As anyone reading the newspapers has heard, the DSM-5 went on sale earlier this year amidst a cacophony of DSM bashing and bashing of the profession in general. The most vehement critics also exhorted the public to not buy this evil book that would lead to the squandering of billions of healthcare dollars and leave millions hopelessly misdiagnosed and taking expensive unnecessary drugs. In some cases that I have recorded on this blog the criticism was even more extreme. Now that the DSM-5 has been out for several months I asked myself what the outcome of all of that bad press has been? Like thousands of my colleagues, I have picked up a copy and glanced at it from time to time. It certainly has not lead to any revolution in psychiatric practice or changed anyone's clinical interviewing or diagnostic process. In fact I have talked with many psychiatrists in the past several months and none of my conversations has touched on the DSM-5. What are the facts of the release after all of the pre-release spin?
First of all, the predicted apocalypse has not happened. I should say the apocalypse happened but it was 30 years ago when the managed care industry essentially converted mental illness into "behavioral health" and began to restrict access to psychiatric care, inpatient and medical care, psychotherapy, and certain medications to people with severe mental illnesses. The predicted apocalypse in response to the DSM-5 did not happen because as I have been saying all along, the DSM has never been the problem. Mental health care can be denied as easily on the basis of a DSM-5 diagnosis as a DSM-IV diagnosis. A diagnostic manual is partially relevant only for people who are trained to use it.
That said, is there any way to estimate whether people are buying it or not? I heard a sales estimate e-mailed by a colleague that suggested brisk sales, but did not have permission to quote him so I started to look for public sources of data on DSM-5 sales. I went to the usual New York Times Bestseller List and could not find it listed. I could not really find any academic books listed there so I wonder if there is not another list. I thought that Amazon would be the next logical stopping point and I did find some data there. I was looking for data in number of units actually sold and I could only find that as proprietary data that somebody would sell to me. I did find it as # 8 in Best Sellers of 2013 so far. This link shows it has been in the Top 100 books for 167 days but that it has fallen to the number 4 position. Interestingly the Publication Manual of the American Psychological Association had been on the same list 8 times as long. I also found it in a sequential list of DSM-5 products and related variants including 2 books about the DSM-5 by Allen Frances, MD. It made me think about obvious conflict of interest considerations in the psychiatry criticism industry that are never mentioned when they get free press. If somebody can suggest that I have been getting a free lunch from a pharmaceutical company when I haven't seen a drug rep in over 25 years, they should at least point out that somebody can currently make money - possibly even a good amount of money by criticizing psychiatry regardless of whether or not that criticism is remotely accurate.
That is all I have so far. If you have reliable public data on the actual sales of this manual and would like me to post it here, please send me the information. I have requested the actual sales figures in an APA forum but I doubt that anyone will provide them to me. The APA is a very conservative organization and I doubt that they would want you to see those sales figures posted here, even if if this is probably the only public forum that takes a very skeptical look at all of the critics of the DSM-5 and psychiatry in general.
George Dawson, MD, DFAPA
Saturday, September 14, 2013
Tuesday, September 10, 2013
A Poem About Grandiosity
I came across this poem as part of the Breaking Bad series on AMC. It applies to their plot line, but it is also a testament to grandiosity as a reaction to the existential concerns about death and meaningfulness. As I drove in to work this morning I thought about the fact that the physical monuments to people, especially the ones that are personally erected in one's own honor rarely stand the test of time. There is imagery at several levels in the poem from the archaeological to the psychological and the impact that culture has on that psychology.
Thoughts, ideas, and deeds are the best way to be remembered. And the people who are remembered in this way would not be interested in monuments in their honor. A good example is the focus on Shelley's poem nearly 200 years after it was originally published.
Ashes to ashes........
Ozymandias
by Percy Bysshe Shelley
I met a traveller from an antique land
Who said: Two vast and trunkless legs of stone
Stand in the desert. Near them, on the sand,
Half sunk, a shattered visage lies, whose frown,
And wrinkled lip, and sneer of cold command,
Tell that its sculptor well those passions read
Which yet survive, stamped on these lifeless things,
The hand that mocked them and the heart that fed:
And on the pedestal these words appear:
"My name is Ozymandias, king of kings:
Look on my works, ye Mighty, and despair!"
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.
Should existential themes be important to a psychiatrist? I answered that question for myself over 20 years ago when I picked up a copy of Yalom's Existential Psychotherapy. At that time I was working in a pediatric setting and talking with residents and staff who actually seemed interested in talking with a prospective psychiatrist. Two of the physicians in the group had the rare experience of seeing motorcycle accidents on the freeway and being first responders and saving the crash victims. We discussed Yalom's conceptualization of death anxiety and how it might apply and it made sense to both of them. Since then I have found it much easier to talk about these themes when they occur rather than trying to elicit specific symptoms since they are very important themes associated with anxiety and depression. The meaning of those symptoms is still important to most people whether that happens from a psychodynamic, cognitive behavioral or existential perspective.
And yes - I have recognized the grandiose adaptation to death anxiety and meaningfulness, many times.
George Dawson, MD, DFAPA
Bryan Cranston's dramatic read of Ozymandias. The graphics may not mean much unless you have watched the television series.
Jim Amos, MD. Did Ozymandias Weep? The Practical Psychosomaticist Blog. Jim Amos has been thinking about this poem a lot longer than me. Read his associations to it at this link.
Thoughts, ideas, and deeds are the best way to be remembered. And the people who are remembered in this way would not be interested in monuments in their honor. A good example is the focus on Shelley's poem nearly 200 years after it was originally published.
Ashes to ashes........
Ozymandias
by Percy Bysshe Shelley
I met a traveller from an antique land
Who said: Two vast and trunkless legs of stone
Stand in the desert. Near them, on the sand,
Half sunk, a shattered visage lies, whose frown,
And wrinkled lip, and sneer of cold command,
Tell that its sculptor well those passions read
Which yet survive, stamped on these lifeless things,
The hand that mocked them and the heart that fed:
And on the pedestal these words appear:
"My name is Ozymandias, king of kings:
Look on my works, ye Mighty, and despair!"
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.
Should existential themes be important to a psychiatrist? I answered that question for myself over 20 years ago when I picked up a copy of Yalom's Existential Psychotherapy. At that time I was working in a pediatric setting and talking with residents and staff who actually seemed interested in talking with a prospective psychiatrist. Two of the physicians in the group had the rare experience of seeing motorcycle accidents on the freeway and being first responders and saving the crash victims. We discussed Yalom's conceptualization of death anxiety and how it might apply and it made sense to both of them. Since then I have found it much easier to talk about these themes when they occur rather than trying to elicit specific symptoms since they are very important themes associated with anxiety and depression. The meaning of those symptoms is still important to most people whether that happens from a psychodynamic, cognitive behavioral or existential perspective.
And yes - I have recognized the grandiose adaptation to death anxiety and meaningfulness, many times.
George Dawson, MD, DFAPA
Bryan Cranston's dramatic read of Ozymandias. The graphics may not mean much unless you have watched the television series.
Jim Amos, MD. Did Ozymandias Weep? The Practical Psychosomaticist Blog. Jim Amos has been thinking about this poem a lot longer than me. Read his associations to it at this link.
Saturday, September 7, 2013
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.
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.
Monday, September 2, 2013
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.
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.
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.
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.
Sunday, September 1, 2013
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
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
Friday, August 30, 2013
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
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
Sunday, August 25, 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
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
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