We Need More Unapologetic Psychiatrists…..

 

I am not sure he would agree with the characterization but I came up with this title when I decided to comment on Daniel Morehead, MD.  I have never met him but I have read everything he has written in the Psychiatric Times.  He is director of residency training in general psychiatry at Tufts. In the most recent column, I notice the heading Affirming Psychiatry – that I wish I had thought of.  That was one of the primary goals of this blog when I started writing it 13 years ago.

This month’s column was titled Psychotherapy: Lies Cost Lives (1).  He starts writing about a New York Times column about psychotherapy that starts positive but rapidly shifts to ambivalent. He points out that this is characteristic of most headings that have to do with psychiatry and speculates about the origins.  Controversy, mouse clicks, and advertising dollars for sure.  He lists several titles and several themes of articles that with similarities and points out the only logical conclusion:

“The take-home message is that psychiatry rests on shaky foundations and does not quite know what it is doing, rather like someone feeling their way through a darkened room. Psychiatry, as usual, lags behind the breezy confidence of other medical fields, where no one wrings their hands about whether antihypertensives really work or whether surgery is just a lingering form of inhuman medieval butchery.”

That is certainly one way to describe journalistic gaslighting. I have offered several explanations for it on this blog.  First, folk psychology. Trying to figure out basic motivations and behavior of the people we encounter on a day-to-day basis is an adaptive human skill.  Many people think that psychiatry is therefore just common sense and that anyone can do it – at least until they encounter problems severe enough to where that level of common sense fails completely.  Second, there is the impression that anyone who prescribes psychiatric medications is basically equivalent to a psychiatrist. That is a trivialization of the psychiatric skill set and training.   Third, antipsychiatry is a cottage industry in the US and other countries and our detractors have had an inordinate amount of success in getting their rhetoric published in both the popular press and professional publications. The previous post on this blog was all about that. There are no other equivalent movements attacking other medical specialties even though their good outcomes are equivalent and their bad outcomes are generally much worse.  Fourth, , the reality is that about 40,000 psychiatrists go to work every day in the US.  The demand for psychiatrists is high. That demand is fueled by successful treatment and a niche that is unfilled by other medical staff.  Fifth, at least part of that demand is because psychiatrists have unique skills. We are the treatment providers of last resort, and other specialists know that and refer patients at all levels of acuity. The only way that happens is if you know what you are doing.

Psychotherapy is part of that skill set and that is the focus of Dr. Morehead’s column.  The science is there, even though there is a constant debate about clinical trial design and replicability.  Specific brands of psychotherapy have been investigated and shown to work.  There is also research into important non-specific factors in psychotherapy that branded therapies have in common. Even more basic than that are the interviewing techniques and courses taught to second year psychiatric residents focused on facilitating information exchange with patients for both diagnostic formulation and intervention. Communication is a critical skill in psychiatry.  In this era of checklists, screening, and electronic health records – it is easy to forget there is a much larger set of important information and like all things it requires a lot of training to do it right. It is that body of information that allows for the treatment of each patients as a unique person.  Personalized medicine has become a buzzword lately but from a communication perspective psychiatrists have been providing that for decades. 

These basic skills in talking with people and talking in therapeutic ways are hardly ever mentioned in discussions about psychiatrists. Criticism of psychiatry commonly seeks to portray psychiatrists unidimensionally - as excessive prescribers of medication rather than communicators.  Throughout my career the number one reason I was consulted was to establish communication with a person and figure things out where nobody else could.

Even in the case of prescribing medications, there is typically a lot more going on than a discussion of medications. One of my colleagues established the largest clozapine clinic and long-acting injectable medication clinics I have ever seen.  When he moved on, his patients asked me regularly where he was and how he was doing.  They valued the relationship with him even when he was providing a unique medical service. Ghaemi has written about existential psychotherapy and how it can occur during appointments that are medication focused (2,3).

The overall message that Dr. Morehead is trying to convey is that psychiatrists cannot let others characterize what we do.  When that happens there are multiple agendas operating that can lead to the clear distortion that psychiatry is not quite up to the level of other medical disciplines.  There is typically an overidealization of those other branches of medicine with a focus on innovations that often do not materialize.  The real message rarely gets out and that is – psychiatrists are uniquely trained, we are interested in problems that nobody else is and that other physicians often avoid, and we are good at what we do.  It is highly problematic that journalists seem reluctant to get that message out to the public. When I first read Dr. Morehead’s writing I found it refreshing because there are very few psychiatrists who want to get that message out. Most will cave in to the first suggestion of a level of uncertainty that every specialist in medicine has to deal with – the persistent risk no matter how small and the lack of a guaranteed outcome.

I look forward to a new generation of psychiatrists who can start to set the record straight.

 

George Dawson, MD, DFAPA

 

Supplementary:

Decided to add this explanation anticipating the typical criticism:  “Well he is arrogant isn’t he? We always knew he was arrogant.  All psychiatrists are arrogant!”  When I say unapologetic – I mean unapologetic for just existing and trying to help people.  That is the level that psychiatrists are forced to operate at that no other medical specialist is. There are the usual misunderstandings, errors, and adverse outcomes in psychiatry that there are in any other medical specialty.  There are psychiatrists who are burned out, forced to practice in a way that they would rather not, and even personality disordered - just like any other specialty.  But in those other specialties the assumption is that these problems are handled on a case-by-case basis by the responsible physician, clinic or hospital administrative structure, or medical board. There is no similar assumption in psychiatry.  Instead, there is an assumption that the entire profession can be condemned for some adverse outcome, unprofessional conduct, historical event, or any unreasonable criticism that someone can come up with. As I have pointed out in the previous post - many criticisms are fabricated or just absurd.

So when you read these unrealistic criticisms about psychiatry in the papers – keep in mind that there has been a doubling down on the rhetoric unlike what happens with any other specialty in medicine. Use that knowledge to moderate your reaction to it. 

References:

1:  Morehead D. Psychotherapy: Lies Cost Lives. Psychiatric Times 40(11).  Published online on November 10, 2023  https://www.psychiatrictimes.com/view/psychotherapy-lies-cost-lives

2:  Ghaemi SN. Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger. American journal of psychotherapy. 2001 Jan;55(1):51-64.

3:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the" Med Check". The Journal of Clinical Psychiatry. 2018 Apr 24;79(4):6935.

Photo Credit:

Many thanks to Eduardo Colon, MD

 

  

Benjamin Rush - Myths Turned Into Propaganda

  

If you are a casual reader of this blog, you may not have noticed a large post in the past that was dedicated to countering common antipsychiatry propaganda that involved Benjamin Rush (1746-1863).  Rush was a physician who was a participant in the Continental Congress and a signer of the Declaration of Independence. He is considered both a Founding Father and the Father of American psychiatry.  In the latter case, I have expressed the opinion that he was not really a psychiatrist and that his methods as a physician were somewhat primitive – particularly the propensity for bloodletting that he encouraged his own physician to use. Of course, writing this in 2023 and calling his 18^th century methods primitive is an easy task and I am sure that if civilization lasts – 24^th century physicians may say the same thing about the current practice of medicine.  The reason why Rush’s connection to psychiatry has persisted is that he was an important historical figure and prolific writer, he made useful observations about alcoholism and the care of patients with mental illnesses in his time and provided asylum care.  He was considered one of the most prominent physicians of his time.  There is also overlap between Rush’s lifetime and the American Journal of Insanity (1844-1943) – the precursor to the American Journal of Psychiatry. 

His historical prominence  was probably the reason the American Psychiatric Association (APA) incorporated Rush and his image into various seals, certificates, and awards.  As an example, I have two medals and two certificates that contained his embossed image and name from the APA.  These same considerations are probably why the detractors of psychiatry have either made up stories about him or interpreted his work in the most negative possible light. Much of that rhetoric has been so successful that it now exists in the psychiatric literature.  In a 2015 rebranding the APA dropped Rush's image from its logo - but retained the image for ceremonial purposes. 

Rush has been a target of antipsychiatry criticism and rhetoric since the 1970s. Some of the most enduring but inaccurate tropes have been about him – most notably involving the invention of the condition negritude and being affiliated with Samuel Cartwright – a southern proslavery physician who promoted the concept of drapetomania or a disease that caused slaves to want to run away and the need to treat that condition with physical coercion.  Szasz successfully developed both conditions into antipsychiatry tropes in a 1971 paper.  Both are still actively used today as antipsychiatry critics seek to tie modern day psychiatrists with racism and social injustice as well as early physicians who were not really psychiatrists.  By my estimate the discipline has existed in the US for about 100 years.  These tropes have been so successful that they have found their way into professional literature including the flagship journal of the American Psychiatric Association – The American Journal of Psychiatry.

Here are a few examples of the inaccuracies:

“Of particular interest was Benjamin Rush (considered the father of American psychiatry), who believed that Black skin was a mild form of leprosy that he called “negritude,” which could be cured only by becoming White. An apprentice of his, Samuel Cartwright, coined the diagnosis “drapetomania,” a mental illness that caused Black slaves to flee captivity. After the Civil War, the frequency that severe mental illness was found in the diagnoses of patients admitted in the country’s first psychiatric hospital for Blacks patients—Central Lunatic Asylum in Petersburg, Va.—raises an important question about whether Black patients were overdiagnosed with severe mental illness, as they have been in modern times. In addition, numerous references can be found to the hypothesis that mental illness in the Black population increased substantially with the end of slavery.” (1)

“In 1851, Samuel Cartwright, a prominent Louisiana physician who had studied under Benjamin Rush but was not a psychiatrist, identified two mental disorders peculiar to slaves: Drapetomania, or the disease causing blacks to run away, and Dysaethesia Aethiopica, or the condition that accounted for laziness among slaves. Such diagnoses, of course, were racist pathologizing of reasonable behavior.” (2)

“Cartwright’s theories were embraced in the slave states and mocked in the free states, including in medical journals,” Geller said. “APA was silent, and that is our shame. They were silent then, and we have been silent for 176 years.”

In fact, Cartwright’s theory was not embraced in either group of states, it was not a diagnosis that was used.  The APA and psychiatry did not exist. (3)

“Over 60 years after the ratification of the U.S. Constitution, physician Samuel Cartwright played a prominent role in the rise of racism in the field of psychiatry. His descriptions and characterizations of mental health conditions in enslaved Africans, particularly drapetomania, which he described as the illness of enslaved people wanting to run away and escape captivity, and dysaesthesia aethiopica, a disease of “rascality” or laziness in enslaved Africans, were the beginning justifications of pathologizing normal behavioral responses to trauma and oppression. These “diseases” paved the way for long-standing rationalization of harsh, inhumane treatment of mental illnesses in communities of color; Cartwright’s prescribed treatment for both conditions was whipping (22). The historical origins of racism in psychiatry set the stage for instances of structural racism that impact the diagnosis, management, and treatment of mental illnesses and substance use disorders to this day.”

If you consider Cartwright to set the “historical origins of racism in psychiatry” then there is no structural racism in psychiatry. (4)

“In 1792 Benjamin Rush, considered the father of American psychiatry and the best known physician throughout America in his era, proclaimed that Black skin was actually a disease. Rush was a remarkable mix of contradictions. He was an ardent abolitionist who owned a slave. He spoke out on the position that Blacks were of equal intelligence and morality as whites. Nonetheless, he created a disease called negritude, a disease whose cure was turning a Black person white.” (5)

“I consider Cartwright's "Report," and especially the two diseases afflicting the Negro that he discovered, of special interest and importance to us today for the following reasons: first, because Cartwright invoked the authority and vocabulary of medical science to dehumanize the Negro and justify his enslavement by the white man; second, because the language and reasoning he used to justify the coercive control of the Negro are identical to those used today by mental health propagandists to justify the coercive control of the madman (that is, the so-called "psychotic," "addict," "sexual psychopath," and so forth); and third, because Cartwright's "Report" is the sort of medical document that has, for obvious reasons, been systematically ignored or suppressed in standard texts on medical and psychiatric history

One such omission, discussed in detail in The Manufacture of Madness, is Benjamin Rush's theory of Negritude, according to which the black skin and other physical "peculiarities" of the Negro are due to his suffering from congenital leprosy (1, pp. 153-159).”

Any serious historical look at the diagnosis of drapetomania would show that it was ignored – even by southern physicians interested in racial medicine.  Szasz's analogy of slavery and mental illness is purely rhetorical. (6)

The tropes about Rush and his relationship to Samuel Cartwright and racial medicine seem entrenched at all levels of discussion of psychiatry including writing by psychiatrists. From a rhetorical standpoint they are used to legitimize an argument that the profession is either racist, built on a racist foundation, or did not actively counter racism when the opportunity presented itself. They are also used to suggest that psychiatric diagnoses are invalid - even though these pseudo-diagnoses by a non-psychiatrist were never used by any physicians.  Those specific narratives are false at best and fabricated at the worst.  This historical record is now clearly available and should be consulted in the future when writing on this topic at the University of Pennsylvania Benjamin Rush Portal.  If you read all the segments what I have written in this post covers only a portion of the myths.  You will also note that some of the myths are described as villainizing Rush.  I think the same characterization could apply to Szaszian rhetoric that has been applied to the entire profession of psychiatry in modern times on a repetitive basis.

While it may be unrealistic to think that historically accuracy will have much of an impact in this era of for-fame-and-profit-misinformation, I am suggesting a higher standard.  That standard is that members of the psychiatric profession and the editors of that literature should be aware of it and make the necessary changes.  I am fully aware of the current concerns about structural racism and building diversity. That cannot be based on a false narrative.  In fairness to Rush, I think it is necessary to set the historical record straight as his biographer Stephen Fried has done. Like most of the historical figures I write about on this blog – I see him just as that - with no relevance to modern day psychiatry.  Anyone reading Fried’s detailed biography of Rush will see him as a progressive thinker that would probably easily maintain that description even in today’s polarized political climate.

    

George Dawson, MD, DFAPA

 

 

References:

1:  Dike CC.  Misuse of Psychiatry.  Psychiatric News. Published Online:23 Apr 2022 https://doi.org/10.1176/appi.pn.2022.05.5.30

2:  Jeffrey Geller, MD, MPH. The Rise and Demise of America’s Psychiatric Hospitals: a Tale of Dollars Trumping Decency.  Published Online:26 Feb 2019 https://doi.org/10.1176/appi.pn.2019.3a36

3:  D’Arrigo T. Black Psychiatrists Call on White Colleagues To Dismantle Racism in Profession, APA.  Psychiatric News Published Online:23 Jun 2020 https://doi.org/10.1176/appi.pn.2020.7a34

4:  Shim RS. Dismantling Structural Racism in Psychiatry: A Path to Mental Health Equity. Am J Psychiatry. 2021 Jul;178(7):592-598. https://doi: 10.1176/appi.ajp.2021.21060558

5:  Geller J.  Structural Racism in American Psychiatry and APA: Part 1.  Psychiatric News.  Published Online:23 Jun 2020 https://doi.org/10.1176/appi.pn.2020.7a18

6:  Szasz TS. The sane slave: An historical note on the use of medical diagnosis as justificatory rhetoric. American Journal of Psychotherapy. 1971 Apr;25(2):228-39.

 

 

Supplementary:

I decided to include a section on Rush’s theory of black skin color to avoid the typical gotcha arguments from antipsychiatrists.  These arguments are contained in the reference below and I have supplied a link where you can download the entire paper. Context is always important when considering the medical, social, or political opinions from over 200 years ago.  The important contexts would include prevalent racial bias that obviously persists today, and the lack of important medical advances including germ theory, general pathophysiology, and medical genetics. 

He opens by referencing An Essay On the Causes Of The Variety Of Complexion and Figure In The Human Species by Rev. Samuel Stanhope Smith, DD – a professor of moral philosophy.  The essay is a book the content of which was based on a previous lecture given on February 28, 1787.  Rush touches on the four main causes listed in this text – climate, state of society, diet, and diseases.  Citing a moral philosopher and clergyman is not an ideal start to an opinion piece on pathology or pathophysiology, but it forms the main outline of his essay.

He suggests that the color and figure “of that part of our fellow creatures who are known by the epithet of negroes, are derived from a modification of that disease, which is known by the name of Leprosy.”  He says the leprosy outbreaks in Europe in the 13^th and 14^th centuries were caused by “unwholesome diets.”  He observes that “in some instances” leprosy causes a black color of the skin and that some Africans have other symptoms. He notes Biblical and real world observations describing inconsistencies in skin color. He suggests that “insensibility” as a feature of leprosy (meaning sensory neuropathy) may explain why people with African origins have a lower pain sensitivity.  He also connects leprosy with “strong venereal desires” and suggests this is also true in people of African origin.  He comments that leprosy can produce characteristic skin changes in whites as well and notes that matted hair in people of Polish descent is a sign.  He notes the longevity of the illness and that it took 3 to 4 generations to clear in Iceland.  He gives other examples of physical signs that are locally transmitted among ethnic groups.

He anticipates the objection that leprosy is an infectious disorder but that does not appear to be the case in Africans by saying that it has “ceased to be infectious” but also that there are exceptions in the case of mixed-race couples where white women acquired the features and skin color of their black husbands. Since he expects that leprosy does not significantly affect longevity he expects these traits to continue.  The causative bacterium for leprosy (Mycobacterium leprae) was eventually discovered in 1873 by Hansen.  The genetics of skin coloration was not discovered until the 21st century.

These are clearly very weak and biased observations.  Rush’s conclusions based on these observations are interesting.  First, claims of superiority of whites based on skin color are “founded in ignorance and inhumanity.” He suggests that if a disease is causing this difference “it should entitle them to a double portion of our humanity, for disease all over the world has always been the signal for immediate and universal compassion”.  Second, the facts outlined should teach white people to not keep intergenerational prejudices. Third, science and humanity should unite to find a cure for the disease, but the science at the time was non-existent. He goes on to list several anecdotal approaches.

Rush ends his paper speculating about how curing this disease of leprosy producing blackness would add greatly to the happiness in the world and that of people with African ancestry.  He qualifies that by noting that black people seem to prefer their skin color to white. He wraps it up in a Biblical myth at the end to say:

“We shall render the belief of the whole human race being descended from one pair, easy, and universal, and thereby not only add weight to the Christian revelation, but remove a material obstacle to the exercise of that universal benevolence which is inculcated by it.”     

This was 60 years before Darwin's Origin of the Species. It is doubtful than anyone at the time had a theory of how isolated groups of humans might evolve with different characteristics.

Although Rush did not technically invent a disease or word called negritude or suggest that it was responsible for skin color in African Americans – he certainly proposed what I would characterize as an off-the-wall theory.  His writing further suggests that a solution of universal white skin would allow for a more harmonious existence – with less discrimination and that would be a solution to the problem of racism. It is an overly simplified and biased solution by today’s standards.  Since Rush was obviously not racist the logical explanation for this opinion is a significant knowledge deficit and speculating outside of his lane.     

 

Rush B: Observations intended to favour a supposition that the black color (as it is called) of the Negroes is derived from the leprosy. American Philosophical Society Transactions 4 (old series): 289-297, 1799.  Link directly loads PDF:  https://canvas.emory.edu/courses/86982/files/5134312/download?download_frd=1

The Times They Are A-Changin’ – or Are they?

I was walking around last week at dusk on a couple of nights. For the first time I decided to listen to some music as I walked. I would never do this if I was cycling because you need to hear the tire noise of approaching vehicles and I was using noise cancellation headphones tied into my music library. I also decided to use shuffle mode and that is also unusual – I typically repeat tracks until I get tired of them and that often takes a long time. For some reason, my phone kept playing Dylan songs. It reminded me of how I really did not like Dylan when I was young and listening to Hendrix and the Who. My interest peaked when he got the Noble Prize for Literature. It peaked again when I heard him interviewed and he talked about how easy it was to write music when he was younger. The music just seemed to flow and all he had to do was write it down. It was how mathematicians were described in Nasar’s biography of John Nash. Young mathematicians typically produced most of the ideas that advanced the field.

A lot of the songs were melancholy tunes about relationships gone bad.  Some were lessons in how not to be codependent. I was acutely aware of being an old man dressed in black listening to this music and free associating to similar events in my life from long ago. Before it got too maudlin - The Times They Are A-Changin’ came on:

Come gather 'round people

Wherever you roam
And admit that the waters
Around you have grown
And accept it that soon
You'll be drenched to the bone
If your time to you is worth savin'
And you better start swimmin'
Or you'll sink like a stone
For the times they are a-changin'

I could have sworn that what I heard walking around in the dark was a direct reference to the United States in that song. But looking it up later - it was not there. The song snapped me out of interpersonal reflection and into the current threat to American democracy.  For the past several days I had been responding to social media posts about the disconnect between what appears to be going on in national presidential politics and the reality of the situation. Just that day I responded to a poster questioning why Christians appear to be in lock step with a candidate who does not appear to have similar values and how Biden has done very well in the White House but seems to be struggling in the polls against a candidate with a known poor record who orchestrated an insurrection against the US government? A candidate who has been charged with 91 felonies. Even more mysteriously, the entire Republican party with rare exceptions is supporting Trump and most want his endorsement in local and state elections. How can a candidate with that many flaws still be in contention at this point and dominating a party that was originally abolitionist and got Lincoln elected as their first President before the start of the Civil War?  It does not make any sense and I will look at the hypotheticals below.  I tried to put as many as possible into the graphic at the head of this post – but only the coarsest details are possible:

1:  A general lack of critical thinking:

It has been a long time since I took a high school English class, but from what I recall even back in those days there was very little emphasis on rhetoric. Critical thinking generally involved the decoding the author’s intent, detection of symbolism and defending an opinion on a theme: “Do you find Lord of the Flies to be optimistic or pessimistic and why?”  Rhetoric was largely confined to debate teams that a small percentage of students participated in.

It has never been more important for the average citizen to be informed and aware of what might be rhetorical distortions. There used to be some level of assistance from professionally edited news, but that is no longer reliably available. Today it is possible to get all your news from a site that you agree with on ideological grounds – no matter how far from reality that site gets. Apart from these echo chambers on the Internet, the main street news offers minimal assistance.  You might find stories about the polarized electorate with no discussion of what that means or if one side is more polarized than the other.  Threats and overt violence were introduced into the political scene with no comment that this is almost an entirely right-wing phenomenon that is often tied in with gun rights and bragging about who owns the most guns. The right wing owns both moral and gun extremism in the US and yet there no criticism of this in mainstream media. Most importantly, political violence against specific groups should be unacceptable in the US and it is increasingly apparent.

2:  President Biden is too old: 

This seems to be a popular trope in both campaign propaganda and as material for comedians.  Bill Maher for example, will often detail the accomplishments of the Biden administration as being some of the most significant in decades only to incorporate polling questions about his age and conclude he should step down and let someone else run. No suggestions about who that should be and judging from the declared candidates there is no one of suitable name recognition or accomplishment who could run and expect to get support equal to Trump’s locked in MAGA constituency. If you look at my graphic – any candidate the Democrats advance will not have the amount of leverage with the voters based on the factors listed.

But backing up – is 80 years old – too old?  I saw President Biden on the bike and I saw him fall. It was clearly a mistake that people make when they are not used to toe clip pedals. The part that most people seem to ignore is that he got up with no problems. That is not the mark of a feeble old man and neither is the current schedule he has been keeping. More to the point – he has an awareness of how things need to run in the Executive Branch, how information needs to be managed, how consultation with staff is a critical function, and how to manage alliances.  There is minimal evidence that his predecessor has that level of awareness.  

There is certainly no current evidence that Biden cannot do the job given his list of accomplishments and some high-profile incidents – most notably his performance at the last State of the Union address. Ageism is certainly a prominent cultural bias in the US.  If I were a foreign actor wanting to manipulate the American electorate – I would use it, especially if I knew the opposition party could easily be convinced to use it.  The current group of Republicans could be expected to jump on it even though some of their members of Congress are older than Biden.

3:  The Republican base has been manipulated and brain washed by culture war tropes: 

This is undoubtedly a factor at some level.  I have written on this blog about how the GOP has become a party of gun and moral extremists – not out of some strict Constitutional interpretation or religious belief, but out of political expediency. It is easy to manufacture some ideological position to elicit emotional responses from some voters and get them to believe they are in a morally or Constitutionally superior position. Fortunately, that is not how democracy works but it is how the current crop of Republicans want it to work. In the meantime, public safety, education, and women’s health have all been compromised. On the day I am typing this a Constitutional Amendment for reproductive rights was passed in Ohio blocking attempts to pass restrictive abortion laws. Whether this can be a rallying point against moral extremism is an open question at this point.

4:  Fragmentation among Democrats: 

There is some concern that progressives within the party have gone too far in areas of social consciousness particularly social justice issues involving race and the LGBT community. The concern is amplified by the Republican’s rhetorical use of the term woke as a pejorative. That has allowed them to indiscriminately use the term to criticize health care, educational, social, and economic policies as being too woke (translation politically correct) and simultaneously suggest that most Americans would not find it to be acceptable. That can range from books in a high school library that were read by several older generations to college admission policies to protests about excessive use of force by the police.

The current war between Israel and Hamas is a similar flashpoint. One analysis suggests that progressives see the world though a simple lens of colonizers and victims. That has been spun into Israel starting a genocidal war in Gaza or even the US starting or backing such a war. In the most extreme case, social media was abuzz with young people supporting a letter allegedly written by a famous terrorist, blaming the United States for terrorist attacks. That has also led to protests and threats to Jewish college students in the United States. All of that misses the point that violence is being incited against US citizens who happen to be Jewish and that Hamas clearly started the war and clearly stated their ongoing goal is to destroy Israel and kill their citizens.

5:  Activation of far right white supremacist and antisemitic groups:  

There is no doubt that fringe groups that were essentially silenced for many years were activated during the Trump administration and actively support him. In my own neighborhood there was widespread dissemination of white supremacist literature for tens of miles in all directions.  That has never happened in the Midwest during my lifetime. Further investigation linked the same group spreading that literature to antisemitism.  Investigation by local officials and law enforcement did not identify the specific perpetrators and no charges were ever filed.

6:  Activation of antisemitism in younger generations: 

The facts are not disputed and various theories have been proposed. The history is forgotten explanation seems to have a lot of traction.  At least it seems to have garnered the most speculation. In other words, with less exposure to Holocaust survivors and the history of World War II, younger generations are unlikely to believe the actual historical events – a clearly documented genocide against the Jewish people. That seems to minimize any role of activated antisemitic hate groups and social media. Many of these groups are now at the point that they show up in public demonstrations and are attempting to recruit new members from suburban neighborhoods. The wave of antisemitism in the younger generation has had far reaching effects on college campuses, in some cases to the point that departments and administrations failed to condemn the recent terrorist attack against Israel or an obvious problem of antisemitism on their campuses. This generation uses TikTok as a preferred social media site. In a recent press release they described removing tens of thousands of antisemitic posts.  Just how long that posting has occurred is unknown.

I think it is also useful to recall that political violence directed at minority groups is a well-known tactic of fascist and totalitarian states.  In the early days of the Internet online discussions often became heated to the point that accusations of Naziism were often made.  This led to Godwin’s Rule or as an online discussion grows longer (regardless of topic or scope), the probability of a comparison to Nazis or Adolf Hitler approaches 1.  That is basically nerd speak to say that analogies to Nazis based on Internet discussions is probably absurd. What I have seen lately suggests to me that we are beyond the absurd stage when people are injured and living in fear.  If it walks and talks  like a Nazi….

 7:  The social media propaganda machine:  

Social media seems to always be in the news. The common topic is how it is a malignant force in the lives of teenagers and children. There is concern that you can get “addicted” to rapidly scrolling and clicking on too many sites. People talk about the dopaminergic effects of this activity – like the neuroscience is known. Even though we had a foreign government actively interfering in the last Presidential election through social media and email hacks – nobody seems focused on that happening again. US Intelligence agencies predicted that it would happen again and it would probably be more vigorous than the last time. It is also more difficult to detect because the foreign actors are all using servers within the United States. Several agencies are responsible for detecting and monitoring this activity – but 1 year out none of them are reporting on what they see or what kind of misinformation is being posted. You don’t have to be a secret agent to think about who these foreign actors are. Russia was clearly involved in the last Presidential election and given the situation in Ukraine – they would clearly prefer Trump over Biden.  Putin has actively encouraged Russian hackers at all levels including those who steal money from average Americans.  Trump has made it clear that he would not support Ukraine and he clearly had a negative impact on NATO.  Biden has been able to reverse most of that damage and unify NATO.  Iran, China, and North Korea also have an interest in a Trump presidency.  These countries either have a direct interest in supporting Trump based on his probable policies or just weakening the US by more divisiveness in the electorate.

 8:  Uncritical voters:  

I heard Iowa voters asked about why they are voting for Trump and why he is so popular in their state.  I heard the following responses:

 “He is a businessman.”

 “He says what is on his mind.”

 “I don’t care what he has said or done – I am voting for him.”

These responses and his previous performance – all indicate that many Trump voters are not focused on any policy.  It would probably be difficult because most of the policies that Trump seems focused on at this point have to do with revenge against his perceived enemies.  That is typically a low bar – they are people who either disagree with him or want accountability.  That leads me to a previously stated conclusion I made that a lot of Trump’s base are nihilists who just want to burn the system down. It is difficult to find more nihilistic behavior than orchestrating an insurrection against the US government and refusing the peaceful transfer of power.

Given the above analysis – I think the negative sentiment about President Biden is primarily the product of foreign actors manipulating the American electorate. That also explains the disconnect between many of the demographic features of Trump voters and their candidate.

I do not want to put all of this on young voters.  There are clearly older voters who demonstrate similar levels of cluelessness, probably borne out of long-standing biases.  It is up to voters of all ages to not believe what you see in social media echo chambers, clear propaganda from hate groups, and similar attitudes that may have existed in your culture for generations. We cannot turn the United States over to a man and a party of extremists who have proven time again that they have no vision for the country or where it is headed. In Congress the Republican majority has clearly demonstrated that they cannot govern. We cannot be influenced by groups seeking to divide Americans and destroy the values that this country was founded on.

We all must start swimmin’ to save American democracy.

 

George Dawson, MD, DFAPA

References:

1:  Hotez, Peter. "On Antiscience and Antisemitism." Perspectives in Biology and Medicine, vol. 66 no. 3, 2023, p. 420-436. Project MUSE, https://doi.org/10.1353/pbm.2023.a902035.

2:  Scherer, Nancy & Miller, Banks. (2009). The Federalist Society's Influence on the Federal Judiciary. Political Research Quarterly - Polit Res Quart 62. 366-378. https://doi.org//10.1177/1065912908317030. 

Graphic Credit: I made this graphic 

Supplementary 1:  Why I wrote this post - this post is not an analysis of the psychiatric status of either candidate.  I am on record on this blog that the role of assessing the President's fitness to work in that office is supposed to be assumed by lay people working with him or her.  Many people working with Trump have provided scathing critiques of what they observed. I have not seen any from the Biden administration. 

This post was written basically as an exploration of how a candidate who seems so intellectually, emotionally, and temperamentally unfit for the office (as determined by multiple independent assessments by non-mental health professionals) has such a draw with the electorate. It seems mystifying until you look at the diagram and realize that more of the factors that leverage the electorate are stacked against Biden rather than Trump. In fact - replacing Biden in the graphic results in minimal gains. If I had to speculate on the biggest effect I would see it as all of the factors impinging on the social media on Trump's side.  

For the record, I am not a life long Democrat and in fact ran as an Independent in 2000 for the US Senate from Minnesota. As a life long skeptic of both major parties, that was an eye opening experience. I am currently highly motivated to write about political extremism that I see from Republicans and the fact that it is only getting worse.  Giving Trump the job again when we already know what happened the last time is a clear mistake.  Allowing the Republican Party to maintain a nongoverning, culture wars, nihilistic response is also a massive mistake for the Republic.   

 

Supplementary 2:

Will add some examples to highlight the graphic as the I see them on a day to day basis:

Taylor Lorenz - excellent example that I saw today on TMZ is this interview.  Before this the TMZ crew showed Biden's attempt at humor with a birthday cake and they continue this into the interview like he is trying to win young voters with jokes.  Ms. Lorenz of course jumps on the opportunity to point out that Biden has not been focused on what Millennials or Gen Z want.  She cites an example of student loan forgiveness was not a focus apparently forgetting that his $430B student loan forgiveness plan was shot down by the right wing Supreme Court.  All three justices appointed by Trump (Gorsuch, Kavanaugh, Barrett) voted against the plan in a 6-3 vote (Biden v. Nebraska).  Instead she praises Trump for being "authentic."  With brilliant analyses like that Biden does not stand a chance. 

Adam Kinzinger - seems like a rare positive force in American politics today.  I saw him on Real Time with Bill Maher last week where he clearly stated that there was only one pro-democracy political party in the US and it was the Democrats. The former Republican Congressman clearly described why fanaticism is a negative coercive force in politics and that is why it needs to be eliminated. He also founded the Country First PAC as a way to distance himself from right wing extremists and conspiracy theories. 

Gen. Mark Milley - questioned about President Biden's performance by 60 minutes.

Hierarchical Diagnoses

 

The notion of hierarchical diagnoses comes up from time to time, so it is about time that I made some comments about it. Like most criticism of psychiatry, I think the concept is overblown and will illustrate why that is. The idea of hierarchies in diagnosis is basic.  It means prioritizing the most clearly defined illness.  Clearly defined in this case may mean a clearcut phenotype or disease mechanism.  In the psychiatric examples provided that generally means a feature high in the hierarchy that is not replicated at lower levels, but many features at lower levels that overlap.  

The overall goal is to not end up with a long list of conditions or diseases that could fit the presenting problems and end up treating everything on the list rather than the most likely cause of the problem.  I think of it as second year med student differential diagnosis.  When you are learning physical diagnosis you take an exhaustive history, review of systems, and physical exam and try to come up with a differential diagnosis list.  Even with that beginning level of knowledge in medicine you start to realize that diagnosis number 3 to 8 are improbable and start to focus just on the top 2. By the time you are an intern those lengthy differential diagnoses lists are a remote memory.

It also involves the application of the parsimony principle.  Is there a single diagnosis that incorporates all the features of the observed disorder rather than a list of conditions?  I can illustrate this with an example right out of my physical diagnosis text from medical school (1):

“In selecting the diagnosis from a list of hypotheses, the physician is to choose a single disease to explain all of the patient’s manifestations rather than explain them by the coincidence of several diseases.  This is called the law of parsimony. For example, when a patient is found to have a dilated heart, hepatomegaly, ascites, and pedal edema, the single diagnosis of cardiac failure explains all of the findings. It is more likely to be the true diagnosis than to suppose a coincidence of heart disease producing cardiac enlargement, cirrhosis of the liver producing hepatic enlargement, and nephrosis leading to edema from hypoproteinemia.  Nevertheless. The “law” must be applied cautiously.  The experienced clinician realizes that in the process of aging the patient accumulates the more debilitating conditions the longer he lives, and his demise is often accompanied by a combination of several diseases.” (p. 3-4)

And from a comparable section of DSM-II (2):

“The diagnostician, however, should not lose sight of the rule of parsimony and diagnose more conditions than are necessary to account for the clinical picture. The opportunity to make multiple diagnoses does not lessen the physician's responsibility to make a careful differential diagnosis.”

This excerpt on strictly physical diagnoses of non-psychiatric conditions illustrates a couple of points.  First is that disease states in general do accumulate over time.  Some are more likely to occur during different time frames during a life time.  The age at onset is a relevant concept but even then, there are exceptions. Secondly, transdiagnostic symptoms (covering many diagnoses) are common in the physical world. In the example edema and ascites are the obvious example but even the gross organ findings can be considered transdiagnostic signs.  For example, there are hundreds of possible causes of cardiomegaly and hepatomegaly, even though from a clinical standpoint the majority are not all fully investigated.  Once heart failure develops it is treated as a syndrome without a specific pathophysiological cause.  That illustrates a third point in the diagnostic process and that is the triage aspect.  Whatever is acute and life threatening gets priority and is diagnosed and treated first. I will illustrate how all these concepts apply directly to psychiatric disorders.

Hierarchies are thought to be more important in psychiatry because of symptom overlaps as well as certain diagnoses being more important not to miss. A common problem is the overlap of anxiety and depression. Some people have long history of both disorders concurrently or one morphing into another. Ghaemi (3) has suggested that mood disorders should be prioritized over anxiety disorders in the hierarchy.  He stresses the importance of diagnosis in this process and suggests that treatment of depression in this case would be the priority. He also briefly reviews some evidence in diagnostic hierarchies that basically show that they can be arranged so that diagnoses at the top of the hierarchy would contain the symptoms of every lower level in the hierarchy. For example, if bipolar disorder with psychosis is at the top of the hierarchy those patients would also have the symptoms seen at defined lower levels in the hierarchy like unipolar depression, schizoaffective disorder, schizophrenia, anxiety disorders, and personality disorders.  He claims that there is a current emphasis to make every possible diagnosis rather than a hierarchical approach, but does acknowledge that some psychiatrists “intuitively practice this way.” (p. 223).  Treatment setting is an obvious factor – with acute care psychiatrists seeing clear presentations of the more severe forms of schizophrenia, unipolar depression, and bipolar disorder.  They would be most likely to treat these acute forms and the pharmacotherapies are very similar.

It is always good to remember the task of the psychiatrist in all these academic exercises particularly when they are coupled with criticism of the psychiatrist in the field. What is the task of that psychiatrist?  That task varies with setting but after 22 years in acute care, the job is to recognize the acute illness and treat it while keeping the patient and the staff safe.  How well does a bipolar disorder->unipolar disorder->schizophrenia-> obsessive compulsive disorder-> anxiety disorder-> personality disorder->attention deficit~hyperactivity disorder (BUSOAPA) hierarchy hold up in that setting?

Probably not very well. That psychiatrist is confronted with an entirely different hierarchy. The first syndromic level encountered: “Is this patient medically stable? Are these symptoms I am seeing manifestations of an intoxication, withdrawal, or secondary medical condition?”  I routinely encountered these cases and often had to send them directly to the intensive care unit for both acute conditions threatening the life of the patient and acute conditions creating the psychiatric symptoms. The second syndromic level: “Is this patient responsive to me during the interview?  If not, are they delirious, catatonic, or is there another psychiatric reason?  Did I miss an acute medical condition like a stroke and aphasia at the first syndromic level?  The third syndromic level: “Is this person able to produce an accurate history that I need to make a diagnosis and formulate a treatment plan? Does the history that they are giving me sound plausible?”  If not why not why - and what needs to be done?  Do I need to gather a lot of collateral history to get the full picture?

These considerations place the BUSOAPA hierarchy at the minimum as a hierarchy within a hierarchy that contains about 40 or 50 psychiatric diagnoses and many more if all possible medical diagnoses masquerading as psychiatric diagnoses are considered. The diagnoses also have clear implications for Ghaemi’s concern that a hierarchical model would reduce misdiagnosis and polypharmacy.  Patients with alcohol use disorder (AUD) can experience psychotic symptoms and mood symptoms.  I have seen them misdiagnosed as having schizophrenia and bipolar disorder. Does that mean AUD should be at the top of the hierarchy?  Placing it there would skew the data because most people with AUD do not have those severe symptoms, but on the other hand if they were misdiagnosed with schizophrenia or bipolar disorder – appropriate treatment with benzodiazepines for alcohol withdrawal may be held to the detriment of the patient.

A recent exercise was sent to me to see if it suggested a need to modify DSM criteria for major and mild neurocognitive disorder.  The patient was described as having Alzheimer’s disease, cerebrovascular disease, an HIV infection, and heavy chronic alcohol use.  They had symptoms of psychosis.  They were coded as having major neurocognitive disorder due to all the listed etiologies.  The problem is that the current diagnostic criteria use a hierarchical approach and state that for probable Alzheimer’s Disease in both the major and mild neurocognitive disorder categories the mixed etiologies need to be ruled out or eliminated. That is currently difficult to do on a clinical basis and will lead to more uncertainty in the Alzheimer’s Disease diagnosis using these criteria. In terms of the BUSOAPA hierarchy – it is an argument to put the neurodegenerative disorders diagnoses at the top since they frequently contain most of the symptoms of psychosis, mood disorders, and anxiety while having unique cognitive profiles that would not be seen at lower levels.

Getting back to Ghaemi’s original argument for empirically studied hierarchies in psychiatry to reduce misdiagnosis and improve treatment by reducing polypharmacy – is that likely? They might work at the level of nomenclature only.  Hierarchies might work in highly selected environments with low acuity patients.  I am thinking about an outpatient psychiatric teaching clinic. It might be easy to illustrate how the patient population matches what is happening hierarchically.  In other settings looking at higher levels of acuity – the acuity becomes the hierarchy. Residents in acute care should learn almost immediately that pharmacotherapy in the inpatient setting needs to be directed at the likely acute diagnosis.  Even then that clearcut diagnosis can be obscured in the outpatient setting. The best example I can think of is women with postpartum bipolar disorder +/- psychosis who are stabilized and eventually readmitted with diagnoses of schizophrenia or schizoaffective disorder. In that case, the diagnosis was in the top spot of the BUSOAPA hierarchy based on the direct observations of the inpatient psychiatrist, but it was modified on an outpatient basis by staff who did not directly observe the acute manic episode. A violation of the hierarchical model to be sure, but also poor continuity of care and ignoring what happens in acute care.         

That brings me to the issue of hierarchies in previous versions of the DSM. I will focus on DSM-II because it is the most clearcut.  The explicit hierarchies in DSM-II included both acuity and severity.  Specifically:

“1. The condition which most urgently requires treatment should be listed first.”

And:

“2. When there is no issue of disposition or treatment priority, the more serious condition should be listed first.”

And:

“It is recommended that, in addition to recording multiple disorders in conformity with these principles, the diagnostician underscore the disorder on the patient's record that he considers the underlying one.”

These three sentences from DSM-II capture what appears to be the concern about diagnostic hierarchies in subsequent versions of the DSM.  They easily map on to what happens clinically as depicted in my diagram at the top of this post. It is also consistent with the general approach to all medical diagnoses and the training of psychiatrists.

A long list of diagnoses is a rookie mistake. Experienced psychiatrists are generally trying to address the main problem and the urgent problem. There is some evidence for that in the numbers of diagnoses that are used in clinical practice and those numbers are considerably lower than the usual DSM-5 count. That does not mean that polypharmacy will not be involved, but it does mean that any polypharmacy used is there to address the main problem and not multiple separate diagnoses all at once.  The concepts of comorbidity and transdiagnostic symptoms are discussed these days like they represent new ideas. Any physician trained in a medical school and residency program knows about both starting with medical and surgical diagnoses and progressing to psychiatric diagnoses. The general concepts are the same. The necessary evaluation in psychiatry should adequately reflect the complexity of the situation and that means a detailed longitudinal history and that can include disorders that are commonly viewed as symptoms – like primary insomnia. 

A detailed longitudinal history may not lead to a correct current diagnosis until the symptom patterns change. The best example in the case of a pure psychiatric disorder is bipolar disorder.  Goodwin and Jamison (4) make this point in their discussion of false unipolar disorder – people with recurrent unipolar depressive episodes until the first episode of mania occurs. In their table they show that according to three different longitudinal studies, patients experience 1 to 5 episodes of unipolar depression without a manic episode and they constituted a significant portion of the unipolar sample.  A hierarchical rule in this case results in misclassification until a manic episode occurs. 

A strictly hierarchical diagnosis will also not capture clinic reality.  It can potentially lead to catastrophic results.  The best example I can think of is schizophrenia and depression. If you consider schizophrenia in a hierarchy independent of depression, you will miss the opportunity to treat serious depression in patients with a schizophrenia diagnosis.  It is also a case of seeing a new patient treated for both diagnoses and considering what medication to stop.  The features of schizophrenia are such that the presentation of depression is very subtle and medication changes of antidepressants and antipsychotics should only be changed with extreme caution and after adequate collateral history has been obtained.

Criticizing DSMs is a popular American sport. That has resulted in elevating the DSM to levels that are really not consistent with the way these documents are viewed by psychiatrists. The documents are generally limited by the fact that they are not treatment manuals and do not incorporate considerable amounts of research that could provide guidance in these areas. With a document that is limited to nomenclature – any changes including hierarchies will result in a loss of information at another level.  To me this seems like an endless exercise in trying to reduce uncertainty to an unachievable level.  

That is why psychiatrists need to be trained and don’t result from reading a manual.  

 

George Dawson, MD, DFAPA

 

References:

1:  DeGowin RL.  Bedside Diagnostic Exam.  3^rd ed.  Macmillan Publishing Company, New York, 1976: 3-4.

2:  Diagnostic and Statistical Manual of Mental Disorders. 2^nd ed. Washington, DC.  American Psychiatric Association. 1968: 2-3.

3:  Ghaemi SN.  The concept of a diagnostic hierarchy. In: Ghaemi SN.  Clinical Psychopharmacology: Principles and Practice.  New York.  Oxford University Press. 2019: 222-230.

4:  Goodwin FK, Jamison KR.  Manic-Depressive Illness. New York.  Oxford University Press. 2009: 66.