A Simple Case of Depression

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

It started off as a seemingly straight-forward case, as it often does. The patient ("Kevin") was a shy, quiet 13 year-old young man, one who had "never caused any trouble," according to his parents. Until earlier this year, he had gotten straight A's, enjoyed reading, and regularly hung out with several friends. Then, during the second semester of the previous school year, he just stopped doing his homework. He also started spending more time on the computer and less time with friends. His grades dropped to C's and D's, and two weeks into this school year, he was still not doing his homework, which is what prompted the evaluation.

Talking with Kevin, his face was a blank mask. He did not feel sad or depressed, but he no longer enjoyed reading or felt motivated to do homework like he used to. He spent all his time on Facebook or playing computer games. He stayed up late and woke up early, felt tired all the time and had trouble concentrating at school. He occasionally had thoughts of not wanting to live, though he has never seriously contemplated suicide or harmed himself. He was also eating less than usual, and often had negative thoughts about himself, that he was a failure.

He clearly met the criteria for a major depressive episode, and if I were using a purely biomedical approach to psychiatry, I might have been satisfied with starting him on a serotonin reuptake inhibitor and hoping that he will be feeling better in about a month. However, his seemingly out-of-the-blue changes in mood and behavior struck me as odd. I was also struck by the fact that he was only now being evaluated, even though his grades started dropping over 6 months ago.

During the initial visits, Kevin's parents had insisted that there was no family history of any mental illness or substance abuse. They had a close relationship with their son, and they frequently went to the movies or baseball games as a family. However, the more I talked to Kevin, the more I learned about the nuances of his family. His parents were widely inconsistent in how they approached his struggles. His mother yelled at him when he got bad grades and told him he could not use the computer, while his father was more lenient, did not set limits, and even bought him an iPad after his grades started slipping. When one parent's approach did not seem to work, the other parent took over for a while, until that approach failed as well.

I spent a good deal of time talking with Kevin's parents about the importance of them both agreeing on their parenting approach, so they can set reasonable limits around electronics use and enforce bedtimes that allow Kevin to get adequate sleep. After a couple of weeks, Kevin's sleep improved, and he felt less tired during the day, but he still was not doing his homework. I continued to talk with Kevin about his family life, having him walk me through what happened in the evenings. The picture that emerged was not that of a close-knit family. Over the last few years, the family had stopped eating together at the dinner table since Kevin's father had been getting home later from work. After work, both parents tended to unwind by drinking. Their jobs have gotten more stressful in the past year, and Kevin told me that they have been drinking more as a result, at least 3 to 4 drinks per parent per night. He was essentially left to his own devices while his parents enjoyed their beverages.

I have no way of proving this, but I thought it was a strong possibility that Kevin's refusal to do homework was an attempt to get his parents to notice him and reengage with him. When I brought up the issue of alcohol with Kevin's parents, they both seemed surprised that he was aware of their drinking habits. They told me that they were doing most of their drinking when Kevin was already asleep, which really made me wonder just how much they were drinking. I did not tell them outright to stop drinking, but I asked them to think about if and how their drinking may be impacting Kevin.

After that, I never heard from them again. Perhaps I came across as judgmental, or perhaps I tried to push for too much change before I had established enough rapport with the family. But it was clear to me that Kevin's "depression" could not really improve without some serious behavior change from his parents. Sometimes I think about the appeal of simply focusing on the identified patient and what brain chemicals may be awry. But then I remind myself that complexity is what drew me to psychiatry in the first place. With a more comprehensive approach, at least I sometimes feel that I get a peek behind the curtain at what's really happening, even if I am often unable to do more to influence the outcome.

Louis C.K., Mindfulness Guru?

Note: The last couple of months have been very busy for me, so I apologize for the infrequency of posts. Now that things have gotten back to normal, I hope to resume posting weekly.

Louis C.K.'s recent appearance on Conan has already been linked to on multiple sites, with most of the headlines reading something like "Louis C.K. on why kids shouldn't have smartphones." Check out the video below if you haven't yet see it:



C.K. is one of my favorite comedians, and this clip shows why. Like many comedians, he often says things that people are thinking but are too afraid to say themselves. Here, he puts a voice to many things that I as a child psychiatrist would love to say to parents, but have a hard time finding a diplomatic way to do so.

To me, what he said is not about "hating cellphones" or "kids shouldn't have cell phones." His riff is much broader than that. He starts out talking about parenting, and how parents give in to their kids and get them phones because "all the other kids have the terrible things." Of course, this happened long before cell phones became common, and gets to the heart of how much trouble parents have in setting appropriate limits because they are afraid of momentarily making their child sad or mad. However, if a parent doesn't teach his or her child how to handle being being disappointed or told "no," then who is? Why not "let your kid go and be a better example to the other [bleeping] kids," as Louis C.K. says?

He then talks about how face-to-face interactions can help build empathy, but when a child engages in cyber-bullying, he or she does not get the feedback of seeing the other child's expression turn to sadness, and instead "when they write 'you're fat', then they just go mmm..that was fun, I like that."

Next, C.K. gets to the heart of what mindfulness is about to me. "You need to build an ability to just be yourself and not be doing something. That’s what the phones are taking away. The ability to just sit there, like this. That’s being a person." I would add that of course, the ability to just sit and tolerate being yourself was already difficult before smartphones became ubiquitous, with a 2006 Kaiser Family Foundation report showing that American youth spent almost 4 hours a day watching TV/videos, over 1.5 hours listening to music, about 1 hour on a computer, and almost another hour playing video games, with many of these activities happening simultaneously. Let's not forget all the other mindless ways of distraction other than smartphones.

C.K. even ventured into existentialism, how "underneath everything in your life, there's that thing, that forever empty…that knowledge that it's all for nothing, and that you're alone." He dares to utter the truth, long known to Buddhists, that "life is tremendously sad, just by being in it." He adds, "That's why we text and drive, pretty much 100% of people who are driving are texting…people are willing to risk taking a life and ruining their own cause they don't want to be alone for a second."

Lastly, Louis shared a story about how he was driving one day, and a Bruce Springsteen song came on that made him feel really sad. Instead of avoiding his sad feelings by texting people, "I pulled over, and I just cried…so much, and it was beautiful…sadness is poetic, you're lucky to live sad moments…I was grateful to feel sad, and then I met it with true, profound happiness." His overall message is one that I try to tell patients all the time. They often tell me that they don't let themselves feel sadness or grief, because they're afraid of feeling overwhelmed. However, attempts to suppress those sad feelings just get in the way of a person truly being content with life. As C.K. said, "Because we don't want the first bit of sad, we push it away...and you never feel completely sad or completely happy, you just feel kinda satisfied with your products, and then you die."

Despite the jokiness of the delivery, Louis C.K.'s message is quite serious and well thought-out. I hope everyone listens.

What Jean Twenge Gets Wrong About Narcissism

Earlier this week, a New York Times article, Seeing Narcissists Everywhere, featured psychologist Jean Twenge, who has documented the rise of narcissism in Millenials in academic papers and two books. She has also made numerous appearances on TV programs such as Good Morning America and Today touting her view that the promotion of self-esteem over the past few decades has led to the current generation's sense of entitlement. She bases much of her views on standardized questionnaires given to college students, especially the Narcissistic Personality Inventory (NPI).

Unfortunately, the article featured only the most superficial criticism of Dr. Twenge's work, including other researchers who "calculated self-esteem scores" over time and did not find a change, or who disagree that the NPI actually measures narcissism, or who analyzed other sets of NPI data and did not see a significant change over time. I would like to offer some more in-depth critiques. To be clear, I absolutely agree that narcissism is prevalent in our society and that it leads to a host of ills.

Endemic, not epidemic

First, I find the title of one of Twenge's books, The Narcissism Epidemic, to be deeply misleading and alarmist. According to the MedlinePlus Medical Dictionary, "epidemic" is defined:

affecting or tending to affect an atypically large number of individuals within a population, community, or region at the same time

What's "atypically large" about the prevalence of narcissism, given our status and wealth-obsessed culture? I think it would be more accurate to call narcissism "endemic" rather than "epidemic." We all have narcissistic tendencies, and to characterize it as an epidemic externalizes and puts the focus on others. It's as misguided as those "how to spot a narcissist" articles. The title also implies that Twenge has somehow discovered something new, which is certainly not the case. In 1979, Christopher Lasch published The Culture of Narcissism: American Life in an Age of Diminishing Expectations, a deeper critique of our culture that obviously predates the "self-esteem movement" of the 1980's.

More than meets the eye

Narcissism presents in more than just one way. There is the stereotypical view of a self-absorbed, overconfident, extroverted, somewhat callous individual, and this is likely the construct that the NPI measures. However, there's also covert narcissism, which is well-recognized in the literature, but which Twenge does not seem to appreciate. For example, suppose there are people who think I'm more altruistic than anyone else or no one else can appreciate the uniqueness of my suffering, or who base their sense of self-worth entirely on what other people think while outwardly appearing anxious or depressed. I would argue that these people also have narcissistic issues, even though their form of narcissism is not well-measured by the NPI or formally a part of the DSM definition of narcissistic personality disorder (NPD). Originally, the DSM-5 draft had proposed changes to NPD that encompassed the covert form as well, but ultimately (and unfortunately) those changes did not make the cut.

Beyond the explicit message

Twenge seems to think that there's a direct path from parents telling their children how special they are to the children becoming narcissistic and entitled adults. That may be true, but people are a bit more complicated than that. I won't talk about any particular person, since it's unethical for me to diagnose someone I'm not treating. But let's say there's a politician who has done little over his career other than appearing on TV and provoking the opposition. And suppose this politician admits in a major interview that when growing up, his parents were distant and far from the self-esteem boosting types. And then suppose that this man's sexually-charged text messages are released to the public and reveal a deep fount of insecurity rather than confidence.

Thus, the implicit message that children and adolescents receive from parents and from society is just as influential or more so than the explicit message. Take for example this passage from the NYT article:

 "I got a onesie as a gift that I gave away on principle," said Dr. Twenge, 41, a professor of psychology at San Diego State University and a mother of three girls under 7, in an interview at a diner on the West Side of Manhattan.

"It said, 'One of a Kind,' " she said, poking at a fruit salad. "That actually isn’t so bad, because it’s true of any baby. But it’s just not something I want to emphasize."

So she's not telling her children they are "unique" or "special." That's all well and good, but what if she's reinforcing society's message that to be successful, one has to publish best-selling books or appear on the Today show? How she handles these issues with her children is far more important than what's on the onesies that they wear. If she truly is not aware of this, then perhaps the article would be better titled: "Seeing Narcissists Everywhere, Except the One in the Mirror."

Is Psychiatry Residency Training Backwards?

For decades, the process of turning a medical school graduate into a psychiatrist has remained essentially the same: A post-graduate year 1 (PGY 1) internship that includes rotations in medicine and neurology in addition to psychiatry, followed by 3 additional years of residency training focused on psychiatry. Even though psychiatry residency programs are famously diverse, they almost always follow the pattern of mostly inpatient psychiatry for PGY 1-2 and mostly outpatient psychiatry for PGY 3-4. Child psychiatry exposure typically occurs for only a few months during PGY 2 or 3.

Earlier this year, 1Boring Old Man had an excellent series of posts that included a look back at his experience as a residency training program director in the 1970's, when he pulled his residents from a large state hospital because the experience was no longer educational. Yet most psychiatry programs across the country still have their psychiatry residents staffing inpatient units during their first two years of training, even as the length of stay at acute inpatient psychiatry units continues to decline. What does this do? I think it puts an emphasis on "medication-first" thinking, because changing some meds around (usually by adding more rather than taking any away) is really all one can do for a patient who is just going to be in the hospital for a few days.

Additionally, I believe that being exposed to the most severe mental illnesses during PGY 1-2 primes young clinicians to over-pathologize when they end up interacting with less ill patient interactions later on. Ordinary sadness or grieving may be called depression. "Hearing voices" (which is how many people describe their intrusive thoughts or internal monologues) starts to sound like schizophrenia. Mood swings or anger outbursts often get diagnosed as bipolar disorder. Of course, there are certainly other forces driving the pathologizing of normal behavior, but I do think the way training is structured facilitates this type of thinking.

Lastly, the focus on treating adult individual psychopathology deprives trainees of developing a crucial developmental and social perspective. Family therapy is something that is usually taught briefly, if at all, during the PGY 3 or 4 years. During my years of general psychiatry residency, I had the vague sense that a patient's interactions with family or her experiences growing up may have influenced her symptoms over the course of her life, but the attitude of my attendings seemed to be: since those things can't really be changed, why focus on them? It wasn't until my two years of child psychiatry training that I finally started to understand the roles that early childhood adversity and interactions amongst family members play in an individual's patterns of behavior.

I think that psychiatry residency programs would be improved immensely by earlier clinical exposure to assessing children (both "normally-developing" and ones with behavioral problems) and their families, as a counterpoint to the biomedical neurotransmitter-based framework that residents are most familiar with. This not an original idea. Other psychiatrists have suggested the same thing, including Dr. Carl Feinstein, head of child and adolescent psychiatry at Stanford (which is somewhat ironic given Stanford psychiatry's overall biological orientation). Daniel Carlat's book Unhinged proposes some more fundamental changes in the process of training psychiatrists.

Sadly, as psychiatry becomes increasingly driven by managed care, it looks like residency training will continue to languish as psychiatry departments come under pressure to increase patient volumes so they can operate in the black.

Movie Review: The Bling Ring

Sofia Coppola's The Bling Ring is one of my favorite movies of the year. Set in 2009 and "based on actual events," it tells the tale of a group of SoCal teens obsessed with celebrities and their bling, who end up stealing millions from the homes of Paris Hilton, Lindsay Lohan, Audrina Patridge, Orlando Bloom, etc. The ringleader Rebecca (played by Katie Chang) is fearless and quite possibly a psychopath. The closest thing to a protagonist in movie is Marc (Israel Broussard), a social outcast whose fortunes rise after he meets Rebecca at his new school. Also part of the group are best friends Nicki (Emma Watson) and Sam (Taissa Farmiga), and Rebecca's friend Chloe (Claire Julien).

Although the acting is fantastic, many professional film critics were lukewarm about the movie as a whole, as exemplified by the concluding paragraph of A. O. Scott's New York Times review:

“The Bling Ring” occupies a vertiginous middle ground between banality and transcendence, and its refusal to commit to one or the other is both a mark of integrity and a source of frustration. The audience is neither inside the experience of the characters nor at a safe distance from them. We don’t know how (or if) they think, and we don’t know quite what to think of them. Are they empty, depraved or opaque? Which would be worse?

Ignatiy Vishnevetsky has a similar conclusion in his review at rogerebert.com:

[...] Coppola neither makes a case for her characters nor places them inside of some kind of moral or critical framework; they simply pass through the frame, listing off name brands and staring at their phones. About an hour into the film, one starts to get the nagging feeling that Coppola's "neutrality" is a dodge; she avoids moral commitment, thereby creating a movie ambiguous enough to be interpreted in several ways, but too vague to have much meaning in any interpretation.

I disagree completely. I don't believe the movie is neutral or uncomitted at all; it is a satire aimed at not just the adolescents who browse TMZ, but also at their parents and society as well. Certainly, how I interpret the movie is a reflection of my own experiences working with families in which parents are at a loss as to how to rein in their teen's behavior. When I suggest setting some sensible limits, like no electronics after 10pm, I sometimes hear parents say things like: "That wouldn't work. He's like water, he always finds a way around things." Well, that's completely normal! The job of a teenager is to test the limits, to see what they can get away with. What's not normal is parents who cannot set limits or teach the teenager about acceptable behavior. The more the teen is like water, the more the parent needs to be like a vessel that can provide structure for the water.

In The Bling Ring, we see what happens when there is no such water container. For most of the main characters, we only get brief glimpses of their interactions with their parents, which I think was intentional, to reflect the fact that their parents are just not very involved. Katie's parents are divorced and her father lives in another state. Marc's father is often away on business. Chloe's parents are around but barely involved: there is a great shot of Chloe and her parents at breakfast, each separated from the others by the maximal distance that would allow them to still be in the same room. Sam was abandoned by her parents and adopted by Laurie, Nicki's mother. Laurie is the parent who gets the most screen time. Though she means well, she is portrayed as clueless and ineffective, a dispenser of Adderall who tries to teach her children lessons about character using a collage of Angelina Jolie photos. Instead of chastising her daughter after the teens are arrested, she tries to steal the limelight when a reporter interviews Nicki at their home.

In his review, Vishnevetsky's found the movie's use of celebrity cameos problematic:

[...] Paris Hilton and Kirsten Dunst have non-speaking cameos as themselves; more importantly, Hilton's real house is used throughout the film. The characters gawk at Hilton's real possessions and rifle through her real closets.

This points to the movie's most serious problem: the "impartial" viewpoint. Is "The Bling Ring" a movie about characters ogling at celebrities, or is it an excuse for the audience to ogle along with them? [...]

I really believe that Coppola was being subversive in her use of Paris Hilton's mansion. Sure, filming in Paris Hilton's home causes the audience to ogle, but my impression is that Coppola's goal was to show how ridiculous the place was, with its overstuffed glitz and wall-to-wall monuments to Paris herself. She returned to that location repeatedly, I believe, as a way of evoking disgust in the audience. After forming this opinion, I came across an interview that Coppola gave in which she was asked about the experience of filming at Paris Hilton's house (starting at 3:25). Here's what she had to say: "When we first got to see Paris Hilton's real house, it was like nothing I've ever seen before, and I had heard that she had a nightclub room, but then to really see it, and just all her pictures, and the pillows, with her pictures and stuff, it was very, um...exotic [shrugs]. I really appreciate how she let us into her, you know, real private world [smiles]." All that was missing was a wink.

The Bling Ring may not be a Great Movie, but it is certainly an important and alarming one. It's unfortunate that so many missed its subtly, and only 47% of film-goers on Rotten Tomatoes liked it. However, I do wonder about the reasons for audience members not liking the movie. Did it make them feel uncomfortable with themselves? If so, then perhaps Sofia Coppola has achieved her desired effect.