Friday, August 28, 2015

The Old Man: A Story

Part I

The first time I met the old man was during my residency interviews. He was spry and looked younger than his age, and why not? He was at the top of his game: head of a department, boatloads of research funding, one of the most well-known psychiatrists around. Another psychiatry department chair who had interviewed me previously hinted that the old man was quite a businessman and enjoyed cozy relations with industry.

As he asked me his first question, the old man practically winked: "So, are you single, in a relationship, or married, or what?" That was my first hint that he might not be the most ethically-inclined individual. I had been told by my medical school before interview season that such personal questions were definitely off limits. Yet he made his greeting seem like the most natural and friendly thing in the world.

Part II

The old man was fuming. He was supposed to be giving a talk on depression treatment, but what seemed to preoccupy his mind was a just-published study from Irving Kirsch suggesting that antidepressants were not better than placebo for mild to moderate depression. Our speaker seemed deeply and personally offended. After many words assailing Kirsch's motives, he concluded: "Even if it's no better than placebo, it doesn't mean we shouldn't treat the patient!" Almost sounded like advice from Allen Frances, but twisted.

Part III

By random chance, I saw the old man again recently, when I was going out to dinner in the city where he lives. There he was, walking down the sidewalk with his wife, right past where I had just parked my car. He was wearing a sweatshirt with the name of his university employer on it. I'd never seen him out of a suit before. I thought he seemed older, frumpier, humbled. Or perhaps that was just my wishful thinking?

A lot has happened since the last time I saw him. He was no longer the department chair, replaced by someone known for work related to ethics. I briefly considered going up to him and saying something, but what? "Thank you for being an example of what not to aspire to?" Or, "That's a very plain-looking sweatshirt; did all your industry funding dry up?" Poor sportsmanship and too passive-aggressive. I briefly imagined following him down the sidewalk, yelling: "Shame, shame, shame!"  But he probably would've mistaken me for a Scientologist or something.

Saturday, July 11, 2015

A Child Psychiatrist's Review of Pixar's Inside Out

I finally watched Disney/Pixar's Inside Out, and I agree with the consensus opinion that Pixar has done it again, making a movie that's both fun and poignant, with a narrative that young children can understand while containing deeper messages for adults. Read on for more of my thoughts, but be aware that MAJOR SPOILERS FOLLOW, since it is hard to discuss my thoughts as a child psychiatrist on the movie's depiction of emotions without going into the details.

Fear, Disgust, Joy, Anger, and Sadness.
The main characters: Fear, Disgust, Joy, Anger, and (sigh) Sadness.


The plot of Inside Out is fairly straightforward: a preteen girl named Riley moves with her parents from Minnesota to San Francisco, and she experiences a crisis in her emotional state, in her relationship with her parents, and in her concept of herself. Most of the action takes place inside Riley's head, where 5 different emotions (Joy, Sadness, Anger, Disgust, and Fear) take turns at the control center of the brain's headquarters, directing Riley's actions depending on which emotion is at the controls. Joy is the energetic (cheer)leader who attempts to remain in control as much as possible, especially over Sadness. The crux of the movie is about Joy going on a journey in which she (and everyone else) learns to value Sadness.

How the Pixar filmmakers takes us on the journey, though, is where they show off their delightful imagination and remarkably decent grasp of psychology. Here are my thoughts on the aspects of Inside Out that delighted me the most:
  • The movie demonstrates the inner workings of memory in a visually coherent and fairly accurate way. I especially like how Riley's incoming memories, which look like softball-sized glowing orbs, are temporarily kept at headquarters until Riley sleeps, at which point they are sent into long term memory. They also find a way to neatly show core aspects of Riley's identity/personality as floating islands that serve as repositories of concepts such as Family, Honesty, and Goofiness.
  • The depiction of the weight of parental expectations is very well-done. When Riley becomes upset after the move, her parents say to her: "Where's my happy girl?", clearly indicating their preference for how she should feel. This is one way that parents insidiously and inadvertently tell their children it's not OK to be sad, and the fact that (if I recall correctly) each parent says this to Riley on separate occasions shows that Pixar is emphasizing the harm that this sort of communication can do.
  • A critical scene that works incredibly well both as a turning point in the plot and a learning opportunity is when Sadness convinces a character to do something that Joy could not, simply by listening and showing empathy for that character's feelings. This teaches Joy (and us) the importance of validating another person's emotions.
  • Some of my favorite moments in the movie are when it delves into the minds of characters other than Riley. I really enjoyed how each character has a different predominant emotion, and the emotions work together in different ways depending on the individual. For example, inside the head of Riley's mother, the different emotions sit around like a committee with Sadness presiding, while a teen boy's mind is dominated by fear, with all his emotions running amok.
  • When Riley and her father get into an argument during dinner, the camera dives into each person's mind and clearly shows how Anger in one person leads to escalating Anger in the other, in a mutually assured destruction kind of way. This is a good example of an amygdala hijack, which comes up frequently when I discuss family conflict with patients.
  • Despite being a primary emotion, each of the emotion characters are capable of expressing other emotions. This helps make them more interesting and less one-dimensional; it also helps subtly reinforce the point that having one emotion dominate all the time may not be desirable.
  • Initially, each of Riley's memories passing through the control center is a distinct color, corresponding to the emotion associated with the memory. By the end of the movie, memories have become multi-hued, nicely illustrating Riley reaching a developmental stage where she is capable of more emotional nuance.
However, I do have one major criticism, and that is the portrayal of Sadness as short, rotund, and bespectacled. How…sad that Pixar uses such obvious stereotypes to depict her appearance! Sure, this may get more laughs from the audience and fit the look of the actress supplying the voice, and the movie does try to redeem itself by turning Sadness into a heroine. But how would kids fitting that description feel inside early on, even if they're laughing along with everyone else on the outside? I wish Pixar had simply portrayed Sadness on the basis of her facial expressions and body language without adhering to our cultural norms regarding the physical characteristics of a sad person; they're good enough animators to be capable of that. A few of other nitpicks:
  • A scary clown is locked away in Riley's subconscious, visually depicted as a vault in a deep cavern. I'm not sure if even the psychoanalysts still use the term "subconscious," yet it persists in the popular culture, perhaps because it's so easy to conjure up that visual image of something deeply buried.
  • Memories, of course, are not accurate recordings preserved in amber, but are malleable and often unreliable. While it would have been nice for the movie to show this, I understand that it would probably overcomplicate things. Similarly, expanding beyond just the 5 emotions featured would have been nice but too complicated.
  • Though dramatic, I do not feel that the scene of Riley taking a credit card from her mother's wallet and getting on a bus back to Minnesota is very believable. Given her generally good relationship with her parents in the past, it would take much more than a couple of arguments to make a kid who did not have previous conduct problems steal and run away from home.
Despite my criticisms, Inside Out is easily one of my three favorite Pixar movies of all time, along with Wall-E and Ratatouille. I can even envision it being useful in therapy. Asking a child to think about a situation and consider what Joy would say versus what Sadness or Fear would say about it might help make cognitive-behavior therapy more engaging and fun. If you're a child therapist/psychologist/psychiatrist and haven't seen it yet, what are you waiting for? It's the only Pixar movie where I'm eagerly anticipating a sequel, given the portents at the end about Riley turning 12. I'd love to see what Pixar does with the even more tangled emotions and relationships of adolescence.

Tuesday, May 19, 2015

Free Branding Advice For The American Psychiatric Association

On Sunday, while going about my weekend business (which means possibly wasting some time on Twitter), I was greeted with this unsolicited gift from the American Psychiatric Association:
There's also an announcement on the APA website and an accompanying Youtube video. Here's an alternative version of the new logo:

American Psychiatric Association Logo w/ Brain

Now, I'm not an APA member, but as a psychiatrist, this is just embarrassing. Poor Benjamin Rush must be rolling over in his grave! I'm also not a "branding expert," but it seems that the APA could use all the help it can get these days. Thus, I'm offering some pro bono advice as a public service.

Typeface

First off, the text becomes very fashion-forward with the use of a skinny font (resembles Avenir, but I'm not sure exactly what it is) for "American" and "Association." The semi-bold and colored emphasis on the word "Psychiatric" just seems a bit…desperate. Look at us, we're psychiatrists! I'm not saying that the typeface doesn't look nice, but it smacks of trying too hard to match the latest trends in visual marketing:

Apple Watch Edition

Now, Apple can do with this because they actually are producing new high-tech products. But the APA? Sorry, I don't think Understanding Mental Disorders: Your Guide to DSM-5 qualifies. Why not make something that looks timeless and classy, rather than trendy and fashionable? Here's my suggestion:

American Psychiatric Association Classier Type

This has the added benefit of allowing the letters "APA" to line up, emphasizing to the world that the fight over what "APA" stands for is not over, even though the American Psychological Association owns apa.org and the Google search results. We psychiatrists don't give up!

Logo

Though I discussed the choice of typeface first, the new logo emphasizing the brain is the most jarring aspect of the APA brand refresh. Here were my initial thoughts:
A couple of days later, I still feel the same way. If you're trying so hard to signal that the organization is modern and future-looking, then why in the world use such a literal outline of a brain? The whole point of logos is to make a simplified visual representation of something so it becomes an instantly recognizable icon. That's why Apple's logo doesn't look like an actual silhouette of an apple, and the Microsoft Windows logo doesn't look like a photorealistic window. It's also why the serpent on the Rod of Asclepius winding its way through the brain (wisely) does not show snake scales. Also, note what happens to the APA's brain when it's shrunk:

Fuzzy APA Brain Logo

Look how fuzzy the brain becomes, while the Rod of Asclepius retains its shape nicely. So, APA, if you're going to use a brain with folds, then at least make them look somewhat rounded:

Rounded APA Brain Logo

Even though it's a bit cartoony and not anatomically accurate, it's at least visually cogent, especially at smaller sizes. Alternatively, you can get even more minimalistic:

Smooth APA Brain Logo

These changes took me all of 20 minutes in Photoshop, and I'm no graphic artist. I wonder how much the APA paid their consultants for all this?

Tagline

Finally, that tagline: "Medical leadership for mind, brain and body." While I won't argue too much over the missing Oxford comma, I do think: wouldn't it be nice if the tagline matched the typeface and the logo? The typeface signals future-think, while the logo features a traditional symbol of medicine within the brain. I don't see anything conveying "mind" or "body." Since I believe honesty is the best policy when it comes to branding, why not this:

APA: Leaders in medicalizing the brain.

Or even better, if the focus in going to be on medical brain disorders, why not a complete rebrand of the APA into something even awesomer?

American Clinical Neuroscience Association: Leaders in medicalizing the brain.

There, that's more like it!

Sunday, May 3, 2015

One Pringle

Like many psychiatrists, I see a fair number of patients whose relationship with food has been fraught with difficulty. Some of the patients that we worry about the most are those with anorexia, who are at a high risk of dying from their illness. However, it seems that those who have problems with binge or over-eating are much more common.

One memorable patient that I saw during residency was a man in his 50s, who reported feeling severely depressed ever since he had gastric bypass surgery 2 years prior. The man had been obese his whole adult life; he ate whenever he felt lonely, bored, or stressed, and eventually he weighed close to 400 pounds. I was surprised when he told me this, because he was trim and fit when I first met him, and he was fortunate enough to not have noticeably loose skin from losing over half his body weight. Of course, his doctors initially wondered whether a nutritional deficiency caused his depression, but all their tests came back normal. The patient himself attributed his mood change to no longer being able to eat the foods that he used to enjoy, and no amount or combination of medication made a difference. It seemed that his main coping skill was taken away without him gaining anything to replace it. Seeing this patient led me to think a lot about how one develops or fails to develop self-control with food.

Growing up, I sometimes travelled with my family to visit my grandparents, who lived in another country. During one week-long visit to their home, one of the things that drew my interest was a can of Pringles® sitting high on a book shelf in the living room. Day after day, it remained there, out of my reach. I'm sure I would have eaten most of the can during that time if it were more easily accessible. Then one day, I saw my grandfather open the can, take one chip out, and then he put the can back on the shelf. He bit off half the chip, closed his eyes, and chewed slowly and deliberately, savoring every last bit of that salty, crunchy goodness. Then, he did the same thing with the other half. One Pringle, and he was done. I can't even type the word "Pringle" without the spellchecker highlighting it and suggesting that I change it to "Pringles", but there was my grandfather, eating just one at a time, less than once per day.

While writing this, I checked out what Pringles® is using as their latest marketing slogan. Here it is:

Pringles: You don't just eat 'em
Well, my grandfather did in fact "just eat 'em," and he would have easily won a bet with anyone repeating the Lay's® phrase "betcha can't eat just one." How was he able to do that? I never thought to ask him directly, but I've often wondered how his journey through life shaped him. His father died when he was still an infant, and he was raised by his mother and grandfather. His was a scholarly family, and despite growing up in a place under foreign occupation during World War II, he was able to do well academically, eventually attending medical school. After the war, instead of enjoying the consumer exuberance that swept the U.S., my grandfather had to contend with decades of ongoing deprivation and strive while working long hours and raising a family.

Since I grew up in America, I had abundant access to food and never had to worry about getting enough to eat. I was also exposed to all the mass media messages that we Americans are inundated with. I craved Happy Meals® and Kellogg's® Froot Loops® and Nabisco Chips Ahoy!® and anything from those cute Keebler® elves. Not surprisingly, I often did not stop eating when I was full; there have been times when I ate so much at buffets that I felt sick. Yet as I got older and was faced with the temptations of overeating, I would often think back to that image of my grandfather and his one Pringle, and then I would ask myself, "Do you really want that extra serving?” And over time, my self-control gradually improved. How much of that was influenced by the fact that I randomly witnessed my grandfather's way of snacking? I'll probably never know, but I'm still grateful for the memory.

Of course, my grandfather was not perfect; he had his bad habits just like anyone else. He was a pulmonologist, but he also smoked cigarettes for many years. However, when he smoked, guess how many cigarettes he had on each occasion?

Monday, April 27, 2015

The Most Popular Psychiatrists in America (According to Twitter)

All the recent hubbub over Dr. Memhet Oz got me thinking more about fame when it comes to medical doctors: how they gained their popularity, to what end they employ their platforms, and how they keep (or don't keep) their professional integrity. One of the easiest ways to estimate popularity is to look at how many people follow an individual on Twitter. There, Dr. Oz is clearly way ahead of the practicing physician pack with 3.75 million followers. Dr. Drew Pinsky is second at 3.16M, while CNN's Dr. Sanjay Gupta is a distant third with 1.98M. In comparison, well-known blogger Dr. Kevin Pho "only" has 122K followers.

Curious about who the most popular psychiatrists are, I searched Twitter for individuals (not organizations) with profiles matching "psychiatrist" on 4/26/15. I examined the first 100 or so profiles written in English, looking at the follower count and selecting the 4 psychiatrists with the most followers for further scrutiny (and speculation), focusing on the nature of their popularity and just how much B.S. they espouse. Here's what I found:

#4: Judith Orloff (40.0K followers | following 10.3K)

Claim to fame: According to her Twitter profile, Dr. Orloff is a "psychiatrist, intuitive healer, and author of THE ECSTASY OF SURRENDER about how to let go of stress, trust intuition, and embrace joy." She has also written other books with titles such as [her CAPS]: EMOTIONAL FREEDOM, POSITIVE ENERGY, INTUITIVE HEALING, and SECOND SIGHT. I have never heard of her or any of her books; judging by their descriptions, they are very much targeted toward a non-scientifically-minded audience (which is to say, just about everyone).
B.S. meter: 7 poo. Dr. Orloff's about page emphasizes the power of intuition to help us "heal—and prevent—illness" and is full of quotations describing her as "a prominent energy-based healer" and a "positive energy guru." I have no doubt that she is a great psychiatrist who helps her patients and readers feel better, and I happen to agree with the message in her latest book about the importance of letting go as opposed to "pushing, forcing, and over controlling people and situations." Yet my intuition tells me that anyone who promotes herself with a sentence like "Dr. Orloff is accomplishing for psychiatry what physicians like Dean Ornish and Mehmet Oz have done for mainstream medicine" needs to be approached with a healthy dose of skepticism.

#3: Daniel Amen (78.7K followers | following 29.3K)

Claim to fame: Frankly, I was surprised that he was not #1. He's the only psychiatrist that I immediately recognized out of the 4 I found doing this search and the only one with a verified Twitter account, which Twitter only bestows upon "key individual and brands." Dr. Amen is the founder of Amen Clinics, which uses SPECT brain scans to purportedly diagnose mental disorders. He has been featured in programs running on PBS, and he even has influence amongst Christian audiences. In 2012, a Washington Post article called him "the most popular psychiatrist in America."
B.S. meter: 8 poo. There have been numerous well-articulated criticisms of Dr. Amen and his ridiculous claims regarding SPECT scans that I won't rehash here, save for one especially galling fact: his clinic charges $3500 for an initial evaluation and SPECT scan, which is generally not covered by insurance. While the clinic's website does not reveal this cost up front, it does say they've done over 100,000 scans, so you do the math. PBS's own ombudsman has disavowed any association with Dr. Amen's infomercials that were aired by local PBS affiliates without adequate disclaimers. Dr. Jeffrey Lieberman, former president of the American Psychiatric Association, was quoted in the Washington Post article as saying this about Amen: "In my opinion, what he’s doing is the modern equivalent of phrenology." On that point, Dr. Lieberman and I can agree.

#2: Brian Weiss (80.7K followers | following 25)

Claim to fame: Dr. Weiss's website tells us he "was astonished and skeptical when one of his patients began recalling past-life traumas that seemed to hold the key to her recurring nightmares and anxiety attacks. His skepticism was eroded, however, when she began to channel messages from 'the space between lives,' which contained remarkable revelations about Dr. Weiss's family and his dead son. Using past-life therapy, he was able to cure the patient and embark on a new, more meaningful phase of his own career." He is the author of books such as Miracles Happen: The Transformational Healing Power of Past Life Memories, and Many Lives, Many Masters: The True Story of a Prominent Psychiatrist, His Young Patient, and the Past-Life Therapy That Changed Both Their Lives. Not surprisingly, his homepage prominently features a photo of him and Oprah. He runs 5-day workshops costing $1000/person for "anyone interested in exploring these profound psychospiritual techniques."
B.S. meter: 10+ poo. Someone in a past life once told me, "If you ain't got nothin' nice to say, then it's better to say nothin' at all." I will stick with that for my current life and any of my future lives…

Thus far, the trend seems to be greater popularity correlating with ever escalating levels of B.S. I was losing what little faith I had entering this exercise. So I was shocked by who ranked first:

Dr. Tobias Fünke

For a moment, I thought I was looking at Dr. Tobias Fünke from Arrested Development. But no, it's actually this guy:

Dr. Normal Rosenthal

#1: Norman Rosenthal (101K followers | following 28.3K)

Claim to fame: I have never heard of Dr. Rosenthal before, but he is the only psychiatrist I can find with over 100K followers. According to his website, he "has written over 200 scholarly articles, and authored or co-authored eight popular books. These include Winter Blues, the New York Times bestseller Transcendence, and the Los Angeles Times bestseller The Gift of Adversity. Rosenthal has conducted numerous clinical trials of medications and alternative treatments, such as Transcendental Meditation for psychiatric disorders, and the treatment of depression with Botox." Watching him on Youtube, it seemed that his South African accent instantly gave him added authority and gravitas (I call this the Salvador Minuchin effect).
B.S. meter: 1 poo. I was ready to be skeptical of Dr. Rosenthal, and this promotional page for his newest book is chock full of celebrity endorsements, including one from Dr. Oz himself. But the book actually seems to offer very sensible advice (based on Dr. Rosenthal's own life) on how to cope with adversity, and reading a passage from it on Google books, I even learned some interesting things about how the NIMH worked during the transition to the Steve Hyman/Tom Insel era. Dr. Rosenthal's research publications also left me impressed. He worked at the NIMH for 2 decades, and he did impactful studies on seasonal affective disorder, sleep disturbance in mania, and the use of light therapy for delayed sleep phase syndrome. He still sees patients in his clinical practice, where he seems to emphasize integrating different treatment modalities instead of pretending there's some magic bullet. And this is my own personal bias, but I find it touching that his son Joshua has followed in his footsteps, becoming a child and adolescent psychiatrist.

So what did I learn about psychiatrists and fame, at least when it comes to Twitter? Obviously, it helps to write multiple best-selling books and to regularly appear on television. Presenting oneself as an "alternative" practitioner with special knowledge or healing techniques helps as well. I won't delve into the content of their tweets in this post, but it seems relentlessly positive messages and pithy tips on how to improve one's life are a must in order to reach as broad an audience as possible.

Also, 3 of the 4 psychiatrists employ the method of following tens of thousands of people in hopes of trying to get as many people to follow them back as possible. In contrast, the truly famous doctors tend have much more sane follow counts: Dr. Oz follows 85, Dr. Pinsky follows 422, and Dr. Gupta follows 198. Thus, Dr. Weiss may well have the most impressive follower count amongst psychiatrists, given that he only follows 25 people for a follower:following ratio of 3228!

Before doing this search, I did not follow any of these top 4 psychiatrists on Twitter. Of the accounts that I follow, 8 of them follow Dr. Amen, 4 follow Dr. Orloff, 4 follow Dr. Rosenthal, and only 1 follows Dr. Weiss (really, @AACAP?). While writing this post, I've decided to follow Norman Rosenthal. He's the one out of the 4 who seems to have most preserved his professional integrity without wading deeply into the realm of pseudoscience, pop spirituality, or utter nonsense. I think every psychiatrist (or doctor, for that matter) aspiring to semi-celebrity status can learn something from him ;-)