Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, May 31, 2015

The Blank Screen

The question of the psychiatrist's relative anonymity has come up lately in an interesting way. In a recent twitter conversation, Jeffrey Lieberman made a comment about a piece in the NY Times, to which Dinah from Shrink Rap responded, and things went back and forth, with others chiming in. Dinah noted that one of the "chimers" was driving some of the contention, but does not identify himself, and that to effect real change, perhaps he should.

More recently, Dinah published a post on Shrink Rap about this issue. The bottom line is that she is basically herself with her patients, but not fully so.

Dear readers, you may have noticed that I don't use my real name on this blog. The reasons are complicated. In truth, a strongly determined patient could figure out that her psychiatrist writes this blog. Just as a moderately determined reader could figure out my real name. I haven't tried to make it impossible.

But I do think there's a difference between a patient seeking out a connection, and my shoving my opinions and experiences in her face. The former is the proverbial grist for the mill. The latter is my making my patient's treatment about me.

I like the way a little anonymity frees me up to make snarky, sarcastic, or even kind, generous comments. I like the fact that I'm writing my own blog, not for some other publication, where I would contain, or at least subdue my personal take, in favor of something more evenhanded. In fact, I have done just that writing for Carlat. 

In my work with patients, I rarely offer advice, mostly because how am I supposed to know better than my patient what he should do, or if I can figure it out, so can he, so there's something important to understand about why he hasn't done so. 

Granted, I no longer work with patients who are very sick. Back when I did, I was much freer with advice and suggestions, because I felt that's what they needed. 

Similarly, I rarely share my opinions, or personal information. But sometimes I do. It all depends on whether or not I think it's helpful. And sometimes, it's hard to know.

I don't practice that way, and it's not how psychoanalysis in general is practiced these days, nor  has it been for quite some time, but the stereotype (Freud, S. (1912). The Dynamics of Transference. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913), 97-108, p.99.) of the silent analyst sitting behind the couch, acting only as a mirror or a blank screen persists.

So let's consider the concept of the blank screen.

The earliest reference I can find in the analytic literature (on pep-web), is in Jelliffe, S.E. (1930). British Journal of Medical Psychology. Psychoanal. Rev., 17:348-359.

The analyst becomes a blank screen upon which are projected pictures of the patient's infantile life. 

In Character Analysis (1933 New York: Orgone Institute Press, 1945 pp. 4ff., 119-140, p. 137) Wilhelm Reich makes the following statement with respect to countertransference:

… it is a mistake to interpret the general analytic rule that one has to approach the patient as a blank screen onto which he projects his transferences in such a manner that one assumes, always and in every case, an unalive, mummy-like attitude. Under such circumstances, few patients can "thaw out, " and this leads to artificial, un-analytic measures. It should be clear that one approaches an aggressive patient unlike a masochistic one, a hyperactive hysteric unlike a depressive one, that one changes one's attitude to one and the same patient according to the situation, that, in brief, one does not behave neurotically oneself, even though one may have to deal with some neurotic difficulties in oneself.

Yes, this is the same Wilhelm Reich that Lieberman writes about in Shrinks. He had his nutty ideas about "orgone", but he also wrote an amazing book on character.

These are some more references:

The concept of the analyst as a blank screen is an abstraction...The countertransference appears today as an inevitable impurity due to the fact that every analyst, in spite of his analysis, remains an individual with his own characteristic interpersonal patterns which he cannot entirely eliminate from the treatment situation, just as he cannot change the timbre of his voice, the expression of his eyes, the height of his body. Alexander, F. (1954). Some Quantitative Aspects of Psychoanalytic Technique. J. Amer. Psychoanal. Assn., 2:685-701.

In the psychoanalysis of adults, the psychoanalyst keeps his personality in the background as much as possible. The better the psychoanalyst succeeds in being like a blank screen, the easier it is for the patient to regress from an object relationship to a transference relationship, to project upon the psychoanalyst infantile fantasies and to re-enact phases and situations of the remote past. It is, in other words, desirable that the analyst avoid becoming a member of the patient's primary group. Sperling, O.E. (1955). A Psychoanalytic Study of Social-Mindedness. Psychoanal Q., 24:256-269.

the old concept of presenting a blank screen to the patient may have been reduced to absurdity by many psychoanalysts, [but] the fact remains that deliberately adopting special attitudes and time restrictions for special cases changes the character of therapy in these cases, converting it into a form of rapport therapy. This may indeed have excellent results. What form of psychotherapy cannot produce its quota of excellent results or, for that matter, condign failures? It may indeed be the only alternative in cases which are inaccessible to the customary technique. The important issue cannot be burked. Do such practices constitute psychoanalytic therapy or are they simply forms of rapport therapy?Glover, E. (1964). Freudian or Neofreudian. Psychoanal Q., 33:97-109.

And more recently:

The assumption, for example, that the blank screen was the aspirational goal for the analyst to maintain can not only be challenged on theoretical grounds, but also on the more relevant observation that there is no such thing as a blank screen, and analysts are always revealing themselves consciously and unconsciously to the patient. MacGillivray, W.A. (2011). Psychoanalysis Never Lets Go Freud and His (Reluctant) Followers: From Classical to Contemporary Psychoanalysis: A Critique and Integration by Morris N. Eagle New York and Hove: Routledge, 321 pp., $36.95, 2011. DIVISION/Rev., 3:10-13.

Freud does not explicitly use the term ‘blank screen' in his work to describe the neutrality of the analyst, but rather gradually develops a non-invasive approach to psychotherapy in which the analyst ‘gives up the attempt to bring a particular moment or problem to light’ (Freud, 1914, p. 147), and refuses to ‘decide [the] fate’ of the patient or to ‘force our own ideas upon him, and with the pride of a Creator to form him in our own image and to see that it is good’. Carpenter, A. (2010). Towards a History of Operatic Psychoanalysis. Psychoanal. Hist., 12:173-194.

In, Observations on Transference Love (Freud, S. (1915). Observations on Transference-Love (Further Recommendations on the Technique of Psycho-Analysis III). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913), 157-171, p 163.), one of his 5 technique papers, Freud writes about "neutrality".

...we ought not to give up the neutrality towards the patient, which we have acquired through keeping the counter-transference in check.

Freud certainly was not anonymous to his patients. Many were colleagues and friends, not to mention his daughter. He saw them in his home. He took up a collection to help provide income for the Wolf Man. He joked with his patients. Flirted with them. He did a lot of things most therapists would call boundary crossings or violations today. And we now know not to do these things, in part, because he did them.

But he tried his best, based on whatever he knew at any given time, not to get in the way of the analytic process. To let the patient free associate, and to maintain an attitude of observation and inquiry toward the patient's productions. I think that's what he meant by neutrality.

A good exposition is given by Glover (Glover, E. (1928). Lectures on Technique in Psycho-Analysis (Concluded). Int. J. Psycho-Anal., 9:181-218.):

Is it actually the case that in the customary analytic methods we do preserve complete detachment? It is immediately obvious that in certain respects we do not. For example, we are rarely content with the material given to us, but by interpretation imply that material exists which for some reason or another has not been presented to us...
...we have to admit that interpretation is not strictly detached, but, on the other hand, whatever the patient may think, it is not an actual repetition of a parental attitude. Again, when a patient comes late we do not remain detached; if need be we go out of our way to bring this fact into associative connections. Again the patient reacts as if we had said, 'You miserable little procrastinator, what do you mean by not coming when I told you to come?', and again we are able to investigate this repetitive reaction...In fact, whether the analyst is content with a simple suggestion or backs it with authority, he will usually find that his patient takes occasion to react to the situation in some typically infantile way, and he will be able to make some capital out of the analysis of such a reaction. Nevertheless, in a negative way he has on this occasion abandoned neutrality and has taken up a parental rôle, which the patient legitimately identifies with the prohibitive activities of his own super-ego, or, going further back, with the categorical forbiddings issued by his parents...
...It is therefore true to say that, in the usual analysis, there are isolated occasions when the analyst abandons his attitude of neutrality...or, in other words, plays the part of parent or super-ego...

So the idea was that full detachment and neutrality are impossible, but should be pursued by the analyst in order to allow the patient to engage in the analysis and to examine patterns of thinking, feeling, and behavior. If the analyst abandons neutrality and intervenes, she is participating in those patterns rather than facilitating their examination.

Nonetheless, it has become clear in the intervening century since Freud started developing these ideas that not only are full neutrality and detachment impossible, but the attempt at achieving them can create a stilted analysis, and make it impossible for the patient to make use of the treatment. So the blank screen is no longer considered a goal for the analyst. 

In 1995, Owen Renik wrote, The Ideal Of The Anonymous Analyst And The Problem Of SelfDisclosure ( Psychoanalytic Quarterly, 64:466-495).

Renik believes that ANY anonymity is impossible, a myth, a self-idealization. If an analyst states an opinion, Renik sees this as a way to encourage the analysand to explore his own opinions. He advocates a less authoritative stance by the analyst, and references Winnicott's notion that when he discussed his own ideas in a session, these were merely, “subjective objects placed between analyst and patient,” to be examined and tossed around and understood. 

In other words, Renik rejects the blank screen as an authoritative stance by the analyst, and a false one, at that, designed to promote idealization of the analyst in the analysand. He believes that the analyst's thinking should be made available to the patient. My impression is that he believes this should be true at all times.

I think Renik is extreme, and the disclosure he encourages can amount to a narcissistic turning of the treatment's focus on the analyst, rather than the patient. But I agree that a complete absence of disclosure is both impossible and undesirable. The real skill is in discerning when it will and won't be helpful to disclose.

I don't hold by the belief that telling a patient something about myself will necessarily prevent the development of fantasies. Sometimes it facilitates them. 

In, Some Reflections on the Question of Self-Disclosure (Journal of Clinical Psychoanalysis, 1997, 6:161-173) Ted Jacobs writes: 

...certain revelations on the part of the analyst can limit or inhibit aspects of the patient's imagination and the free flow of fantasy. Since we are interested in the patient's creations, and, theoretically, these are stimulated by nondisclosure and analytic anonymity, the use of self-revelation would seem to work against our aims. If a patient knows, for instance, that I was skiing in Vermont a few weekends ago, it is unlikely that she will imagine me tanning myself on the beaches of Oahu. Clearly, this is a limitation. On the other hand, nondisclosure and analytic anonymity, especially if rigidly and automatically applied, can have a far more limiting effect.

In certain patients, those who have had long experience with secretive, nonresponsive parents or whose self-esteem is particularly fragile, the traditional analytic attitude with regard to self-disclosure may have a stultifying, and quite inhibiting, effect. Instead of functioning to free up the mind and to open up communication, it can shut it down.

It is good to remember, too, that if, for a particular reason, I choose to reveal where I've been on my brief vacation, that surely does not put an end to my patient's fantasies. It may, in fact, prove to be a powerful stimulus to them. There remains much room for my patient to fantasize, much in his inner world to explore. The patient, for instance, is quite free to imagine me, as often happens, as a tangle foot novice on the slopes, nearly breaking my neck on the beginners' hill; or, less frequently, but more accurately, as completing the giant slalom in record time.

In this post, I've used the terms, "anonymity", "neutrality", "detachment", and "blank screen" somewhat interchangeably, but they are not identical. I suppose, for me, anonymity means not linking to my blog from my LinkedIn profile. Neutrality means listening openly and without prejudice to what my patients tell me, and not taking sides, either with the patient, or with whoever the patient perceives to be opposing him, or in the way of Anna Freud, remaining equidistant from the patient's Ego, Id, and Superego. Detachment refers to that delicate place of remaining emotionally engaged, allowing my personality, my humor to show through, but with the clear message that the patient's emotional reactions are not mine. And the blank screen? It's not what I do, or try to do. It isn't part of my clinical "vocabulary".

Thursday, May 28, 2015

More on the Ritalin-Induced Psychosis Study

I'm following up on my last post, I Don't Know What to Think. A friend (not the same one who sent me the Levine piece) had access to one of the full articles, and forwarded it to me. This is the 1987:

Prediction of Relapse in Schizophrenia paper, from Arch Gen Psych. Having read it, what they were trying to do makes more sense to me, but it's still problematic.

The paper's introduction comments:

...A major deficiency in the clinical management of schizophrenia is the lack of proven methods for predicting the subsequent course of illness and identifying those patients who require neuroleptic maintenance to prevent relapse or, alternatively, those who would remain stable for substantial periods of time without drug treatment or while receiving substantially reduced dosages.

There were some previous studies suggesting that behavioral response to psychostimulants could be used as a predictor of relapse. They chose ritalin because it preferentially inhibits uptake of dopamine, and they were trying to find support for the dopamine hypothesis in schizophrenia.

The reason given for conducting the study is:

The application of a psychostimulant provocative test using methylphenidate with stable schizophrenic outpatients undergoing neuroleptic maintenance treatment is an attempt to study whether it may be feasible to exploit this phenomenon for clinical purposes.

That's it. Vague, but it kind of makes sense. It's like a glucose challenge test. You want to know if a specific patient will relapse if you take him off his meds. So you do the ritalin challenge test, and if he responds in a certain way, you know he needs to stay on his meds. And if he responds another way, you can take him off. And what are those "ways"? That's what the study is trying to find out.

They gave most of* the subjects a ritalin infusion, and a placebo infusion, 1 week apart, in random order, while they were still taking meds. They did this in a double blind fashion. They rated the subjects before and after infusions for behavioral, physiological, and physical states and changes.
Then they repeated this process several weeks after discontinuing meds.

This is what the ratings found:

The white bars are before infusion, and the black bars are after.

You'll notice that while it was double blind, you can pretty much tell when the patient got ritalin.

Then they followed the patients for a year, or until they relapsed and needed meds again. And they looked at how response to ritalin infusion correlated with time to relapse. This is what they found:

Patients with greater behavioral and TD changes in response to ritalin, as well as patients with greater baseline TD, had significantly shorter times to relapse. Blink rate and pulse rate were not significantly correlated.

The paper does a bunch of additional analyses, with groups of symptoms rather than individual ones, to get more of what they wanted. But to me, the most interesting result is that patients with more baseline TD relapsed more quickly. That could be a useful piece of data, and it doesn't require a ritalin infusion.

There are technical problems with the study. It had very few subjects, there was a protocol change after the study had begun* (that's why some subjects only had infusions after discontinuing meds), and the paper was written before follow-up had been completed on all the subjects. Also, I can't quite figure out if they did an intent to treat analysis.

They also fudged a bit in the comments section:

...Specific biologic and clinical variables, including behavioral response to methylphenidate, presence of TD, blink-rate response to methylphenidate, and pulse rate response to methylphenidate, under specific pharmacologie conditions, are associated with outcome in terms of time to relapse following neuroleptic withdrawal. 

In the results, blink rate and pulse rate are not so associated.

Here's the ethical problem. Participation in the study could not possibly have benefitted any of the subjects. It only had the potential to do harm. It's not like the authors were positing that a ritalin infusion might delay or prevent relapse.

So I'm skeptical about the consent process. We're not talking about healthy grad students who volunteer to stay awake for 3 days in exchange for $10 and meals. Did the subjects really understand that participation was completely altruistic? That the results could only benefit others, down the road, and maybe not even that?

I would have felt better about it if the idea had been addressed. They mention in the methods section that patients were evaluated for ability to give consent. But I think that somewhere, the authors should have written about the fact that the study was designed in a way that would not benefit the subjects. And that a shorter time to relapse after ritalin infusion might imply a different subgroup, one that might have had a longer time to relapse if they hadn't been given ritalin.

What do you think?

I Don't Know What to Think

A friend forwarded me this piece:

Leading American Psychiatrist Conducted Disturbing Experiments -- and Now He's Smearing Journo Who Uncovered It. (Bruce Levine/Alternet)

It's about experiments conducted by Jeffrey Lieberman. Here are the abstracts:

Arch Gen Psychiatry. 1987 Jul;44(7):597-603.
Prediction of relapse in schizophrenia.
Lieberman JA, Kane JM, Sarantakos S, Gadaleta D, Woerner M, Alvir J, Ramos-Lorenzi J.

Despite the proven efficacy of neuroleptic drugs in the acute and maintenance pharmacotherapy of schizophrenia, practical methods for identifying patients who require neuroleptic treatment to prevent relapse are lacking. This study evaluated the use of a methylphenidate challenge test to predict the outcome in 34 stable outpatients with schizophrenia receiving neuroleptic treatment. Patients received two infusions, one of methylphenidate and one of placebo, in randomized order one week apart while receiving neuroleptic treatment and again three weeks after drug withdrawal. Behavioral, cardiovascular, and neurologic responses were evaluated before and after infusion under double-blind conditions. Patients were then followed up without medication for 52 weeks or until symptom recurrence. The results indicate that specific measures, including behavioral response to methylphenidate, presence of tardive dyskinesia, and, under specific pharmacologic conditions, tardive dyskinesia, blink-rate, and pulse-rate responses to methylphenidate, are associated with time and propensity to relapse following neuroleptic withdrawal. These measures may be potentially useful in the identification of candidates for neuroleptic withdrawal and/or dosage-reduction treatment strategies.
PMID: 2886110 [PubMed - indexed for MEDLINE]

Psychopharmacol Bull. 1990;26(2):224-30.
Behavioral response to methylphenidate and treatment outcome in first episode schizophrenia.
Jody D1, Lieberman JA, Geisler S, Szymanski S, Alvir JM.
Sandoz Pharmaceuticals, Sandoz Research Institute, East Hanover, NJ 07936-1951.

In order to examine the relationship of behavioral response to psychostimulants and acute treatment response, we administered methylphenidate (0.5 mg/kg i.v.), an indirect dopamine (DA) agonist, to 38 patients who met Research Diagnostic Criteria (RDC) for definite or probable schizophrenia or schizoaffective disorder, were experiencing their first acute episode of psychosis, and had received less than 12 weeks or no prior lifetime neuroleptic exposure. Following baseline methylphenidate infusions, patients received a standardized regimen of acute neuroleptic treatment. Methylphenidate produced an increase in psychopathology reflected by a worsening of both positive and negative symptoms. Using a priori criteria, 61 percent of patients exhibited psychotic symptom activation, and 39 percent showed no change. Activation during methylphenidate infusion during the initial acute phase of illness was not correlated with time to achieve antipsychotic treatment response but was associated with side-effect vulnerability.
PMID: 2236460 [PubMed - indexed for MEDLINE]

In the 1987 study, they were trying to figure out which patients with schizophrenia require maintenance treatment with neuroleptics to prevent relapse. So they took 34 stable outpatients who were on meds and gave them IV ritalin, so they might get psychotic. Then they kept them off meds for a year or until they got psychotic. They learned that certain responses to ritalin are associated with a tendency to relapse. I don't have access to the full article, so I don't know which responses.

How did using the ritalin help answer their question? They could have just taken them off their meds and followed them. Sure, that would have been uncontrolled. But how does trying to make stable patients unstable tell you which stable patients will relapse off meds? It only tells you which stable patients given ritalin will relapse off meds.

In the 1990 study, they took 38 first break patients and gave them IV ritalin, which made 61% of them sicker. Then they looked at how these patients responded to antipsychotics. 

Also back in 1987, Lieberman wrote a review of 36 studies that established the pscyhotogenic potency of ritalin. So the authors of the two studies above were aware that ritalin would likely make the patients psychotic.

According to the Levine piece,

On April 26, 2015, Jeffrey Lieberman, former president of the American Psychiatric Association, stirred up controversy by calling investigative journalist Robert Whitaker a “menace to society” on CBC radio because Whitaker, in his book Anatomy of an Epidemic, had challenged the long-term effectiveness of psychiatric medication...

In Whitaker’s Globe 1998 series in the segment “Testing Takes Human Toll,” he interviewed Lieberman about his and other psychotic symptom exacerbation and provocation experiments. Lieberman asserted, “To say that increasing a particular symptom—like hearing voices for a couple of hours in somebody who has been hearing voices for 10 years—is causing [suffering] rather seems like a stretch.”

I don't know what to think. I don't truly believe Lieberman is a monster. A jerk, maybe, but not a monster. But first break patients haven't been hearing voices for 10 years.

Maybe the idea was that they could learn a lot about who did and didn't need meds by causing a little bit of extra suffering, and that ultimately, that knowledge would help a lot of people. The same way it hurts to be vaccinated, but it's helpful. 

Maybe it was easy to get stuff like this by an IRB in the late 80's and early 90's.

Maybe the patients were able to give consent, and understood what was being done to them. To me, that, "Rather seems like a stretch." You're hearing voices that are frightening you? We'll just give you something to make those voices worse, and by doing so, we'll know exactly how to treat you. 

Maybe it's the same kind of logic that comes up in Shrinks. We'll do a scan of your brain, and then we'll know exactly what's causing your mental illness.

Levine wants to blame the APA. He states, "Why would the American Psychiatric Association elect Lieberman president in 2012? Because psychiatry sees nothing wrong with these psychotic symptom exacerbation and provocation experiments."

Obviously, I don't agree with that opinion. And I also don't equate the APA with psychiatry.

There just seems to be so much stuff that comes up around this one guy.

I just don't know.

Sunday, May 24, 2015

Tools to Prevent Cognitive Decline?

I like to play Hitori. For those not familiar, it's another one of those Sudoku-type games that are great for convincing yourself you're doing something useful, i.e. keeping your reasoning skills sharp, when you're probably just wasting time. Those games-minesweeper, ken-ken, pixel games (I'm partial to Pic-a-Pix), are all wonderful for dealing with mild anxiety. They require just enough concentration to be distracting, but not enough to really be a strain, or make you feel like it's an effort to play.

But today, I was playing Hitori, and the site came up with one of its weird ads. This particular site may be a little sketchy, which is why I didn't link to it, because when I first started playing, I got ads for what seemed like mail-order brides from Eastern Europe. I'm not sure what text Big Brother Google was reading in my emails that made it believe those ads would appeal to me, but that's what I got. Those ads went away pretty quickly.

Then I started to get ads for devices to treat depression. At least that's not so surprising, given my professional searches and email exchanges. One of these days, I'll read up on the research on that device, the Fisher Wallace Stimulator, which you use for 20 minutes once or twice a day.

Then the ads moved on to brain games like Lumosity. Again, not surprising, since Hitori is another brain game. I've tried out Lumosity, for free, and I found some of the memory games challenging. I didn't use it long enough to see if my memory improved.

Today, I got an ad for cremation planning. I did celebrate a birthday earlier this month, but not one that puts my age at death's door. So I guess people are using games like Hitori to ward off dementia and their expected mental decline due to aging.

Lumosity claims to take standard neuropsych testing out of the lab, and turn it into games. It adds new games, and then tailors a program "for you". There's a whole section on their research, some of which is performed in Lumos Labs. The site has 13 summaries of peer reviewed papers, including topics like cognitive training in cancer survivors, training for girls with Turner's syndrome, Lumosity in the classroom, Lumosity for emotion regulation, etc.

There's one study called, Investigating the effects of Lumosity cognitive training for healthy adults:

Twenty-three volunteer participants were randomly assigned to one of two groups: a training intervention group or a waitlist control group. Intervention group participants completed Lumosity training 20 minutes a day for 5 weeks. At the end of the training period, participants in this group saw improved performance on a divided visual attention assessment in which the user must identify a central target and report the location of a peripheral target, and on a forward and reverse working memory assessment in which the user must click in the same or opposite order that they were highlighted. Control participants, on the other hand, who did not undergo Lumosity training, did not show changes in performance on these assessments.

The original article, published in Mensa Research Journal, is here.

Another study, not performed at Lumos, examined use of Lumosity in adults with MCI. The summary is this:

Dr. Maurice Finn, a clinical psychologist and researcher at the University of New South Wales in Sydney, Australia found that training with Lumosity improved visual attention performance on the Cambridge Automated Neuropsychological Test Battery (CANTAB) in patients with Mild Cognitive Impairment (MCI). 

The original article, in Brain Impairment, concludes:

Results indicated that participants were able to improve their performance across a range of tasks with training. There was some evidence of generalisation of training to a measure of visual sustained attention. There were no significant effects of training on self-reported everyday memory functioning or mood. The results are discussed along with suggestions for future research.

There's a poster about age-related effects on learning. And another poster about Lumosity's Brain Performance Test (BPT).

There's also a link to ongoing research topics.

Basically, there's a lot of self-serving noise, which doesn't mean Lumosity isn't helpful, but it doesn't mean it is, either. It seems to me that these studies measure improvement on their own tasks, or games, as they call them. It's not clear what these improvements imply for the rest of life.

On the flip side, there's this piece in Science, indicating that:

Aging baby boomers and seniors would be better off going for a hike than sitting down in front of one of the many video games designed to aid the brain, a group of nearly 70 researchers asserted this week in a critique of some of the claims made by the brain-training industry. 


For those who choose to play brain games regardless, recent research suggests that playing some video games developed solely for fun may be as effective, or more, than those developed for cognitive self-improvement. Scientists at Florida State University randomly assigned 77 undergraduates to play either Lumosity or the popular video game Portal 2, in which players take on the roles of robots to solve interactive puzzles to face off against a “lethally inventive, power-mad A.I. named GLaDOS.” After 8 hours of play, Portal 2 players scored higher than Lumosity players on three standard cognitive tests of problem-solving and spatial skill, and Lumosity players “showed no gains on any measure,” the team reported online this summer inComputers & Education.

A 2010 Systematic Review of the Literature, published in the Annals of Medicine, found:

...high-quality evidence for only 1 factor's effect on cognitive decline. Cognitive training on processing speed or reasoning showed a decreased risk for cognitive decline in the specific targeted cognitive abilities over a 2-year follow-up, and the evidence was rated as high-quality primarily on the basis of 1 RCT . Observational studies of self-reported engagement in cognitively stimulating activities suggest an association with less cognitive decline, but this exposure is probably different from the cognitive training used in the RCT.

A chapter from the Handbook on the Neuropsychology of Aging and Dementia
Clinical Handbooks in Neuropsychology 2013, pp 167-192, indicates:

Specific dietary changes rich in vegetables, fruits, and fish and low in carbohydrates and saturated fat are advisable, with particular emphasis in patients at risk of developing Alzheimer’s disease (AD) or vascular dementia. Patients should remain active physically and mentally. Physical exercise is among the best of all potential interventions against AD.

One study with an n of 488 initially cognitively intact subjects found that doing crossword puzzles delayed the onset of accelerated memory decline by 2.54 years, in those subjects who ultimately developed dementia. It's not clear from the abstract if doing crossword puzzles kept subjects from developing dementia, at all-I assume that's not what they were studying, or able to study.

The most frequent preventive factor I could find was physical activity. But it's clear that there's something unclear here. So maybe I should stop playing Hitori and swim more. Or maybe I should stop researching whether I should stop playing Hitori.

Thursday, May 21, 2015

Because I Couldn't Resist

I just read an interview with Jeffrey Lieberman in the May edition of Psychiatric Times, and I couldn't stop myself from writing about the nonsense he spouts.

For example, he's asked why mental illness and psychiatry are still stigmatized, and he replies:

Originally no one understood what the causes of mental illnesses were. It was thought that mental illness was due to some supernatural phenomena, demon possession, being cursed by the gods, or so forth. 
Beginning in the 19th century, there were efforts to try to understand the neurologic basis of the illness. But the tools and technology of the time were inadequate. 
Then Freud came along. As compelling and intuitively interesting as his theories were, they did not explain why somebody was schizophrenic, manic-depressive, or depressed; or had OCD or panic disorder; or was autistic or demented. 
It was not until the latter part of the 20th century that psychiatry began to radically change, and we started to acquire a scientific foundation. But, even though things have changed dramatically in recent decades, old attitudes still prevail and mental illness is still considered different from other types of medical illnesses and psychiatry is considered a step-child of medicine. 

I'm not sure how to think about what he says. Does Lieberman believe we now understand what causes schizophrenia, etc., just because we have brain imaging? Does he not believe it but want to imply it, and that's why he answered cagily? He mentions a "scientific foundation". What does he understand science to be?

The notion of "sciencey-ness" certainly exists-machines that whir and light up and produce pretty pictures of the brain, lab equipment with bubbling liquids, numbers and percentages thrown into paragraphs for good measure, Latinate terms bandied about. 

Those are all "sciencey".

But science, real science, is how a toddler figures out that holding onto a helium balloon does not prevent him from falling on his butt. 

I think "sciencey-ness", not science, is what Lieberman is referring to, and I'm very concerned that he doesn't know the difference between the two. 

He claims, "We do have effective treatments...as effective as treatments in any other field of medicine." But, he says, people don't get these treatments because of shame or stigma or poor government policy. 

Does he really believe that if only everyone had access to psychiatric medications and CBT, suffering from mental illness would all but cease?

To put it bluntly, is he lying, deluded, or stupid?

And I know I don't need to worry about retribution for writing that, since he'll never read it. I can't seem to get him to engage in any exchange, no matter how provoking I am. But maybe this one will get through, somehow.

The other topic that came up in this interview that is greatly concerning is Lieberman's understanding of suffering. He states:

When we talk about mental illness, we're not talking about the "worried well" or problems in living. We're talking about what might be considered to be brain disorders, which include traditional mental illnesses, addictions, and intellectual disabilities...The number of people affected by mental illness is enormous, and the costs of neglecting their treatment is staggering. 

Now, I'm not trying to minimize the misery of people with schizophrenia or bipolar disorder or depression, or their difficulties obtaining care outside the penal system. But in a room filled with 100 random people, on average, one will have schizophrenia. How many will have "problems in living"? Troubles with work, or family, or romantic partners. Debilitating troubles. Troubles that cause pain to themselves and those around them. And why doesn't their suffering matter?

Wednesday, May 13, 2015

Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory Over Papa Freud

I finally finished reading Shrinks, and I submitted a 1 star review to Amazon, with the heading, "Painful to read, misleading, and with no insight into its own deficits. Don't buy it! Don't borrow it! Don't read it!" The following is not what I wrote on Amazon, but it's related.

I've given a lot of thought to how I want to write this full review (see my partial review here). Shrinks is an excruciating rant-sneering, caustic, and just so wrong in so many ways. It was tempting to just shred it point by invalid point. But the truth is, there's something pathetic about the lengths to which Lieberman goes to "prove" that his version is the only true psychiatry.

So I decided to focus on my real concern-the impact this book may have on a lay audience. This is where I think it's downright dangerous. Lieberman writes about present day psychiatry as though it's already achieved all the goals it aspires to. He speaks as though current brain imaging has already explained the etiology of all mental illness, and as though DSM has classified every possible psychiatric disorder: 

...the book precisely defines every known mental illness. It is these detailed definitions that empower the DSM's unparalleled medical influence over society.

He writes about the wonderful breakthroughs that Thorazine, lithium, and imipramine represented-and I agree that these drugs were godsends to many people, but he includes virtually no information about the problems that these and other meds can cause, or about the fact that they don't always work. To hear him tell it, biomarkers are already in widespread use and predictive of treatment response in many psychiatric illnesses. And most of all, his version of psychiatry is, wait for it, SCIENTIFIC.

As I read Shrinks, I tried very hard to imagine what it would be like if I were a reasonably intelligent adult with no particular knowledge of psychiatry, but who was interested in learning about the field. (Okay, cue the jokes about my being reasonably unintelligent and questionably adult)

It's an unrealistic thought exercise, but I imagine I might think I'm reading a book by someone who is an expert in his field, chair of psychiatry at a prestigious hospital, former president of the APA, so he must know what he's talking about. I'm pretty sure I wouldn't be familiar with the immensely varied modes of thinking that exist in psychiatry. I suspect I'd assume psychopharmacology and psychoanalysis are areas that all psychiatrists are trained in. And since Dr. Lieberman is a psychiatrist, psychoanalysis must be part of his field, so if he's claiming there's no validity to it, he must be telling the embarrassing but necessary truth. And if he claims drugs and CBT are effective and "scientific", he must be right about that, too. 

I hope I would pick up on the painfully disparaging tone, and the fact that sneering does not constitute evidence, but I'm not sure I would. 

At some point, I realized I didn't need to speculate about what a layperson would think of the book, I could, instead, read reviews on Amazon. And it turns out that, for the most part, it got good reviews from people outside the field, and bad reviews from people who know something about psychiatry, or its history. Here are some examples, both good and bad:

April 12, 2015
Shrinks by Dr. Jeffrey Lieberman is a fantastic read and a real eye opener for those of us who know next to nothing about psychiatry...The bottom line is that Shrinks brings to light many myths about psychiatry, but it also points out its historic shortcomings. More importantly it presents mental illness not as something to be ashamed of or for which there is no cure, but rather as a medical condition just like any other which can and should be addressed with proper treatment. Thankfully the advances in neuroscience and psychiatry, reviewed by Dr. Liberman in his book, have enhanced the understanding of the causes of mental illness and vastly improved the methods of its treatment.

April 1, 2015
...In his book, Dr. Lieberman clearly offered his experience as a scientist and physician and the history of psychiatry...The best parts of the book describe the rise and fall of theories championed by Freud and how they stymied real science and the description of the motivation behind some of organized psychiatry's most barbaric practices...
Dr. Lieberman explains so well the past failures, the research being presently done and the future of psychiatry. What an honest book...
Lieberman tells this story with remarkable clarity, complete honesty about his own viewpoint, and unusual humility for someone in the field. The human mind, whether it functions well or ill, is poorly understood, but recent progress in both understanding and treatment is significant...but most importantly, there is help.. the right help and the exciting future with DNA exploration...
This top psychiatrist says his field of medicine has recently turned a corner and he shows how it is offering real help to those with anxiety, eating disorders, phobias, obsessions, PTSD, bi-polar disorder, etc. And for people facing brain issues like Parkinsons, autism, Alzheimers, etc, scientists are getting oh so close.

March 28, 2015
I'm biased. I am a historian of psychiatry. Really. I have a PhD from the University of Michigan, served on the faculty of the University of Chicago, and wrote a book on the history of psychotherapy. ...So arrogant as this may sound, I know what I'm talking about. This book is compendium of errors -- at least from a historian's perspective. It fails to consider virtually all of the scholarship produced over the past fifty years on the subject, cites virtually no primary sources, and simply recycles common stories -- many of which have long since been discredited....this book does an extraordinary disservice to those who have been producing exceptional scholarship in the field for decades. What's more, it reveals how easy it is for a well-respected (and deservedly so) physician to publish nonsense about a subject about which he knows little and has probably read even less....You might not agree with me. But I can promise you this: I did my homework. That's not something Dr. Lieberman can say. What's more, I didn't pay someone to write my book for me.

To read this book, you would think that everyone who was treated with psychotropic drugs was miraculously cured and anyone who was not sunk into misery or worse. There is no mention of the millions of prescriptions written to treat questionable disorders for children as young as two, or of the terrible side effects of the some of the powerful medications that Dr. Lieberman evidently eagerly dispenses to virtually every patient who walks into his office. You would further conclude that no one was ever helped by psychoanalysis, nor for that matter any other form of therapy than his. This is a book filled with half truths, omissions, distortions, and propaganda. The "untold story of psychiatry" indeed.

In my earlier review, I wrote that I was willing to buy into the historical information included in the book. I stand corrected.

The basic outline of the book is this: first we had "alienists", who oversaw the care of the mentally ill in institutions, even though there was nothing much to be done for these patients. Then Freud came along and treated the "worried well" with what we now know is a bogus treatment designed by Jews and for Jews (not clear to me why Lieberman emphasizes that particular point, but he seems to feel it's important). Beginning in WWII, a taxonomy of mental illness was finally! developed, by an analyst, no less, and this ultimately led to the DSM-III, the savior of psychiatry. Then meds came along, and brain imaging, and CBT, and more recently, genetic markers. And today, psychiatry can proudly state that it understands the etiology of mental illnesses, and has the tools to successfully treat them. 

The book's argument reminds me of people who understand evolutionary process to mean that living beings have maintained a progressive course over eons just to reach the pinnacle of existence that is humanity. 

Lieberman never explains why the things he sneers at are unscientific. He just states it as fact. He has no understanding or knowledge of, nor does he make any reference to, psychoanalysis as it has been practiced and understood for the last 30 or so years. His bio on the Columbia site indicates that he is a, "Physician and scientist," so it's hard to understand why he doesn't even attempt to give a factual basis to his assertions. 

And he seems completely unaware of his own internal contradictions. He criticizes psychoanalysis for blaming family members for a patient's illness, such as the idea of the "refrigerator mother" in autism, or the "schizophrenogenic mother". 

But then he goes on to describe several of his cases, in which his recommended treatment failed because of the patients' families, who he criticized. 

I told them quite bluntly that their decision to withhold treatment was both cruel and immoral-though tragically, not illegal...

Lieberman seems to think that only his recommendations matter, and once he's made them, there's no need to establish a rapport with a patient's family, in order to help the patient. They should just do what he says because he's right. 

He has no clue about the limitations of the DSM, which he refers to repeatedly as "The Bible of Psychiatry". He's convinced that everything in the DSM is "scientific", despite his own descriptions of how many of the decisions about its content were made-often as compromises and to reassure the public and get proper insurance reimbursement.

He thinks that knowing there's an amygdala-hippocampus-prefrontal cortex loop in PTSD explains why people get PTSD. He claims that some people have genetic differences that predispose them to PTSD, and that's why some get it and some don't.

He proudly describes two traumatic experiences of his own-his apartment was invaded and he was robbed at gunpoint when he was in medical school, and 12 years later, he accidentally dropped an air conditioner out of his 15th floor apartment window. No one was hurt in either incident, but he was not traumatized by the former (the robbery), and had some PTSD symptoms following the latter (the air conditioner). Obviously, he can't claim his genetic predisposition changed in the intervening 12 years. Instead, he comes up with a long-winded story about how he had the illusion of control when being robbed, but not when dropping the air conditioner and that created a different amygdala loop. It never occurs to him to ask WHY he had the illusion of control in one situation but not the other. He has no sense that the two events had different meanings for him. And it certainly doesn't occur to him that HE was the aggressor in the incident that gave him PTSD symptoms.

Meaning, for Lieberman, is meaningless. All that matters are symptoms and getting the diagnosis right.

I'm trying not to harp on this part, but another truly dangerous aspect to the book is the way Lieberman disses any type of talk therapy that isn't CBT. Especially psychoanalysis. Here's some of the language he uses:

Gradually, physicians came to recognize that focusing on unobservable processes shrouded within a nebulous "Mind" did not produce lasting change...

...Sigmund Schlomo Freud stands in a class of his own, simultaneously psychiatry's greatest hero and its most calamitous rogue. (Incidentally, Freud's accurate birth name was, "Sigismund", not "Sigmund")

Freud ended up leading psychiatry into an intellectual desert for more than half a century...

As a psychiatrist who lived through many of the worst excesses of the psychoanalytic theocracy, I regard Freud's fateful decision (to discourage scientific questioning) with sadness and regret.

(On the move of many early analysts to American due to WWII): These psychiatric refugees would soon change the fundamental nature of mental health care in the United States, but not necessarily for the better. They brought with them the dogmatic and faith-based approach to psychiatry that Freud had espoused, discouraging inquiry and experimentation. Eventually,...psychoanalysis would become a plague upon American medicine, infecting every institution of psychiatry with its dogmatic and antiscientific mind-set...

...By 1940, American psychoanalysis had become a unique phenomenon in the annals of medicine: a scientifically ungrounded theory, adapted for the specific needs of a minority ethnic group (Jews).

Knowing that the path to influence ran through medical schools and teaching hospitals, psychoanalysts began targeting universities.

Had it been able to lie upon its own therapeutic couch, the psychoanalytic movement would have been diagnosed with all the classic symptoms of mania: extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers.

Talk about projection!

Psychoanalysts  and psychoanalysis are compared to or described as:

omen-divining wizards

the primeval sorcery of the jungle witch doctor

the circus Big Top

a mangled map of mental illness

the psychoanalytic hegemony

The Oracle of Delphi

I get a definite sense of a man with no tolerance for ambiguity or ambivalence. 
He writes about his college experimentation with recreational drugs, which involved his researching which drug would be the best for him, before going on to try it. This is clearly not a guy who dropped acid because someone offered him some at a party. 
He idolizes Robert Spitzer for creating the DSM-III. He relates an anecdote in which a teenage Spitzer, at summer camp, was confused about his feelings towards girls, so he made charts of those feelings and kept them on his bunk wall. This is viewed, in the book, as a demonstration of Spitzer's great promise as a researcher, not as an indication of a highly intellectualized defense.

Lieberman also dislikes the notion that mental illness exists on a spectrum, that there is no clear defining line between sickness and health, and he feels this was one of Freud's great mistakes:

It was no longer acceptable to divide human behavior into normal and pathological, since virtually all human behavior reflected some form of neurotic conflict, and while conflict was innate to everyone, like fingerprints and belly buttons, no two conflicts looked exactly alike...the psychoanalysts set out to convince the public that we were all walking wounded, normal neurotics, functioning psychotics...

No wonder the DSM-III had such great appeal for these men. When Lieberman writes about the standing ovation Spitzer got when the DSM-III was approved, it feels like a conquest, like he has vanquished the evil empire established by Freud, the community from which he was excluded for his "scientific" beliefs, and the sun is finally beginning to shine on psychiatry. 

The title of this post was intended to be provocative, but there really is an Oedipal victory feel to the book. As you can tell from the quotes above, there's a lot of disparaging comparison of psychoanalysis to magic or religion, along with some comments that flirt with antisemitism, but then he keeps calling the DSM the "Bible of Psychiatry". Apparently, his is the better religion.

Lieberman, (or maye it's Ogas) writes with particular vehemence about the period when most psychiatrists did analytic training. It made me wonder if he was rejected from a training program at one point, or if he was in an analysis that he quit because he found it intolerable. I have absolutely no basis for these thoughts- they're just conjecture. But here's the description:

Think about that for a minute. The only way to become a psychiatrist-a bona fide medical professional-was to share your life's history, innermost feelings, fears, and aspirations, your nightly dreams and daily fantasies, with someone who would use this deeply intimate material to determine how devoted you were to Freudian principles. Imagine if the only way you could become a theoretical physicist was to confess an unwavering and unquestioning dedication to the theory of relativity or the precepts of quantum mechanics, or if the only way you could become an economist was to reveal whether Karl Marx appeared as an angel (or devil) in your dreams. If a trainee wanted to rise within the ranks of academic psychiatry or develop a successful practice, she had to demonstrate fealty to psychoanalytic theory. If not, she risked being banished to working in the public-hospital sector, which usually meant a state mental institution. If you were looking for an indoctrination method to foster a particular ideology within a profession, you probably couldn't do much better than forcing all job applicants to undergo confessional psychotherapy with a therapist-inquisitor already committed to the ideology.

Nowhere does he indicate that he has even considered the possibility that understanding ones own limitations can make one a better clinician. He doesn't even seem to get that if one is caring for patients, it might be helpful to know what it's like to be a patient. And forget the idea that an analysis is intended to be helpful. He seems to view it as nothing but a threat. The analyst as, "therapist-inquisitor".

Reading the paragraph above, it really is hard to believe Lieberman's claim that he likes psychoanalysis. 

The final concern I have has to do with Lieberman's inability to imagine that other people may not think the same way he does. Here's a quote:

...a psychoanalytic diagnosis of Abigail Abercrombie might account for her spells of anxiety by connecting them to the way she reacted to her parents' strict Lutheran upbringing, combined with her decision to leave home at an early age to work rather than marry. A Kraepelinian diagnosis would characterize Abbey as suffering from an anxiety disorder based upon her symptoms of intense fear and discomfort accompanied by heart palpitations, sweating, and dizziness, symptoms that occurred together in regular episodes.

Lieberman obviously believes that the analytic approach is wrong, and the Kraepelinian approach is right. But leaving aside the issue of which is correct (and why can't there be some of both?) I feel like he's assuming everyone prefers to have his internal
experience described by symptoms and their duration. There's no sense that some people might prefer his way, but others might prefer to have their experiences of anxiety considered in the context of a fuller narrative of who they are, with some continuity to how they got to be this way. Some might even find it offensive to be reduced to a bunch of symptoms and a diagnosis code. 

And unlike Lieberman, some people might be comfortable with a little ambiguity. 

J Am Psychoanal Assoc. 2015 Apr 24. pii: 0003065115585169. [Epub ahead of print]
The Psychiatrist, Circa 2015: "From Shrink to Pill-Pusher".
Hoffman L. PMID: 2591090

Monday, May 4, 2015


I really thought I was on an extended hiatus from being irked by the American Board of Psychiatry and Neurology. I was all set to wait until I get the bill for the annual fee to be pissed again, but they got to me sooner.

I haven't yet received my new board certificate. When I got my board scores, the package included a certificate shipping form that I could fax to them if I wanted to change my shipping address. It also had a box you could check if you were willing to waive the required signature. I wanted to do this in case no one was home when it was delivered, but the form was incomprehensible, because it wasn't clear if you had to change your address to check that box, or if you should include your current address or leave it blank because you don't have a change of address. I figured anything I did would only make it worse, so I didn't bother with it.

That was bad enough. Today, I get a letter from Jim Henry, Inc, informing me that my certificate is being prepared, and will be mailed to me on June 30, 2015. It also offered me, "A choice of quality frames as described in the enclosed brochure... Just indicate your choice of frame...and return it to us with your remittance no later than May 19, 2015. If no order is received from you by this date, your certificate only will be sent to you unframed at NO CHARGE." (boldface and caps are theirs, not mine).

I am so done with these people. The frames range in price from $70 to $600, with additional costs for special finishes. I already have a framed certificate. The ABPN sent it to me the first time around. It has a little rectangular piece in the lower left hand corner with the expiration date, and that's all that needs to be replaced. But they're sending an entirely new certificate with no expiration date which will need to be framed.

If I bother.

Do I have to speculate about whether the ABPN gets kickbacks on the frames? Honestly, the brochure looks like something from a company that does high school yearbooks. And if you checked out the link to their site, you may have noticed the "pharmaceutical" tab at the top. It links to this page, with the image:

Thousands of dollars in direct payment, board review, and lost patient hours already spent, and now they want me to pay for a crappy frame. Boy they must be broke. How fitting that medical associations and the pharmaceutical industry are grouped together.

In the words of someone very wise, "Sheesh!"