Being Flynn - Another Cinematic Portrayal of Alcoholism

My previous post looked at the accurate portrayal of alcoholism in the film Flight.  I recently saw Being Flynn starring Robert De Niro in the role of an alcoholic father and self proclaimed novelist.  This film is also a study of alcoholism.

Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men.  In this case we meet De Niro's character Jonathan Flynn in a downward spiral.  We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years.   We first see Jonathan Flynn when he is driving a taxi.  He is drinking vodka on a regular basis.  We see him lose his job and then his housing and end up at a homeless shelter.  Nick is floundering as a poet and author.  He lacks direction and the flashbacks suggest that childhood adversity has played a big role.  He comes to be employed at a homeless shelter where his father eventually seeks shelter.

The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character.  Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted.  It is the reason he was evicted.  At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies.  He uses a lot of expletives and at times seems incoherent.  In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors.  When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.

Nick is on his own parallel journey.  He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff.  The shelter staff and the environment at the shelter is expertly portrayed and very realistic.   The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable.  Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him.   He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year.  Jonathan predictably acts like he relishes the thought and that living on the street is nothing.  When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology.  There is a time when we are not sure whether Jonathan will survive or not.

There are a number of fascinating articles available that look at the process of making this film.  The gold standard for any film is the book and many critics suggest reading that as a starting point.  The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America.  When did it become acceptable?  The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.

As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years.  At some point in time they all create the anger, frustration, and hopelessness portrayed in this film.  Many of them are not only grandiose and paranoid, but permanently delusional or amnestic.  The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself.  This film is similar to Flight in that there are no proposed solutions.  The are no public policy statements.  It is an accurate depiction of real people dealing the the problem of addiction in their daily lives.  Despite those significant problems there are hopeful messages everywhere.  After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.

I also had associations to what I consider to be some of the most important work in alcoholism.  The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author.  Most of the original articles online are available only with steep fees for a one time read.  It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library.  It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995.  The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem.  In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston.  At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized.  One of Dr. Vaillant's characterizations of the recovery process in alcoholism:  "... alcoholics recover not because we treat them, but because they heal themselves.  Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime.  Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384).  Self healing was evident in this film.

The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila.  Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research.  He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol.  These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery.  An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.

This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family.  It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.

George Dawson, MD, DFAPA

Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.

Zemeckis portrayal of addiction in "Flight"

I went to see Robert Zemeckis film Flight starring Denzel Washington as pilot Whip Whitaker yesterday.  Spoiler alert - if you are a person who likes to see new films knowing nothing about the plot - stop reading this post right here.  I work at a large residential addiction facility and ran into one of my colleagues in the lobby.  He told me he was there to see the film because it was a good film about addiction.  I was completely surprised.  Robert Zemeckis made the film that I have seen more times than any other - Forrest Gump.  I generally see anything that Denzel Washington does.  Like everybody else, I like his work and he does not make any bad movies.  His last transportation themed movie Unstoppable cast him the role of a wise engineer trying to stop a runaway train.  The trailers I had seen for Flight suggested a similar role.  I expected a heroic pilot with a similar outcome.

From the outset, it is obvious that Whip Whitaker has a tremendous problem.  He wakes up hung over, snorts some cocaine, drinks what is left of a beer and heads out the door with his pilots uniform on.  Almost incredibly he proceeds to inspect his commercial airliner, fly it through extreme turbulence, drinks some additional vodka in flight and takes a 26 minute nap before the critical scene in the movie where he performs a complicated series of maneuvers to save most of the crew and passengers from a mechanical failure.  Subsequent analysis proves that he is the only pilot who could have saved the plane.  But even those facts are not enough to preserve his fleeting hero status.

Throughout the film we see Whip drinking in an uncontrolled manner.  There is some ambivalence.  He gets out of the hospital post crash and goes to the family farm where he proceeds to dump out all of the beer and hard liquor.  He dumps out his stash of marijuana.  There is the implicit recognition that somewhere there are toxicology results that he is going to have to deal with.  As that part of the plot unfolds, he resumes drinking, smoking marijuana, and snorting cocaine with a vengeance.  In one scene he walks out of a liquor store with a case of beer and what appears to be a three liter bottle of vodka.  As soon as he gets into the car he is drinking the vodka like water and drives around with an open can of beer.  There are several scenes where the interpersonal toll of alcoholism is evident with his potential love interests, his son and ex-wife, and friends and business associates who are rooting for him.  The business associates have a common interest in seeing that he is exonerated for any crimes related to substance abuse.

This film succeeds in its depiction of alcoholism and how it hijacks the life of an otherwise highly successful pilot.  On the surface he is a "functional alcoholic."  His friend and former fellow Navy pilot describes him as a "heavy drinker" rather than an alcoholic   He appears to be successful in one aspect of his life but it does not take long to figure out even that is a charade.  He can't tolerate even the suggestion that he has a problem on the one hand and on the other makes the promise that he will stop and he can stop at any time.  He walks out of an AA meeting when the speaker asks people to raise their hand if they are an alcoholic.  There is a contrast between Whip and his girlfriend Nicole illustrating that addiction has no socioeconomic boundaries.  There were so many scenes in this film that captured the problems of addiction.

As an audience member you cannot help getting caught up in his fight with alcohol.  He is after-all the hero of this film and that is firmly established in the first 20 minutes.  You are hoping that he will not pick up another drink.  You are left with a situation where the hero will be dealt with according to technicalities.  His heroism does not count.  The only thing that matters is that he has an addiction.

This is a compelling film about addiction for families who deal with this problem on a daily basis and for those who do not.  It accurately portrays the central problems of addiction and recovery as not just avoiding punishment or making a conscious decision to stop.  It is a lot more than that and hopefully that message will be clear from watching this film.

George Dawson, MD, DFAPA


References (Doug Sellman has done a great job of distilling out the scientific points of addiction):

1. Sellman D. Ten things the alcohol industry won't tell you about alcohol. Drug Alcohol Rev. 2010 May;29(3):301-3. PubMed PMID: 20565523.

2. Sellman D. The 10 most important things known about addiction. Addiction. 2010 Jan;105(1):6-13. Epub 2009 Aug 27. PubMed PMID: 19712126.

3.  Alcohol Action New Zealand web site (various resources)

4.  Alcoholics Anonymous.  Grounded.  Alcoholics Anonymous World Services, New York City, 2001.

Who Runs My Drug Plan?

The real issue in pharmaceuticals used to treat mental illness is the business practices that looms as an obstacle between the psychiatrist prescribing the medication and the patient who wants to receive the medication.  I have posted about the managed care practices - specifically pharmacy benefit managers (PBMs) that get in between physicians and patients. That previous post shows a diagram from an internal memo that reveals some perspective on the PBM attitude.  The goal for them is to come up with a business argument that will either improve profits for the managed care company or justify the billions of dollars in costs that PBMs add to the health care system every year.

The National Community Pharmacists Association fights back against PBMs from this web site.  A lot of what you find is relevant for pharmacists also applies to physicians - especially wasting physician time, indirectly affecting reimbursement, and disrupting the patient-physician relationship by dictating medications that need to be prescribed that are financially advantageous to the PBM.

Some of the details provided on this site are very interesting.  One example is a $10 price spread on up to 4 billion prescriptions per year.  I once read that PBMs made up an $80 billion per year industry and it is easy to see how they can get there.  In fact, the volume strategies that they use are very similar to the financial services industry.  In both cases, political advantage has added businesses that levy another tax on consumers and do not provide any added efficiency.  It is easy to see how managed care strategies fail to contain health care inflation when the intermediaries with government advantages are set up to maximize profits and waste the time of physicians and pharmacists.  

If you are a physician, watch the "Fed Up With Phil" video and ask yourself if it isn't time to get rid of health care middlemen that are increasing costs and in many cases detracting from the quality of health care?  If you are a physician, isn't it time that you or your professional organization starting putting up web sites like this one to educate the public about managed care and all of its problems?  Isn't it time that we stopped wasting our time and money with politicians?

George Dawson, MD, DFAPA

The diagnosis of anosognosia

Follow up on another blog today where the author proclaims "It is not possible to diagnose anosognosia in schizophrenic patients on brain scan."

No kidding.  Here is another shocker and you can quote me on this - it is not possible to diagnose anosognosia in stroke patients based on a brain scan.  Quoting an expert: "Anosognosia refers to the lack of awareness, misbelief, or explicit denial of their illness that patients may show following brain damage or dysfunction.  Anosognosia may involve a variety of neurological impairment of sensorimotor, visual, cognitive, or behavioral functions, as well as non-neurological diseases."  I  encourage anyone who is interested in this topic to find a copy of this book chapter listed in the references below.  The author thoroughly discusses the fascinating history of this disorder, specific protocols used to make the diagnosis, various neurological subtypes with heterogeneous lesions and the fact that no specific mechanism has been determined.

In a more recent article available online, Starkstein, et al provide an updated discussion in the case of stroke.  They discuss it as a potential model of human awareness, but also point out the transient nature and difficulty in developing research diagnostic criteria.  They provide a more extensive review of instruments used to diagnose anosognosia and conclude: "Taken together, these findings suggest that lesion location is neither necessary nor sufficient to produce anosognosia, although lesions in some specific brain areas may lower the threshold for anosognosia. Strokes in other regions may need additional factors to produce anosognosia, such as specific cognitive deficits, older age, and previous strokes."

The experts here clearly do not base the diagnosis of this syndrome on imaging.  It is based on clinical findings.  For anyone interested in looking at the actual complexity in the area of anosognosia in schizophrenia I recommend reading these free online papers in the Schizophrenia Bulletin in an issue that dedicated a section to the topic in 2011.  You will learn a lot more about it than reading an anti-biological antipsychiatry blog.  But of course you need to be able to appreciate that this is science and not an all or none political argument.

George Dawson, MD, DFAPA.

Patrik Vuilleumier. Anosognosia in Behavior and mood disorders in focal brain lesions.  Julien Bogousslavsky and Jeffrey L. Cummings (eds), Cambridge University Press 2000, pp. 465-519.

E. Fuller Torrey on the New Anti-biological Antipsychiatry

This post by E. Fuller Torrey was noted on another blog especially the phrase "the new anti-biological antipsychiatry".  Torrey explains anosognosia both as a biological phenomenon and why it may be "deeply disturbing" to the new antipsychiatrists.  Basically it represents the difference between social behavior based on choice versus social behavior based on brain damage.  The former  might be a civil rights issue but the latter is a medical problem that benefits from identification, study, and treatment.  Torrey is also clear about the consequences of no treatment, facts that the antipsychiatrists conveniently often leave out of their arguments or more conveniently blame on treatment.

There is a lot of technical information apart from the data on anosognosia that is ignored by the new anti-biological antipsychiatry.  There are studies on the prefrontal cortex that go back for decades and the implications for social behavior and the neurobiology of everything from addiction to dementia.

Here is a link to the original blog post by Duncan Double entitled: "E. Fuller Torrey attacks 'The new antipsychiatry.'"  Defending against attacks by the new antipsychiatry is more like it.  Dr. Double laments the fact that at times he is seen as an antipsychiatrist, even though he essentially maintains many of the positions of mainstream antipsychiatry.   He includes a variation of the old antipsychiatry argument that if you don't have a specific test for a disease - the disease does not exist.  That opinion fails to take into account studies about what is or is not a disease as well as a massive literature of biological psychiatry.  It also fails to take into account the fact that these arguments are political in nature and have very little to do with science.

A good example is the chemical imbalance red herring.  Any psychiatrist trained since the 1970s is aware of the complex neurobiology of human behavior.  I can recall reading Axelrod's paper in Science over 30 years ago.  Since then there have been eight editions of The Biochemical Basis of Neuropharmacology and five editions of the ACNP text Neuropsychopharmacology.  Since then a psychiatrist has won the Noble Prize for contributions in neuroplasticity and wrote a seminal article on neuroplasticity and learning in psychotherapy.  That is apparently ignored by the anti-biological antipsychiatry crowd and those who would characterize the field as prescribers versus therapists.  The Internet is currently full of diagrams of cell signalling pathways with the associated proteins and genetics.  The idea that chemical imbalance reflects some central central theory of biological psychiatry or represents anything beyond pharmaceutical company marketing hype reflects a gross misunderstanding of the field.

Any psychiatrist who tries to respond to these crude arguments is at a disadvantage for a couple of reasons.  It is certainly seems true that the antipsychiatrists political stance is really not conducive to scientific discourse.  Suggesting that the appearance of conflict of interest invalidates psychiatry is an obvious example.  Discounting the amassed research on the neurobiology of mental illness is another.  A political argument is well outside the scope of hypothesis generation and testing.  Dismissing the science by attributing it to the "worldview" of a single person is consistent with that political approach.  

Conflict of interest and psychiatry - what's missing?

A new article looking at conflict of interest in psychiatry was presented on another blog to suggest that new rules are required to improve transparency. The article takes a look at six cases and the process used by Sen. Charles Grassley to publicize these cases. The article suggests that the reason for publicizing these cases was in order to support Grassley legislation (Physician Payment Sunshine Provision).  According to the article it was attached to the Patient Protection and Affordable Care Act and was never voted on alone. 

These cases were repeatedly publicized in the popular media and some of the problems with these cases and Grassley's analysis were never adequately discussed.  The clearest example is the case of Alan F. Schatzberg, MD of Stanford University. He was the chairman of the Department of psychiatry and when Grassley investigated the matter at the level of Stanford University and several pharmaceutical companies. You can read the exact details in this paper but the bottom line is that Stanford University has always maintained that it handled potential conflicts of interest in an appropriate manner consistent with their policies. They actually published a statement on their web page at the time.  He remained the department head and although he was apparently temporarily removed as the principal investigator on a federal grant but he was later reinstated. The authors of the article in this case suggest that exposing the conflict of interest had negligible effect on the outcomes in this case, but the fact is the case was handled according to university policy.

There are really two key elements in this paper that are critical. The first is why Grassley went after psychiatry in the first place. The article suggests this occurs because his aide Paul Thacker "Combed  the media for stories of influential physicians with industry ties. He then requested the physicians conflict of interest disclosures from their AMCs and compared them to payment schedules obtained from companies."  I had always wondered why physicians from other specialties were never mentioned or consultants from other departments. It is fairly well known that scientists and engineers can make substantial incomes to supplement their university salaries based on their expertise. So why was the "media combing" restricted to psychiatry?

If I had to speculate, I would suggest that media bias against psychiatry is a well known fact. It has actually been investigated and the frequency of negative press that psychiatry receives relative to other specialties is well known. (see paragraph 4)  The popular press has an automatic media bias against psychiatry and it should come as no surprise that prominent psychiatrists are investigated and reported more frequently than other specialists. This is why “combing the media” is really not a legitimate research method. It should be fairly obvious that prominent university affiliated physicians of all specialties have similar conflicts of interest and that the business stake in other specialties is probably significantly higher.

The second element that should be obvious to anyone skeptical of Congress is Grassley's quote in the article "The whole field of medicine is connected by a tangled web of drug company money. For the sake of transparency and accountability should the American public know who their doctor is taking money from?"  That sounds like there is an obvious answer in there somewhere but the U.S. Congress is the best case in point that transparency is essentially meaningless. There is probably no better example than Sen. Grassley himself.  You don't have to look too far to find campaign donations that align with the votes and the Senator's denial (see paragraph 8) that there is any connection.

These simple facts are left out of the Journal article and that represents a serious flaw to me. Is the U.S. Congress is a shining example of disclosure becoming a license to do whatever you want to do? If that is the case you really don't have the basis to suggest that transparency will allow the "power of sunlight to disinfect". It clearly does not have that effect in Congress.  That is at the minimum an appearance of a conflict of interest on par with any scenario described in this article.  When I point this out - the usual rebuttal is that doctors should have a higher standard when it comes to the appearance of conflict of interest.  Is that really true?  Should a doctor who already has a fiduciary responsibility to a patient and the patient's well being have a higher conflict of interest standard than one of the 100 most important law makers in the country?

The other issue here of course is that psychiatrists are conveniently thrown under the bus. Despite the qualifier in this paper is that "Nor did Grassley ever assert that psychiatry was more problematic than other specialties." (p 5).  You really don't have to make an assertion when psychiatry is apparently the only field you are investigating. That bias is totally consistent with one of the themes of this blog. 

When all else fails you can more easily scapegoat psychiatrists.  So why look for anybody else?

George Dawson, MD. DFAPA

Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry:
Does transparency matter? Int J Law Psychiatry.
2012 Oct 1. pii: S0160-2527(12)00072-6. doi: 10.1016/j.ijlp.2012.09.009.

[Epub ahead of print] PubMed PMID: 23036364.

The Besieged Minority

October 25 marks the 10th anniversary of the death of Senator Paul Wellstone.  There was an article commemorating this date  in the St. Paul Pioneer Press today.  Senator Wellstone was a favorite and perhaps my only favorite politician after he voted against HJ Res 114: "To Authorize the Use of the United States Armed Forces against Iraq."  His actual statements about the logic of going to war that are linked to this page is the best example of a rational analysis at a time when there was near mass hysteria to go to war.  And compared to all of the evidence that Iraq had weapons of mass destruction that they were somehow going to use against the US, only his analysis has stood the test of time.  Senator Wellstone is always recognized for his fighting for social causes but I think he also deserves a great deal of recognition for this analysis on the appropriate threshold for the use of force in a high degree of uncertainty.  His analysis in favor of peace.

The article describes the Paul Wellstone Mental Health and Addiction Equity Act of 2007 as his signature legislative accomplishment.  His son Dave lobbied for five years to pass this bill after his father's death and the title of this post is excerpted from a quote from his son:"My dad said that folks with mental illness and addiction were a besieged minority."

Paul Wellstone was certainly right about that.  Anyone who comes from a family with mentally ill or addicted members can attest to the lack of resources and assistance to address those problems.  Those same people can also attest to the uneven insurance coverage or in many cases a complete lack of insurance coverage.  When managed care arrived on the scene about 20 years ago a lot of people had the appearance of mental health and addiction coverage only to see it disappeared when needed based on the managed care company's tactics.  An example would be discharging a person with severe mental illness or addiction in a few days because the "acute" symptoms had resolved and they were no longer "dangerous".

Unfortunately these practices have really not changed.  In many cases they are worse.  Each managed care company has what it calls "medical necessity" criteria.  The best example is acute inpatient care.  A reviewer or case manager reads the chart and decides that the person is no longer suicidal or potentially aggressive to other and decides that they can be discharged.  The discharges occur at a convenient time that allows for somebody to make a profit.  The person's overall stability in terms of their ability to function or whether their personality function has been restored is never taken into account.   The likelihood that they will immediately relapse to a life threatening addiction that has only partially been addressed is not taken into account.  The issue of co-occurring addictions and mental illnesses are not taken into account.  The issue of whether that person is capable of managing any associated medical problems like diabetes is not taken into account.  People are frequently discharged with as many symptoms and problems as they were admitted with.

Practically every outpatient psychiatrist I have talked and corresponded with about this problem has given me the opinion that inpatient psychiatry is for all practical purposes - worthless.  In the meantime, one of the country's largest managed care companies reported last week that their profits were up 26%.

Apart from the loss of Paul Wellstone and the activity of Wellstone Action as far as I can tell there is no current politician out there to make sure that the intent of this legislation will ever be realized.   There is no doubt that federal and state law is extremely business friendly and overtly hostile toward physicians working in the health care system.  The deck is clearly stacked in the direction of health care businesses and the new legislation promoted by President Obama will make things even worse.  Unless there are some valid protections at the level of patient and physician interaction - business decisions based on health company profits will  always trump clinical decisions.  There is no better example than what has happened and continues to happen to psychiatric care over the past two decades.

In the meantime I will remember Paul Wellstone on October 25 and wish that he was still the most unique guy in the US Senate.

George Dawson, MD, DFAPA

Bill Salisbury.  Living On In Those He Inspired.  Pioneer Press. Sunday October 21, 2012.