9.9(2.8)	10.7(3.0)	11(4.3)	10.8(3.8)	9.79(2.96)	10.78(3.15)
PANNS N	13.1(4.6)	14.0(5.6)	12.1(5.2)	13.3(6.2)	12.87(4.8)	13.96(5.51)
PANNS G	24.6(6.2)	26.4(6.9)	24.7(7.3)	24.9(6.7)	25.27(6.44)	26.45(6.62)

Although I could not find PANNS scores for the end of the second study, the scores in all categories across studies are strikingly similar.  PANNS, BPRS, and CGI scores have recently been investigated by Leucht, et al who conclude that a change of a 10 point reduction of a PANSS score was the equivalent of mild clinical improvement and a 50% reduction was consistent with “much improvement” in an acutely ill non-refractory sample (5).

I think the reasonable conclusions from this study are:

1.  Mildly symptomatic populations with FEP may be cautiously tapered off low dose antipsychotics over time and experience better functional recovery.  Tapering earlier in the course has a higher risk of relapse.

2.  The treatment recommendation for low dose antipsychotic medication in mildly symptomatic populations is sound practice according to this report.  Another important aspect is that minimal side effects were reported in standard measures in this study.  It is still common to find patients discharged from hospitals on the equivalent of 10-20 mg haloperidol and show up for their first outpatient visit with metabolic or neurological side effects.

3.  FEP needs further study.  I suppose we can wait for a large initiative and I may have missed one in progress, but the best approach at this time would be for large clinics and hospital based programs to all develop FEP clinics staffed by interested staff and networked to share information.  This study highlights that following the remission of psychotic symptoms is not enough and the common practice of following people in an outpatient “medication management” visit is not enough to restore functional capacity or quality of life.  There is also the question of the availability of psychotherapy for people who can successfully taper off antipsychotic medications and for those who cannot.  I have found that psychotherapy is often a useful treatment for people who cannot tolerate low dose antipsychotic medication.

4.  The authors describe reasonable concerns about their study including that fact that they may have selected the “best half” of the subjects from the original trial.  The subjects that were nonparticipants in the second study were described at “functioning at a lower level, less adherent to therapy and more difficult to engage.” But it is difficult to see that in the rankings at baseline.  They also point out that the raters were not blind and suggest that probably would not account for the degree of difference.  Based on studies of clinics that deal well with certain chronic disease (like cystic fibrosis) motivated clinicians with a stake in the treatment method and outcome clearly can make a difference and that might be reflected in ratings.  They discuss a mechanism to account for gains in functional capacity in the DR arm and that is basically less impairment of dopamine signaling and possible impairment in drive, motivation and functional capacity.  They recommend follow up studies of up to 7 years “or longer” in duration to look at these trends.

Finally, there is really no reason why principles discovered in an FEP study or a psychotherapy study of psychosis cannot be applied to patients who have histories of recurrent psychotic episodes.  Highly motivated clinicians can apply these treatment modalities if they have the opportunity.  It is really no different than large scale (but much better funded) efforts in other specialties where the treatments and outcomes are in a state of flux.  A good example would be electrophysiological ablation of atrial fibrillation.  There has been some opinion about the implications of this study for the idea of life-long maintenance therapy but it is equally damning for the model of seeing patients in 15 minute visits and asking them about positive symptoms and medication side effects.  There has always been a need for a much broader focus on cognition and functional capacity.

George Dawson, MD, DFAPA

1: McGorry P, Alvarez-Jimenez M, Killackey E. Antipsychotic Medication During the

Critical Period Following Remission From First-Episode Psychosis: Less Is More.
JAMA Psychiatry. 2013 Jul 3. doi: 10.1001/jamapsychiatry.2013.264. [Epub ahead of print   PubMed PMID: 23824206. 

2: Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in

Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose

Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up

of a 2-Year Randomized Clinical Trial. JAMA Psychiatry. 2013 Jul 3. doi:

PubMed PMID: 23824214. 10.1001/jamapsychiatry.2013.19. [Epub ahead of print]

3: Wunderink L, Nienhuis FJ, Sytema S, Slooff CJ, Knegtering R, Wiersma D. Guided

discontinuation versus maintenance treatment in remitted first-episode psychosis:

relapse rates and functional outcome. J Clin Psychiatry. 2007 May;68(5):654-61.

PubMed PMID: 17503973.

              

4:  Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS)

for schizophrenia. Schizophr Bull. 1987;13(2):261-76. PubMed PMID: 3616518.

5: Leucht S, Kane JM, Etschel E, Kissling W, Hamann J, Engel RR. Linking the

PANSS, BPRS, and CGI: clinical implications. Neuropsychopharmacology. 2006

Oct;31(10):2318-25. Epub 2006 Jul 5. PubMed PMID: 16823384.

Happy Labor Day II - To All of the Docs on the Assembly Line

Last year I posted a Labor Day greeting to all of the docs laboring in American medicine.  I used the assembly line metaphor for obvious reasons - physicians were no longer being treated like knowledge workers but were being treated like assembly line workers.  Circumscribed patient visits were the widgets.  In the case of proceduralists the procedure was the widget.  One of my friends referred to himself as a "scope monkey" based on the expectation for the number of procedures he was supposed to produce every year.  Have there been any substantial changes in the last year?

The bad news is that there have not been. Managed care continues to consolidate its monopoly.  The final product under the Affordable Care Act (PPACA) will result in unprecedented leverage on the part of that industry over physicians and patients.  I often compare the healthcare industry to the financial services industry when it comes to an example of government determined monopolies.  The 401K is a great example of how this works.  The 401K was sold to the American public as a great way to save for retirement.  When the choices in 401K were limited it was sold as a way to simplify the 401K for most people.  The truth about 401Ks is that they have not been a very successful investment vehicle.  They put trillions of dollars of retiree savings at risk and the fees they charge are even more outrageous than medical fees.  I just looked at a bond fund prospectus this morning that shows on an investment of $10,000 I could expect to pay $1,000 in fees every 10 years.  Considering that there are about $9 trillion dollars in 401Ks and IRAs that generates about a trillion dollars in fees (about $90 billion a year) for the financial services industry.  Those fees are generated independent of the general goal of retirement funds - actually having money for retirement.  My prospectus has the usual disclaimer: "The value of your investment in the fund can go up or down.  You can lose money by investing money in the fund."  As many baby boomers found out that can be 30-40% of your principal.

How does managed care compare?  The most interesting game has been the idea that all fees will increase substantially with the implementation of the PPACA.  This bill allows for unprecedented merger and efficiencies.  It allows for only 80% of the health care premium to be devoted to the actual provision of health care services.  It is logical to assume that a greater percentage of the health care dollar devoted to health care would also decrease premiums.  There will be significant hidden savings associated with a model of care that is integrated and minimizes the amount of physician billing.  Insurance company rhetoric suggests that provided additional services to the uninsured with no limitations on pre-existing conditions will more than cancel out the monopoly advantages.  If that was true why lobby for large monopolies?

One of the indicators to me of just how much leverage the managed care industry has is the expected out of pocket costs for a retired couple on Medicare.   That number is currently $220,000 not including nursing home costs.  That is roughly more than four times the average retirement savings for most Americans.

The financial services industry and the medical industry are basically government mandated hidden taxes on the American people.  In exchange for that huge subsidy we get an industry that charges us significant fees to place our retirement funds at risk all of the time and another industry that rations health care and charges whatever they want in order to make money.  In the case of the medical industry the overriding philosophy is not consistent with an enlightened approach to employees that probably know a lot more about the provision of quality medical services than the administrators.

That conflict of interest is central to the deterioration of the practice environment and a diminished focus on quality care and a continued focus of the study and academic aspects of medicine.   Having medical care dictated by administrators using business guidelines or managed care reviewers using the same approach is demoralizing.  Unless this conflict of interest is adequately addressed - the focus of health care will be turning out widgets.  Only the widget producers will be valued.  Administrators making arbitrary decisions run the whole show.

All of this remains decidedly grim in terms of the practice environment where most physicians work.  It is only fair to consider some solutions.  I will try to avoid the political decisions I have advanced in APA and other medical forums over the past 20 years.  Physicians are uniquely oblivious to the fact that the science of medicine is routinely trumped by business and politics.  Are there any possible solutions?  For many years private practice was always considered an option.  With the PPACA that route will be more difficult because the solo practitioners and groups will probably be off the network and professionally isolated, but some will be able to practice in this environment.  There is still niche work where physicians can be paid professional salaries and still have adequate time to complete all of the administrative tasks and focus on quality work, but they are rare.

A single exciting model that I think can disrupt the usual managed care and government restrictions that I expect to flow from the PPACA comes from the University of Wisconsin and their Memory Clinics approach.  This is a statewide network of clinics focused on providing state-of-the-art and quality care across a number of settings.  Guidelines, continuing education, and consultation is provided from a University based department and there is a minimum requirement for for ongoing education every year.  I don't see why this model cannot be widely applied across psychiatry and all other medical specialties.  It brings the academic focus back into medicine instead of the current focus by governments and business.  The practice environment of medicine needs this academic focus and it would greatly enhance the practice environment and get us out of widget production.

That is my hope between this Labor Day and the next.

George Dawson, MD, DFAPA

Response to Dr. Lieberman on the Changing Times for Psychiatry

Jeffrey Lieberman, MD is the current President of the American Psychiatric Association (APA).  He came out today with the first in a series of three statements on the changing profession of psychiatry.  He starts out with an uneven historical recap of the first 200 years of the profession.  I am probably sensitized to his use of Freud as an inflection point with my recent study of the philosophy of science.  Freudian psychoanalysis and Adlerian psychology were Popper's original example of fields that did not meet logical criteria as a science.  They were not falsifiable and therefore were unscientific.  At the same time the neuropsychiatric movement based on phenomenology and neuroanatomy associated with German asylums is not mentioned.  I suppose that a historical context is appropriate when considering all of the inflection points for the profession but let's face it - the first 150 of those 200 years are irrelevant to any scientifically based psychiatry and can be disregarded.  He added a few paragraphs on the advent of psychopharmacology and the DSM as additional innovations and ends with his idea that the rising cost of health care and the pace of scientific discovery will be the two forces that shape the profession of psychiatry going forward.

My first problem with this statement is that there seems to be no role for psychiatrists or their professional organization in shaping the profession.  We are there to be buffeted by rising costs and scientific discovery.  Like most fields of medicine innovation has been driven by the clinicians and researchers in the field.   When Len Stein, MD and his collaborators noticed that patients at the Mendota State Mental Health Institute were residing there in appalling conditions, they invented community psychiatry and community support teams and moved them out.   There have been a long list of innovators in psychotherapy, psychopharmacology, neuroscience and in the general methods of psychiatry.

Taking Dr. Lieberman's points individually and starting with the rising cost of healthcare - what does that mean exactly and what does it mean in terms of psychiatric services?  Thirty years ago some health plans covered unlimited psychotherapy.  Many psychiatric trainees underwent psychoanalysis as part of their training and it was covered by health insurance.  Today they would likely get a brief evaluation or a checklist and the offer of antidepressant medication if they scored high enough on a rating scale.  If they were very fortunate they might see a crisis counselor for two or three sessions.   How could this change in care possibly be related to rising costs?  Psychiatric care has never been cheaper.  The rising costs in medicine have to do with services that have pricing power and that never involves mental health.  The real challenge here is a political one.  It is very apparent that political systems and their partners in the business community will do everything possible to restrict access to psychiatric services - no matter how cheap they are.  In the general scope of actual payments to providers there are no services that are more cost effective than psychiatry and until very recently that was essentially guaranteed by special billing codes that reimbursed psychiatry less.

The impact of rationing of psychiatric services by managed care companies, state and federal governments go beyond the purely economic.  When psychiatric services are easily rationed, evidence based services that are more expensive like Assertive Community Treatment can simply be made a non covered service.  There are few functional detoxification facilities for people with severe drug and alcohol problems.  Most people are sent home from an emergency department with medications to "self detox" or sent to a county run facility with no medical services.  They are readmitted when that fails or when they develop complications that require intensive care such as seizures or delirium tremens.  The majority have no chance to achieve sobriety from outpatient detox of significant addictions.  The hospital evaluation and treatment of severe disorders that often take weeks or months to assess and treat are restricted to a few days.  The actual admission and discharge decisions from hospitals and treatment centers are no longer medical decisions but they are based on arbitrary guidelines made up by business organizations.  Entire hospital and clinic environments are run by administrators with no psychiatric training.  There are actually situations where administrators seem to believe that they can design treatment programs that target behavioral problems when they are not clinicians.  The "rising cost of health care" rhetoric is frequently used to rationalize a nationwide approach to mental illness that is totally nonfunctional.  This has been the result of a series of "reforms" that basically turned the field over to the managed care industry.

Psychiatric research and the neuroscience research that applies to psychiatry is vast.  When physicians are trained we are all taught to value ongoing education.  At some point the education of physicians also became a political football.  There are initiatives to teach physicians how to treat pain.  A decade later there are initiatives to retrain physicians who are prescribing too many opioids - despite the fact that the original initiative had a goal of appropriate assessment and treatment.  Specialty boards and the oversight board unilaterally decided that the public wanted board certification to be time limited.  They came up with a Maintenance of Certification (MOC) procedure despite the lack of evidence that it was necessary.  That allowed several states to consider tying medical licensing to these costly and unnecessary exams.  The best way to educate physicians is an active collaboration at both the clinical and basic science levels like many specialty boards were doing at the time of the new idea about MOC.

These are the dimensions that shape my world as a psychiatrist every day.  They have been responsible for the deterioration of the practice environment and decreased quality of care across most treatment settings.  Contrary to Dr. Lieberman's points there has been no reform and there certainly is no enlightenment.  Despite all of the research and expanding knowledge clinical psychiatry is in the Dark Ages as external forces suppress psychiatrists and limit creativity and innovation.

George Dawson, MD, DFAPA



Jeffrey Lieberman, MD.  Change, Challenge, and Opportunity: Psychiatry in Age of Reform and Enlightenment.  Psychiatric News August 29, 2013



   

Adapting to a Mother with Problems

Mothers have historically held a prominent place in psychiatry.  The public often thinks that mothers are blamed for problems with their children, but the research on the matter is less clear and more subtle.  That is true even in the case of theorists who placed very little emphasis on individual psychopathology and more on problems within the family system.  The concept of "expressed emotion" evolved to describe a critical home environment that may be associated with exacerbations of schizophrenia.  Childhood adversity is the current concept that describes a number of factors that children must negotiate and that can be very problematic.  The goal of looking at these factors in childhood is an important part of any psychiatric evaluation, but not to look at someone to blame.  They are important indicators of the degree of resilience, their perspectives on important relationships and how their relationship with important childhood figures affected their personality development.  Almost everyone can recall a critical event that happened in their childhood and they can freeze it in time based on other memory associations.  I happened to hear a great example of this on the public radio show "This America Life" today.

The theme of the program today was babysitting and the piece I am interested in was the last segment called "Act Three.  Yes There is a Baby"   It is a recollection of how a son and daughter interacted with their single mother.  It is really a story of how two kids adapted to a mother who had severe problems.  It is also a story of how remote events continue to affect people over time.  One of the most surprising and consistent observations I have made in my discussions with people over time is how the relationships with parents and siblings are long lasting.  They don't seem to fade away over time.  Strong emotions and patterns of interpersonal interaction persist for decades if not an entire lifetime.  Having no contact with your parents or siblings for prolonged periods of time usually has little effect on these dimensions.  This story starts out with a teenage daughter making up a family - the McCrearys who she was babysitting for in order to escape her mother's limitations on her freedom  to move around in the 1940s.

This story interested me for a number of reasons, not the least of which is the way it echoed many themes that I have heard from people as well as my own personal experience.  The other important point is that it is a true story.  With the current constraints on the discussion of true stories by medical professionals, I think we will need to rely more and more on true stories that are openly disclosed in the media.  The eliminates any possibility of professional intervention but it allows for the emphasis of important points.  In this case I have linked to the transcript because the audio file is not available until later.  I agree with the disclaimer on the web site that you should actually listen to the audio file to get the full impact and hear the story in the voices of the people involved.

The story begins with the son Myron telling Ira Glass about how the rules about staying out from the family home were very different for him and his sister.  He enjoyed a fair amount of freedom but his mother restricted his sister to going out to church dances.   When his sister Carol is contacted, she describes a situation that is much worse.  She was followed by her mother's friends.  Her mother began calling her a whore at an age before she knew the meaning of the word.  Whenever she was employed as a babysitter, her mother needed to know the number in order to check on her.  She would also remind Carol and Myron that when their father died she got a lot of advice that she she put them both in an orphanage.  She did not and described it as the biggest mistake in her life.

In order to adapt to her mother's restrictive and abusive parenting style, Carol invented a family and would say that she was babysitting for this family when she was really sleeping out on the beach or staying with friends.   Mr.  McCreary was an FBI agent and therefore she could not give her mother their telephone number.  She was also being paid for babysitting in stocks and bonds, so there was no proof of babysitting in money.

The interesting psychiatric aspects of this story are basically threefold.  Early on Myron points out that the whole concept of "imaginary people" was something that he and his sister got directly from his mother.  She talked about seeing a lawyer, a psychiatrist ("psycholotrist"), and a doctor.  In every case the appointments with these imaginary professionals was foreboding.  She told the children that she was seeing the lawyer in order to make arrangements to put them in an orphanage.  The psychiatrist told her that her children were driving her crazy.  The doctor told her she was going to die.

Myron tells the story of coming home one day when he was ten years of age and his mother telling him that she was arranging for him to go to an orphanage with a local priest.  He decided he would go away to school at that time, even though he knew there were any number of ways he could have sabotaged it, basically because his mother had been threatening him with an orphanage "all of my life".  As a part of that process his mother wanted reassurances that he thought about her "crying my eyes out" when he was at  his "fancy school".  He decided from that point on (at age 10) that he would never ask his mother for anything or look to her for anything again.  He had that insight when he was 30 years old.

Carol lashed out at her mother when she was about 35 years old.  Her mother reacted by crying and it was the first time she had ever seen her cry.  When her mother stopped crying she said that she did the best that she could have and this lead Carol to the insight:

"And I thought, oh my god, she did. Her best was so bad. Her best was so empty. But she couldn't do any better.."

Accepting that truth and recognizing the importance that her mother had to her grandmother and aunt lead Carol to modify her emotional response to her mother.

The themes in this story are important in psychotherapy and form the basis for most psychodynamic therapies.  Although they never made it explicit Carol and Myron both had unique strategies to adapt to their mother's problems.  This is a story that has universal appeal.  Everyone has landmarks in his or her personal history when an interaction with a parent or a sibling is an organizing event in the rest of their life.  The number of possible decisions and behaviors based on that event and their complexity are are well illustrated in this family history.  The resilience of these two children and how they overcame childhood adversity is remarkable.

George Dawson, MD, DFAPA
      

Dream recall endophenotypes?

Dreams are important part of psychiatric practice.  A discussion of dreams comes up in a number of contexts ranging from diagnoses like Post Traumatic Stress Disorder to primary sleep problems like Nightmare Disorder.   Dreams can be affected by substance abuse and medications.  Some people are still interested in what a dream might mean or they have their own interpretation that they want to discuss.  Sleep is often a source of stress to people who come in to see psychiatrists and questions about dreams frequently come up in discussion about too much sleep or too little sleep.  As a result, I have done a lot of reading and study about sleep and dreams.  I have the last 5 editions of Kryger, Roth and Dement's Principles and Practice of Sleep Medicine and additional texts and journals.  Since I worked in a residential settings, I see people who have their sleep observed and can tell me if they have apneic episodes or behavioral problems associated with sleep and refer them for polysomnography.  Whenever I ask about sleep there are a significant number of people who tell me: "I never dream."

Is it possible that a person is not dreaming at night?  Since the discovery of REM sleep it is well known that this biological process and dreaming are inextricably linked.  Dream researchers have determined that dream recall is influenced by a number of factors including the setting, whether a person is awakened slowly or rapidly and the sleep stage that they are awakened from.  For example, awakenings form REM sleep can result in 4 or 5 dream narratives per night.  Writing dreams recalled the next morning is not likely to produce that amount of content.

When an article suggesting a marker for differences in dream recall showed up on my Facebook feed I was naturally interested.  The authors in this case had a pool of 1,000 people who completed questionnaires indicating an interest in the study.  They were contacted by phone and asked the question: "on the average, how many mornings in the week do you wake up with a dream in mind?"  That is an important distinction from the people I talk with because they usually say: "I dream a lot." or "I don't dream at all."  For the purpose of this study the authors defined high recallers (HR) as those who recalled dream narratives or images on three mornings per week(4.42 ± 0.25 SEM dream recalls/week).  Low recallers (LR) recalled narratives or images per month (0.25  ± 0.02).   The subjects underwent standard polysomnography and an experimental paradigm that involved presenting a recorded voice saying first names through headphones in the alert and REM state.  Event related potentials (ERPs) and alpha frequency (8-12 Hz) responses to the auditory hallucinations were recorded.        

The authors summarize their data using the above graphics.  The top graphic is a little confusing at first if you are used to seeing similar graphics from QEEG analysis.  It is only alpha spectrum and the white lines represent occurrences of the auditory stimulus.  The bottom row shows the HR - LR power and the significant difference at the Pz electrode.  The black and white graphics at the bottom show ERPs and alpha power in response to first names for HR, LR, and HR-LR.  In general the alpha power decreases during wakefulness and increases during  REM sleep on all graphics.  The HR group had a more sustained decrease in alpha power to first names at 1000 to 1200 ms during wakefulness.

The authors go on to discuss the implications of these findings including the theory that increased alpha power during REM sleep could imply microarousals without awakenings.  A second hypothesis is that increased alpha power during REM sleep implies cortical deactivation rather than microarousal that would lead to decreased processing and less likelihood of awakening.  The authors interpret the greater reactivity in ERPs and alpha activation in the HR state as indicating that alpha is associated with activation in sleep.  They point out that the increased intrasleep wakefulness being great in HR is consistent with that observation.  They go on to point out that this trait may be central to a personality organization and cognitive substrate within the brain.  They pose a larger question about moving from one phenotype to the other.  They make the important observation that a hippocampus needs to be in the loop for dream recall and that there may be a point where functional imaging will be able to provide that level of detail.

I could not help but wonder if dream recall is a possible endophenotype.  What would happen if families were studied on their ability to recall dreams?  Would there be characteristic findings on polysomnography?  What would the pattern of heritability be and what would lead to transitions between phenotypes?  Sleep medicine is one of the areas of psychiatry where there are clear and valid biomarkers and it would be interesting to look at those differences.  In the meantime, it appears that what I have been saying to people about possible REM related dreams seems to be true based on this study.  Microarousals - probably from a number of possible etiologies will probably increase dream recall of characteristic REM type dreams and you may not actually experience interrupted sleep.  There is also the interesting consideration of dreaming without the hippocampus being engaged and have no dream recall on that basis.

George Dawson, MD, DFAPA

Ruby PM, Blochet C, Eichenlaub J-B, Bertrand O, Morlet D, Bidet-Caulet A (2013) Alpha reactivity to first names differs in subjects with high and low dream recall frequency. Frontiers in Psychology 4.

All of the figures in this post are from the above reference and are produced here via Creative Commons license.  Please see the original article for all of the details.

The Psychotherapy of Psychosis

I was lucky enough to find the Practical Psychosomaticist blog recently.  Jim Amos is the productive author of this excellent content that is both scholarly and creative.  In a recent post and comment to my reply he said that is was good that I let people know that psychiatrists do psychotherapy.  I thought I would expand upon that and more importantly the psychotherapy of severe psychiatric disorders - something I happened to learn how to do out of necessity of realizing that there needed to be a lot more communication with people than a discussion of medications and symptoms.  It flows from the way psychiatrists are taught to do comprehensive assessments but these days it is not obvious.

As previously noted, my training occurred at a time when there was often open warfare between the biological psychiatrists and the psychotherapists.  Even though most of the political power in departments had shifted to biological psychiatry there was still an opportunity and expectation that residents would learn how to do psychotherapy.  For my last three years of training I saw at least three patients a week in hourly psychotherapy and was supervised on a 1:1 basis for each of those hours by a psychiatrist or psychologist who was also a therapist.  Those sessions were frequently recorded and the supervisors listened to the audio or reviewed detailed process notes of the sessions.  I had additional supervision for patients who were seen in a more standard follow up clinic setting or in a community mental health center.  I had additional supervision for couples therapy, family therapy, and therapy with children and adolescents.  There were ongoing seminars on psychotherapy  and direct observation experts conducting psychotherapy.  As a medical student, I also had a very unique experience with infant psychotherapy set up and run by two very innovative psychiatrists at the Medical College of Wisconsin.

Talking to people about their problems and how to solve them always seemed natural to me.  I think that there is always an open question about whether good psychotherapists are born and not made.  It makes sense that patience and empathy required are not evenly distributed across the population.  When a psychiatrist learns that you may have an interest in psychiatry as a medical student, the usual areas for exploration is whether you have had personal experience with mental illness or whether one of your family members has.  Even in grade school, I had extensive contact with people both inside and outside of my family with mental illness.  When you have that experience it leads to an appreciation of the whole spectrum of human  thought, emotion and behavior.  Denying mental illness, addictions and brain disorders doesn't work.  I heard the stories and personally witnessed severely disabled people being cared for at home with minimal resources.

Having that type of lifetime experience can result in a better understanding for the problem, but it does not lead to the type of technical expertise needed to talk with people in a therapeutic manner.  I can recall my initial surprise when I witnessed a psychoanalyst tell a sobbing patient that he had to stop crying and try to tell us the details of his history.  It seemed like the wrong thing to say, but it turned out to be highly effective in terms of changing the tenor of the interview and making it more productive.  Seeing psychiatrists interact with patients and studying the theory was one of the more valuable aspects of psychiatric training and it occurred in hospital wards, clinics, research settings, texts, videos, and seminars.  As the influence of psychodynamics seemed to decrease other models were also studied most notably cognitive behavioral therapy of CBT.   It was similar in many ways to what had been taught as supportive psychotherapy as opposed to insight oriented psychodynamic psychotherapy.   Psychotherapy supervisors practice varied schools of therapy and I mine were psychoanalysts, psychodynamicists, a Rogerian, behavioral therapists, cognitive behavioral therapists and supportive psychodynamic therapists.  I eventually learned how to do an assessment and figure out what psychotherapeutic approach might be the most useful.  It also provided me the skill needed to discuss past psychotherapies with patients I would be seeing in assessments. the efficacy at the time and why it might not be working several years later.

The psychotherapy of severe psychiatric disorders is a relatively new innovation.  As part of my studies in the past I had read about Harry Stack Sullivan's approach and more recently (but still 40 years ago) the work of Grinker.  There was some crossover with Kernberg and Kohut and their work on narcissism and borderline personality disorders.  Some of the early large scale work on the psychotherapy of schizophrenia (1,2) showed that supportive psychotherapy may have an impact and that insight oriented psychodynamic therapy probably did not.

On my first job at a community mental health center, I sent a letter to the founder of Dialectical Behavior Therapy (DBT) and she sent me a copy of her research manual from field trials that were being conducted in the late 1980s.  I used Beck and his associates as resources to learn about Cognitive Behavior Therapy (CBT).  In the process I noted a common reference to what Beck described as the initial case of CBT in an outpatient setting with a patient who had a diagnosis of schizophrenia.  Practically all of the CBT in the 1980s and 1990s was focused on depression, anxiety, and later severe personality disorders.

After three years at the community mental health center, I moved on to an inpatient setting for the next 22 years.  Most of the people I saw there has severe mood and psychotic disorders or problems with severe addiction.  The experience a lot of people have in these settings is not very good.  It seems like a situation that is set up for containment and for many people it is.  They found themselves in a crisis and many cases hospitalized for and excessive amount of emotion that fades rapidly after they leave the original situation.  In other cases the emotion does not fade and they remain in a crisis in the hospital.  Some people recognize that something is happening to them and they need a safe place to recover.   Everyone has a theory about how they came to the hospital and whether or not they may need treatment.  Inpatients on a mental health unit are often there because of legal holds based on dangerousness laws that vary from state to state.

I was able to talk with people in an unlimited manner in this setting, sometimes many times a day.  I was able to engage them in a process that looked at their theories about life and about the problems that led them to the hospital.  We could discuss at length what types of treatments they were interested in.  I was also able to talk with them about delusions, hallucinations, and psychotherapeutic approaches to address those symptoms.  At one point along the line, I noticed there was an interest in supportive psychotherapy with patients experiencing psychotic symptoms and it was summarized in 1989 in a remarkable book by Perris (3).  The research evidence and theory continued to build over the next two decades with excellent courses at the annual American Psychiatric Association meeting.  That included a 2009 course given by several experts in the cognitive behavior therapy of severe psychiatric disorders (4).

Decades of training and practice has undoubtedly made me a better psychotherapist. It taught  me why you "practice" medicine and don't master it.  It has also made me mindful of how much of the interactions between psychiatrists and the people they see, need to be seen from a psychotherapeutic perspective.  That includes the environment a person is seen in and anyone else in that environment that they may encounter.  It also allows for a lot of treatment flexibility that reflects a comprehensive psychiatric assessment.  The best diagnostic assessment may suggest a medication is the best solution for a particular set of problems, but knowing you can also address that problem in a different way if the medication cannot be tolerated, if it fails or if the person changes their mind is a game changer.

Sometimes all it takes is an open and highly detailed conversation.

George Dawson, MD, DFAPA

1: Stanton AH, Gunderson JG, Knapp PH, Frank AF, Vannicelli ML, Schnitzer R, Rosenthal R. Effects of psychotherapy in schizophrenia: I. Design and implementation of a controlled study. Schizophr Bull. 1984;10(4):520-63. PubMed PMID: 6151245.

2: Gunderson JG, Frank AF, Katz HM, Vannicelli ML, Frosch JP, Knapp PH. Effects  of psychotherapy in schizophrenia: II. Comparative outcome of two forms of treatment. Schizophr Bull. 1984;10(4):564-98. PubMed PMID: 6151246

3.  Perris C.  Cognitive therapy with schizophrenic patients.  The Guilford Press. New York, NY, 1989.

4.  Wright JH, Turkington D, Kingdon DG, Basco MR.  Cognitive-Behavior Therapy for Severe Mental Illness.  American PSychiatric Publishing, Inc.  Washington, DC, 2009.