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.


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!


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?


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 ;-)

Thursday, April 23, 2015

Success, but at What Cost?

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

The patient, who was in his late 20's, was clearly very driven. He was a straight-A student from K-12, graduated from an Ivy League school with a 3.9 GPA, and proudly tells me that he works at a startup. He wakes up early every morning for his hour-long commute and works 12-hour days. Admirably, he makes sure to exercise for an hour each night after he gets home. Then, after he eats dinner, he even tries to spend a couple of hours with his girlfriend. When he finally gets to bed, he sleeps from about midnight to 5:30am. Ever since starting college, he has not gotten more than 6 hours of sleep a night.

He tells me he's been feeling more tired and less focused over the past year, a period coinciding with him gaining greater responsibilities at work. This lack of focus is not constant, and he tends to have the hardest time concentrating around 2-3pm, when he would often feel tired and sleepy. Not surprisingly, he wonders if he has ADHD and if a stimulant medication can help.

I tell him: "I can't really diagnose you with ADHD because there is no evidence of impairment when you were younger. Plus, most people really do need close to 8 hours of sleep, and almost everyone who gets less than 6 will eventually have trouble staying alert and focused during the day. I recommend that you try to sleep between 7 and 8 hours a night for a few months and see if things improve." He was both dismayed and somewhat defiant: "Look, I'm really busy, and I'm not about to compromise any aspects of my life. There's no way I'm going to work less or give up my workouts or not spend time with my girlfriend."

This was the patient that came to my mind when I was reading the New York Times article over the weekend about adult prescription stimulant abuse:
Elizabeth, a Long Island native in her late 20s, said that to not take Adderall while competitors did would be like playing tennis with a wood racket.

"It is necessary — necessary for survival of the best and the smartest and highest-achieving people," Elizabeth said. She spoke on the condition that she be identified only by her middle name. […]

Elizabeth’s sleep tracker was confused. Her nightly rests were so brief, the iPhone software thought they were just naps. It recorded her average sleep over nine months: from 4:17 a.m. until 7:42.

After founding her own health technology company, Elizabeth soon decided that working hard was not enough; she had to work harder, longer. Sleep went from an indulgence to an obstacle.

So she went to a psychiatrist and complained that she could not concentrate on work. She received a diagnosis of A.D.H.D. and a prescription for Adderall in about 10 minutes, she said.

"Friends of mine in finance, on Wall Street, were traders and had to start at 5 in the morning on top of their games — most of them were taking Adderall," Elizabeth said. "You can’t be the one who is the sluggish one."
I'm saddened that we live in a world where the founder of a health technology company doesn't seem to care about how sleeping 3.5 hours a night affects her own health. It seems very Kafkaesque and short-sighted to me. How did things get this way, to the point where "success" is defined by individual achievement and productivity above all else?

I found David Brooks's column from last week to be quite pertinent. He traced the changes in American society stemming from the late 1940s, when the generation who had suffered through the Great Depression and World War II let loose and embraced consumerism, transforming the culture from one of self-effacement and sacrifice to one of self-expression and indulgence:
But I would say that we have overshot the mark. We now live in a world in which commencement speakers tell students to trust themselves, listen to themselves, follow their passions, to glorify the Golden Figure inside. We now live in a culture of the Big Me, a culture of meritocracy where we promote ourselves and a social media culture where we broadcast highlight reels of our lives. What’s lost is the more balanced view, that we are splendidly endowed but also broken. And without that view, the whole logic of character-building falls apart. You build your career by building on your strengths, but you improve your character by trying to address your weaknesses.
Instead of "broken," I would've chosen "incomplete," but otherwise I agree with Brooks's main points. And speaking of a glorified Golden Figure, I thought I was reading a late April's Fool joke when CNN/Money ran an article last week titled: "Mark Zuckerberg only works 50 to 60 hours a week." Unfortunately, it was not a joke, and of course the author qualified Zuck's work hours with: "But he conceded that if the definition of 'work' were expanded, he'd be working his 'whole life.'" Is this the sort of role model that we want for our kids? Do we want a society where people are admired for driving themselves to extremes, and a lucky few will become fabulously wealthy, while many more get stressed out and sleep-deprived, and a certain regrettable percentage end up with depression, anxiety, or suicide?

Wednesday, April 15, 2015

Disruptive Mood Dysregulation Disorder Revisited

In the brief history of this blog, the post where I shared my thoughts on DSM-5's disruptive mood dysregulation disorder (DMDD) has gotten by far the most pageviews. It's been almost two years since I wrote that post, and I would like to revisit DMDD with some updated thoughts on this diagnosis.

As you may recall, DMDD sprang out of a desire to have a diagnosis other than "bipolar disorder" to describe children who are chronically irritable and have explosive tantrums. Almost all of the children with DMDD also meet the criteria for oppositional defiant disorder (ODD) and are at higher risk of developing depression but not mania. The NIMH researcher Ellen Leibenluft, whose work on severe mood dysregulation (SMD) strongly influenced DMDD's creation, had commented in the past that she was not 100% sure that DMDD was a good idea.

In the last few years, I have only seen a handful of children who met the criteria for DMDD. Here is what I noticed in my own practice:
  • One boy was being raised by a single mother who worked full time, so his grandparents were very involved in childrearing. The mother tried to set rules, but the grandparents were much more permissive, and whenever the mother tired to enforce her rules, explosive tantrums resulted.
  • Another boy was very violent toward his mother on an almost daily basis. His father was home but did not intervene, while the mother had anxiety and literally appeared fearful of her son during their visits with me. When he hit her, she would tell him verbally that it was wrong, but did not do anything else (like using a time-out) to try to change his behaviors.
  • There was a girl (who I'd written about previously) whose mother was very emotionally distant and pulled away further every time the girl acted out because the mother was reminded of her own emotionally intense mother. This distancing seemed to lead to the daughter becoming even more irritable.
  • And then there was a boy who was extremely aggressive at home, constantly fighting with his 3 siblings. The household was very chaotic, with parents still married but frequently arguing with each other. Both parents often resorted to spankings, which did not seem to decrease the boy's aggression or irritability.
Certainly, correlation between the parental characteristics and the children's behaviors does not tell us about causation. It is very stressful raising irritable, explosive children, and the children described above definitely had intense, strong-willed temperaments. My intuition is that it's an interactive process where both parental and child characteristics trigger maladaptive behaviors in each other that escalate over time. But are these families typical of cases of DMDD? I searched Pubmed for "disruptive mood dysregulation disorder" and found 20 papers published in the last 2 years (out of 29 total).

Of the 20, most were reviews/commentary, and only 6 papers were original research. One was a brain imaging study looking at "neural mechanisms of frustration in chronically irritable children." Another examined the prevalence of SMD 2 and 4 years out from initial diagnosis, and found that 40% still met full criteria at 4 years, but a significant number not meeting the criteria were still moderately impaired. Another study from Duke's developmental epidemiology program used a large database to examine the adult outcomes of those who would have met DMDD criteria as children and found higher adult rates of depression, anxiety, adverse health outcomes, impoverishment, police contact, and lower educational attainment.

To my pleasant surprise, there were actually several papers that included data on family characteristics of children with DMDD. The first was a cross-sectional study of a community sample of 6 year-old children, which found that 8.2% of them met DMDD criteria based on a structured interview of parents. Impressively, the study examined 6 domains ("demographics; child psychopathology, functioning, and temperament; parental psychopathology; and the psychosocial environment") for correlates of DMDD. The parents were also interviewed about what things had been like when their children were 3 years old, and here's what the researchers found:
The age 3 years predictors of DMDD at age 6 years included child attention deficit hyperactivity disorder, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, poorer peer functioning, child temperament (higher child surgency and negative emotional intensity and lower effortful control), parental lifetime substance use disorder and higher parental hostility.
The second study was a prospective one that "followed 317 high-risk children with early externalizing problems from school entry (ages 5-7) to late adolescence (ages 17-19)." The children sorted into 3 groups by the time they were adolescents: one group with conduct/criminal problems and anger, one group with mood dysregulation, and one group with a low level of symptoms. The authors found that generally, those who were more overtly aggressive as children tended to have conduct problems as adolescents, while more emotionally dysregulated children had more mood dysregulation in adolescence. The key finding:
For children with early emotion dysregulation, however, increased risk for mood dysregulation characterized by anger, dysphoric mood, and suicidality - possibly indicative of disruptive mood dysregulation disorder - emerges only in the presence of low parental warmth and/or peer rejection during middle childhood.
Another study (with 13! authors) was published in a much more prestigious journal than the previous 2 papers, and to me it was the least enlightening. The study examined the risk of DMDD in offspring of parents with bipolar disorder and found a much higher risk of DMDD (odds ratio = 5.4 "when controlling for demographic variables and comorbid parental diagnoses") compared to offspring of control parents. Given what those two other studies found, I'm not surprised that parents with bipolar disorder, one of the most severe psychiatric illnesses, would have children at risk of DMDD.

One last noteworthy paper that turned up in my Pubmed search is a recent article on whether DMDD should be included in ICD-11. The International Classification of Diseases is the World Health Organization's standard system for classifying every health problem imaginable, and the 11th revision is due in 2017. Even in the U.S., the ICD diagnostic codes are the standard for coding and billing purposes, and each DSM diagnosis is mapped to a corresponding ICD code. In this paper, the authors, who were members of a task group convened by the WHO to provide recommendations on the classification of disruptive behavior disorders, wrote:
The task group has recommended that WHO not accept DMDD as a diagnostic category in ICD-11, but rather approach the issue in an alternative, more conservative and more scientifically justifiable way. Specifically, the group has proposed that ICD-11 include a specifier to indicate whether or not the presentation of ODD includes chronic irritability and anger. We believe this option provides the most parsimonious basis for identifying and appropriately treating children with this maladaptive form of emotional dysregulation.
In my previous post on DMDD, I thought that it was overall a positive step away from the rampant over-diagnosis of pediatric bipolar disorder. But I did not end up using it; I was not about to diagnose those children with bipolar disorder in the first place. Thus, I find myself agreeing with the WHO task group. With ODD, the standard first line treatments are interventions that help parents better manage their children's behaviors and/or improve the parent-child relationship. I still worry about drug companies trying to market a medication for DMDD that supposedly targets a problem in the brain of the child. Thankfully, at least Abilify hasn't been approved yet for treating DMDD and hopefully never will, having gone off-patent this year.