Posts tagged psychology
Posts tagged psychology
A FEW weeks ago, I received an email from the Danish psychiatrist Per Bech that had an unexpected attachment: a story about a patient. I have been writing a book about antidepressants — how well they work and how we know. Dr. Bech is an innovator in clinical psychometrics, the science of measuring change in conditions like depression. Generally, he forwards material about statistics.
Now he had shared a recently published case vignette. It concerned a man hospitalized at age 30 in 1954 for what today we call severe panic attacks. The treatment, which included “narcoanalysis” (interviewing aided by a “truth serum”), afforded no relief. On discharge, the man turned to alcohol. Later, when sober again, he endured increasing phobias, depression and social isolation.
Four decades later, in 1995, suicidal thoughts brought this anxious man back into the psychiatric system, at age 70. For the first time, he was put on an antidepressant, Zoloft. Six weeks out, both the panic attacks and the depression were gone. He resumed work, entered into a social life and remained well for the next 19 years — until his death.
If the narrative was striking, so was its inclusion in a medical journal. In the past 20 years, clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of evidence-based medicine prevails. As a writer who likes to tell stories, I’ve been made painfully aware of the shift. The inclusion of a single anecdote in a research overview can lead to a reprimand, for reliance on storytelling.
My own view is that we need storytelling in medicine, need it for any number of reasons.
Repeatedly, I have been surprised by the impact that even lightly sketched case histories can have on readers. In my book “Listening to Prozac,” I wrote about personality and how it might change on medication. “Should You Leave?” concerned theories of intimacy. Readers, however, often used the books for a different purpose: identifying depression. Regularly, I received — and still receive — phone calls: “My husband is just like — ” one or another figure from a clinical example. For a decade and more, public health campaigns had circulated symptom lists meant to get people to recognize mood disorders, and still there remained a role for narrative to complete the job.
Other readers wrote to say that they’d recognized themselves. Seeing that they were not alone gave them hope. Encouragement is another benefit of case description, familiar to us in this age of memoir.
But vignettes can do more than illustrate and reassure. They convey what doctors see and hear, and those reports can set a research agenda.
Consider my experience prescribing Prozac. When it was introduced, certain of my patients, as they recovered from their depression or obsessionality, made note of personality effects. These patients said that, in responding to treatment, they had become “myself at last” or “better than baseline” — often, less socially withdrawn. I presented these examples first in essays for psychiatrists and then in my book, where I surrounded the narrative material with accounts of research. (Findings in cell biology, animal ethology and personality theory suggested that such antidepressants, which altered the way the brain handled serotonin, might increase assertiveness.)
My loosely buttressed descriptions — and colleagues’ similar observations — led in time to controlled trials that confirmed the “better than well” phenomenon. (One study of depressed patientsfound that Paxil drastically decreased their “neuroticism,” or emotional instability. Patients who became “better than well” appeared to gain extra protection from further bouts of mood disorder.) But doctors had not waited for controlled trials. In advance, the better-than-well hypothesis had served as a tentative fact. Treating depression, colleagues looked out for personality change, even aimed for it. Because clinical observations often do pan out, they serve as low-level evidence — especially if they jibe with what basic science suggests is likely.
To be sure, this approach, giving weight to the combination of doctors’ experience and biological plausibility, stands somewhat in conflict with the principles of evidence-based medicine. The movement’s manifesto, published in the Journal of the American Medical Association in 1992, proclaimed a new era that would see near-exclusive reliance on systematic clinical research — the direct assessment of treatments in patients. But even the manifesto conceded that less formal expertise would remain important in areas of practice that had not been subject to high-level testing.
THAT concession covers much of the territory. Making decisions about prescribing, often I exhaust the guidance that trials can give — and then I consult experts who tell me about this case and that outcome. Practicing psychotherapy, I employ methods that will never be subject to formal assessment. Among my teachers I number colleagues I know only through their descriptions of patient encounters. One psychoanalyst, Hellmuth Kaiser, imparted his wisdom through a fictional case portrayed in a stage play. I follow his precepts daily, hourly.
I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine, the field’s bellwether, opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: “Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of ‘big picture.’ ”
Stories capture small pictures, too. I’m thinking of the anxious older man given Zoloft. That narrative has power. As Dr. Bech and his co-author, Lone Lindberg, point out, spontaneous recovery from panic and depression late in life is rare. (Even those who put great stock in placebo pills don’t imagine that they do much for conditions that are severe and chronic.) The degree of transformation in the Danish patient is impressive. So is the length of observation. No formal research can offer a 40-year lead-in or a 19-year follow-up. Few studies report on both symptoms and social progress. Research reduces information about many people; vignette retains the texture of life in one of its forms.
How far should stories inform practice? Faced with an elderly patient who was anxious, withdrawn and never medicated, a well-read doctor might weigh many potential sources of guidance, this vignette among them. Often the knowledge that informs clinical decisions emerges, like a pointillist image, from the coalescence of scattered information.
HERE is where I want to venture a radical statement about the worth of anecdote. Beyond its roles as illustration, affirmation, hypothesis-builder and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence.
Take psychotherapy. Most of the research into its efficacy concerns cognitive behavioral therapy, or C.B.T., the treatment that teaches patients to moderate their habitual maladaptive thoughts. The reasons for this concentration are historical and temperamental. C.B.T. is rooted in a branch of psychology devoted to research, and the school of therapy attracts students who favor the practical and systematic over the spontaneous and poetic. There are no trials of existential psychotherapy.
But where the comparison has been made — primarily in the treatment of depression — C.B.T. does not outperform alternative approaches. (The alternatives tested are mostly distant derivatives of psychoanalysis.) And detailed research suggests that where C.B.T. works, specific techniques are not the reason. Studies of the components of therapy find that it is factors common to all schools, like the practitioner’s commitment and the alliance with the patient, that do the job.
If we weigh “evidence” by the pound or the page, we risk moving toward a monoculture of C.B.T., a result I would consider unfortunate, since there are many ways to influence people for the better. Here’s where case description shines. We hear the existential psychoanalyst Leston Havens describe his use of imitative statements, exclamations by the therapist that seem to come from within the patient: “What isone supposed to do?” For me, Dr. Havens’s approach — sitting beside the patient metaphorically and looking outward, hand-crafting interventions on the spot — carries what I call psychological plausibility. The vignette corresponds to a convincing account of how people change.
It has been my hope that, while we wait for conclusive science, stories will preserve diversity in our theories of mind. For 17 years, starting in the 1980s, I ran a psychotherapy seminar for psychiatry residents. As readings, I assigned only case vignettes, trusting that one or another would speak to each trainee.
My recent reading of outcome trials of antidepressants has strengthened my suspicion that the line between research and storytelling can be fuzzy. In psychiatry — and the same is true throughout medicine — randomized trials are rarely large enough to provide guidance on their own. Statisticians amalgamate many studies through a technique called meta-analysis. The first step of the process, deciding which data to include, colors the findings. On occasion, the design of a meta-analysis stacks the deck for or against a treatment. The resulting charts are polemical. Effectively, the numbers arenarrative.
Because so little evidence stands on its own, incorporating research results into clinical practice requires discernment. Thoughtful doctors consider data, accompanying narrative, plausibility and, yes, clinical anecdote in their decision making. To put the same matter differently, evidence-based medicine, properly enacted, is judgment-based medicine in which randomized trials, carefully assessed, are given their due.
I don’t think that psychiatry — or, again, medicine in general — need be apologetic about this state of affairs. Our substantial formal findings require integration. The danger is in pretending otherwise. It would be unfortunate if psychiatry moved fully — prematurely — to squeeze the art out of its science. And it would be unfortunate if we marginalized the case vignette. We need storytelling, to set us in the clinical moment, remind us of the variety of human experience and enrich our judgment.
Peter D. Kramer, a clinical professor of psychiatry at Brown University, is the author of several books, including “Against Depression” and “Listening to Prozac.”
Schizophrenia affects around 26 million people across the world and is the focus of World Mental Health Day this year. The Day provides an opportunity for all stakeholders working on mental health issues to talk about their work, and what more needs to be done to make mental health care a reality for people worldwide.
October 10th is World Mental Health Day
We’re helping to shine the spotlight on those affected by schizophrenia - from the 26 million people facing this affliction daily, to their family, friends and society as a whole.
What is Schizophrenia?
According to the World Health Organization, schizophrenia is a severe mental disorder, characterized by profound disruptions in thinking, affecting language, perception, and the sense of self. It oftentimes includes psychotic experiences, such as hearing voices or delusions. It can impair functioning through the loss of an acquired capability to earn a livelihood, or the disruption of studies. Schizophrenia typically begins in late adolescence or early adulthood. Most cases of schizophrenia can be treated, and people affected by it can lead a productive life and be integrated in society.
What is the aim of the 2014 World Mental Health Day?
"To ensure that people with schizophrenia get the best possible care and support to manage their illness and to help them recover." - Mental Health Foundation
To that end, Routledge has compiled a collection of resources in support of those affected by schizophrenia. Get 20% off your order by entering the code WMHD4 on checkout.
Do you believe schizophrenia is about people with multiple personalities?
If the answer is yes, you may be in a broad majority, but that doesn’t mean it’s true, which is why events such as World Mental Health Day are critical to assert the facts and dispel myths.
"Schizophrenia is not a ‘split personality’, says Dr Sheri Jacobson, clinical director atHarley Therapy.
"People with schizophrenia don’t act normal and then suddenly turn into someone else, like a Dr. Jekyll and Mr. Hyde act. A schizophrenic has one personality, it’s their perception of their world that splits."
Despite these high figures, many people living with the condition will not receive a formal diagnosis.
Misinformation in the media about the illness has led to a lack of understanding around it, meaning many suffering do not seek the support they need.
"It is perhaps more important to look at what schizophrenia isn’t, than what schizophrenia is, as films and media often portray it in ways that aren’t helpful views of the condition,"
Schizophrenia affects the way people think and perceive the world around them. Symptoms can include hearing voices or seeing things that aren’t real, depression or becoming withdrawn.
A schizophrenic may also experience delusions, which may start based in truth, but become more complex as the illness progresses.
Nigel Campbell, associate director of communications at Rethink Mental Illness, says: “As you can imagine, it can be very frightening for people when they first start to experience symptoms like hearing voices, or extreme paranoia.
"It can also be hard for people to differentiate between what they’re going through, and reality.
“This can also be very difficult and confusing for their families and friends, who might not understand what is happening to their loved one, or where to turn for support.”
Campbell says one of the biggest problems that people with schizophrenia face is the stigma around the illness - some sufferers still lose relationships with family and friends after opening up to them about what they’re experiencing, while others will struggle to find employment.
"Many employers assume that if you have a mental health problem, you won’t be able to hold down a job. It is a disgrace that only around 8% of people with schizophrenia in this country are in employment," Campbell adds.
Shockingly, people with schizophrenia or other severe mental illnesses die on average 20 years earlier than the general population, mostly from preventable illnesses.
According to Rethink’s 20+ campaign, this is because people with serious mental illness do not get regular physical health checks, and signs of physical health problems are often missed when they seek help.
Clearly we still have a long way to go before schizophrenia is universally understood, but attitudes towards mental health do at least seem to be slowly changing.
A recent survey from Time to Change (a mental health anti-stigma programme), found 79% of people now acknowledge that those with a mental illness have for too long been the subject of ridicule.
Sue Baker, director of Time to Change, says: “In recent years we’ve seen thousands of people starting to speak out, challenging big high street brands that have fuelled stigma and sharing their own experiences to help shift perceptions, including MPs, high profile sportspeople and people in business.
"However, we shouldn’t underestimate the task ahead of securing long lasting, irreversible and far-reaching changes in attitudes, behaviour, policies and systems.
"We will have reached our goal when someone can openly share their diagnosis of depression, schizophrenia or bipolar on a first date or at a job interview without fear of a negative reaction.”
There isn’t one specific cure for schizophrenia, a combination of medication and talking therapy are often prescribed. If you believe you, or a loved one, may be experiencing symptoms, the first step should be to visit a GP.
Dr Fiona Morrison, consultant psychiatrist at the Priory Hospital Glasgow, says well-controlled symptoms can allow a person to function fully in the community, and work.
"Psychiatry and psychology assessments can help with diagnosis and early management. The Hearing Voices Network can be very good for those who wish to use other ways [than medication] to take back control of voices,” she adds.
As well as being frightening for the person experiencing symptoms, schizophrenia can also be challenging for that individual’s friends and family.
Dr Jacobson warns that if you’re helping someone with schizophrenia, it’s advisable to get some help for yourself as well.
"Don’t blame yourself if things become more challenging than you can handle if a loved one suffers from schizophrenia, and don’t blame yourself that your loved one has the condition – it is nobody’s fault.
"Schizophrenia is a challenge for all those involved, and the feelings of fear, frustration and helplessness it can cause can lead to stress and anxiety that can take over your life is you let it,” she says.
Perhaps the most important thing to remember about schizophrenia is that is is not a life sentence.
“With the right support people can recover, ” Campbell says. “About half of all people who are diagnosed with schizophrenia recover after one or two episodes. The key is to get treatment as quickly as possible.”
World Mental Health Day is on 10th October 2014. Rethink’s Schizophrenia Awareness Week runs from the 6th – 10th October. Visit www.rethink.org orwww.mentalhealth.org.uk for more information and advice.
Massive study of 100,000 people finds evidence for long-suspected danger of anxiety and sleeping drugs.
Like many drugs, those prescribed for anxiety disorders, like diazepam and temazepam, have a number of known side-effects like daytime sleepiness, falls, an increased risk of dementia — and they are also addictive.
Now, though, a new study has found evidence for a long-suspected danger of these drugs as well as common sleeping pills: an increased risk of death.
The large study, published in the British Medical Journal, looked at data from over 100,000 patients who had been to their family doctors across seven years (Weich et al., 2014).
It found that taking anti-anxiety drugs (like diazepam) or sleeping pills (like zolpidem/Ambien) doubled the risk of death.
In real terms this meant:
“…there were about four excess deaths linked to drug use per 100 people followed for an average of 7.6 years after their first prescription” (Weich et al., 2014)
There was also a dose-response effect: the more of the drugs people took, the higher their risk of death.
To reach its conclusions, the study matched people who had taken the anti-anxiety and sleeping pills with other similar patients who had not taken the drugs.
The study also controlled for psychiatric illnesses like anxiety and sleeping disorders.
Many of the patients in the study received more than one drug and 5% had taken drugs of three different types over the study period.
Benzodiazepines — like diazepam and temazepam — were the most commonly prescribed drugs.
Professor Scott Weich, who led the study, said:
“The key message here is that we really do have to use these drugs more carefully.
This builds on a growing body of evidence suggesting that their side effects are significant and dangerous.
We have to do everything possible to minimize over reliance on anxiolytics [anti-anxiety drugs] and sleeping pills.
That’s not to say that they cannot be effective.
But particularly due to their addictive potential we need to make sure that we help patients to spend as little time on them as possible and that we consider other options, such as cognitive behavioral therapy, to help them to overcome anxiety or sleep problems.”
When it came to pharmacological solutions to life’s despairs, Aldous Huxley was ahead of the curve. In Huxley’s 1932 novel about a dystopian future, the Alphas, Betas and others populating his “Brave New World” have at their disposal a drug called soma. A little bit of it chases the blues away: “A gramme” — Huxley was English, remember, spelling included — “is better than a damn.” With a swallow, negative feelings are dispelled.
Prozac, the subject of this week’s video documentary from Retro Report, is hardly soma. But its guiding spirit is not dissimilar: A few milligrams of this drug are preferable to the many damns that lie at the core of some people’s lives. Looking back at Prozac’s introduction by Eli Lilly and Company in 1988, and hopscotching to today, the documentary explores the enormous influence, both chemical and cultural, that Prozac and its brethren have had in treating depression, a concern that gained new resonance with the recent suicide of the comedian Robin Williams.
In the late 1980s and the 90s, Prozac was widely viewed as a miracle pill, a life preserver thrown to those who felt themselves drowning in the high waters of mental anguish. It was the star in a class of new pharmaceuticals known as S.S.R.I.s — selective serotonin reuptake inhibitors. Underlying their use is a belief that depression is caused by a shortage of the neurotransmitter serotonin. Pump up the levels of this brain chemical and, voilà, the mood lifts. Indeed, millions have embraced Prozac, and swear by it. Depression left them emotionally paralyzed, they say. Now, for the first time in years, they think clearly and can embrace life.
Pharmacological merits aside, the green-and-cream pill was also a marvel of commercial branding, down to its market-tested name. Its chemical name is fluoxetine hydrochloride, not the most felicitous of terms. A company called Interbrand went to work for Eli Lilly and came up with Prozac. “Pro” sounds positive. Professional, too. “Ac”? That could signify action. As for the Z, it suggests a certain strength, perhaps with a faint high-techy quality.
(X is a pharmacological cousin to Z. Both letters are somewhat unusual, worth many points in Scrabble. It is surely not a coincidence that a striking number of modern medications contain either Z or X, or both, in their names, like Luvox, Paxil, Celexa, Effexor, Zantac, Xanax, Zoloft, Lexapro and Zocor, to name but a few. Not surprisingly, confusion can set in. Zantac or Xanax — remind me which one is for heartburn and which for panic disorder?)
Pendulums, by definition, swing, and the one on which Prozac rides is no exception. After the early talk about it as a wonder pill — a rather chic one at that — a backlash developed, perhaps unsurprisingly. Grave questions arose among some psychiatrists about whether the S.S.R.I.s increased chances that some people, notably teenagers, would commit suicide or at least contemplate it. No definite link was confirmed, but that did not end the concern of some prominent skeptics, like a British psychiatrist, Dr. David Healy. He has dismissed the notion of S.S.R.I.s as saviors as “bio-babble.”
If some users deem Prozac lifesaving, others consider it sensory-depriving. A loss of libido is a common side effect. Some writers and artists, while often relieved to be liberated from depression’s tightest grip, also say that Prozac leaves them mentally hazy. In his 2012 book, “Antifragile: Things That Gain From Disorder,” Nassim Nicholas Taleb offered this: “Had Prozac been available last century, Baudelaire’s ‘spleen,’ Edgar Allan Poe’s moods, the poetry of Sylvia Plath, the lamentations of so many other poets, everything with a soul would have been silenced.”
Then, too, S.S.R.I. critics express doubts that these drugs have proved themselves significantly more effective than placebos. Some among them question the very concept that serotonin levels, on their own, cause depression or prevent it. One psychotherapist in that camp is Gary Greenberg, an author of several books on mood disorders. Writing in The New Yorker last year, Dr. Greenberg said that scientists had “concluded that serotonin was only a finger pointing at one’s mood — that the causes of depression and the effects of the drugs were far more complex than the chemical-imbalance theory implied.”
“The ensuing research,” he continued, “has mostly yielded more evidence that the brain, which has more neurons than the Milky Way has stars and is perhaps one of the most complex objects in the universe, is an elusive target for drugs.”
More broadly, this retrospective on Prozac introduces a discussion of whether the medical establishment, and perhaps society in general, has gone too far in turning normal conditions, like sadness, into pathologies. And have we paved a path — shades of soma — toward wanton reliance on drugs to enhance life, not to conquer true illness?
This is what a prominent psychiatrist, Dr. Peter Kramer, has called “cosmetic psychopharmacology,” a Botox approach, if you will, to matters of the mind: Why not take Prozac and its S.S.R.I. mates even if you are not clinically depressed but believe that they can boost your confidence, or maybe help you make a stronger pitch at the sales meeting?
A response from others in Dr. Kramer’s field is that we are taking traits that are normal parts of human nature and casting them as diseases simply because remedies now exist. For instance, shyness is now regarded by some as a condition in need of treatment. In its more severe form, it is placed under the heading of social anxiety disorder. Then there are those much-heralded life enhancers, Viagra and its erection-aiding cousins. They are marketed not only to men with sexual dysfunction but also to those whose aging bodies are enduring normal wear and tear.
One area of shyness that the S.S.R.I. class has helped overcome is discussion of depression. Decades ago, Hollywood stars and other celebrities dared not touch the subject. Now they routinely go public with their anguish. Robin Williams was an example.
Of course, there are those in other realms of society for whom the topic remains taboo. Take one man who confesses to his wife that he is on Prozac but cautions her to tell no one. “I’m serious,” he says. “The wrong person finds out about this and I get a steel-jacketed antidepressant right in the back of the head.” This is Tony Soprano talking to his wife, Carmela. An extreme example from a work of fiction? Sure. But in all likelihood many Americans have similar fears about what others might think, and keep depression to themselves.
The video with this article is part of a documentary series presented by The New York Times. The video project was started with a grant from Christopher Buck. Retro Report has a staff of 13 journalists and 10 contributors led by Kyra Darnton. It is a nonprofit video news organization that aims to provide a thoughtful counterweight to today’s 24/7 news cycle.