Reflections on a Bully From High School

Brett was the biggest jerk on my JV soccer team. He was short, stocky, and slow. Yet he also had a beautiful shot off either foot, and he was our star striker. He was the one Coach called upon to take all of our free kicks and PKs. He had more goals than anyone on the team.

I played defense, along with my friend Luke. Luke and I rarely got the chance to shoot the ball and almost never felt the glory of scoring a goal. While scrimmaging in practice, we got to spend plenty of time with Brett, since he would just loiter near the goal, never running back to help his side on defense. When the coach wasn’t looking, Brett would try to trip us or kick us in the shins, and sometimes he even jumped on my back and tried to wrestle me to the ground. During games, if the coach asked him to do something he didn’t like, he would curse and mutter insults not quite under his breath. This once led the captain of the opposing team to ask incredulously, “How can you talk to your own coach that way?”

During water breaks, Brett's favorite pastime seemed to be making fun of Luke and myself in front of the whole team. With me, Brett usually mocked my appearance, since I was very nerdy and not yet good at hiding it. There was a silly rumor going around the school that Luke had a testicle removed due to a medical condition, and Brett mercilessly and repeatedly mocked Luke by calling him “One-Ball” and telling him he would never have kids. Most of the team laughed along with Brett.

In the offseason, some of my teammates and I played on an indoor soccer team, which my dad helped coach. In the confined space of an indoor arena, Brett seemed to get even more personal with his insults. He owned the official Adidas soccer ball that my team used. He would tell me, “This ball cost $80. Since you get all your clothes at K-Mart, it’s worth more than your entire wardrobe!" Yet around my dad, he seemed more friendly to me, and I never heard him swear at my dad. On several occasions, he even said to me, “Your dad is so cool!” Back then, I interpreted those comments to be further mockery, which I did my best to ignore. Now, I’m not so sure.

My dad was a frequent spectator at my JV team’s games. He couldn’t make it to the afternoon games, but he invariably came to all of our evening and weekend games. Brett’s parents, on the other hand, were never there. From what I heard, his father was out of the picture, and his mother had to work 2 jobs to support him and his older brother, who was kicked out of high school for drug use. Brett’s brother did sometimes show up to our games, watching quietly from the sideline and usually leaving before the game was over.

There were some occasions when Brett seemed to show a softer side. During lulls in practice, I remember seeing him sometimes looking wistfully up at the sky. Out of the blue, he said to me once, “You see those birds over there? I wish I could be a bird and just be free and fly away.” At the time, I did not give a crap what he may have been trying to fly away from. But now I wonder.

I thought about Brett this week when Facebook suggested I add him as a friend under “People You May Know.” I did not. But he looked happy in his profile picture, and out of curiosity, I googled his name and found that he has moved far from our hometown, and he works as an operations manager for a fancy restaurant chain. I do not know if he has any kids, but if he does, I hope that he is able to go to all of their soccer games.

Euphoria At The Burger Joint

The line at the popular local burger joint was much shorter than usual when my fiancée and I arrived arrived with visions of freshly seared beef and milkshakes dancing in our heads. We couldn’t believe our luck: aside from the people currently ordering, there was only a middle-aged woman and a young couple standing in line in front of us. We didn’t notice anything amiss, at first.

Then I saw that the woman was not actually in line, but she was approaching the couple in front of us, apparently looking to strike up a conversation. Her hair was a bit unkempt, her make-up slightly excessive. And she was holding a thick wad of cash in one hand. She was beaming from ear to ear as she asked the couple in front of us, “Are you two on a date?”

“Yeah, it’s our first date,” said one member of the couple.

“How wonderful!” the woman exclaimed. “I can see love, and I can just tell that you two were meant to be together.”

The couple chuckled nervously, and the the woman started talking to them about the importance of Love in the Universe.

I watched what was happening in front of us with growing unease. I’ve seen this kind of irrational exuberance—and lack of boundaries—before during various psychiatric rotations, in patients who were manic or high. It usually didn’t end well. I noticed that my fiancée and I were standing closer together by now, and I glanced at her with a worried look that said, “What do we do?” She shot me a look back that said, “You’re the psychiatrist, you tell me!” We were both quite hungry, so leaving was out of the question. We stayed in line to await the inevitable.

Eventually, the woman held out a $20 bill to the male half of the couple and said, “Here, take this! I want to celebrate your beautiful young love!” As he reached for the money, the woman moved in closer, wrapping her arms around the guy and giving him a big kiss on the cheek. I think it would have been on his lips had he not turned his head at the last second. “Whoa!” he said, as he hastily backed away to free himself of her, with a new $20 bill in his hand.

Thoughts of worst-case scenarios crossed my mind. What if this lady got really agitated if we didn’t want to talk to her, or we didn’t want to take her money (or kiss her, for that matter)? I tried desperately to remember the brief training I got as a psychiatry resident on how to maintain a defensive stance when dealing with potentially aggressive patients. I stood a bit sideways to the woman, so my vulnerable belly was not as exposed. I kept my right foot, which was closer to her, pointed towards her and my weight on my left foot, in case I had to move in either direction. I crossed my arms and then pretended to stroke my chin with my right hand, so my arms would not be sitting uselessly by my side if I needed them.

Sure enough, the woman approached and asked us, “Are you on a date?”

I made sure not to look at her too directly as I mumbled, “Not really, just here for some burgers.”

Still, she held out a $20 and said, “Here, I have a present for you!” Not wanting to escalate the situation by saying no to her, I decided I might as well take it. I stuck my arm out as far as I could towards her, so that it would be more difficult for her to step closer for a smooch. I held my breath as she put the money in my hand and swiftly moved on to the next person in line behind me. “Whew,” I thought. “Guess that training really worked!”

As I looked at the $20 bill in my hand, I asked my fiancée, “What should we do with this?” Again, she would not let me off the hook. “You’re the one who took it, you decide!” I briefly debated paying for our meal with that money, but it just felt a little…crass. I paid with a credit card instead, and put the bill in my wallet. Once we got our food, I turned back towards the entrance to see what the woman was up to, but she had left, presumably to do good deeds elsewhere. I felt guilty, of course. It would certainly have been worse if she had been giving away Benjamins, but who knows what percentage of her personal savings she was wasting like this, one 20-dollar bill at a time?

But would it have made sense to call the police on her for causing a disturbance, or for sexual harassment, given her unwanted kissing? Even if they came, took it seriously, and hauled her to the nearest psychiatric ER, would there have been enough to involuntarily detain her? What if she had just won the lottery and was being very happy and generous?

Still, those burgers and shakes were tasty, and well worth the time spent standing in that particular line.

Readers, what do you think you would have done in this situation?

My Free-to-Play Gaming Postmortem

So there was this period of time from mid-September 2015 to mid-October 2017 in which I didn’t write a single blog post. What happened? This post is my attempt to reflect on my hiatus from blogging.

The most convenient answer—and the one most friendly to my ego—is that I had simply gone through some Major Life Changes that got in the way of devoting time to this blog. However, if I dig deeper, I must admit to myself that October 2015 is when I started playing a free Japanese mobile game called Puzzle and Dragons (PAD), and October 2017 was when I started to get tired of playing it; I finally deleted the game from my phone last week.

Left: A random person's monster collection. Right: a monster card in all its glory.

The basic gist of PAD is that you assemble a team based on different “monster cards,” each of which has different properties. You obtain the best cards by spending “magic stones” on a Rare Egg Machine, which pops out a random monster card at a cost of 5 stones. The stones can be earned for free by beating levels in the game or purchased for $0.99 each (or only $59.99 for 85!). With your team, you fight your way through various dungeons, doing damage to the enemies based on how many orbs of the same color you can match in rows or columns of at least 3 on the game’s puzzle board. As with any decently fun game, it felt rewarding to finally beat a difficult level after multiple tries. And the artwork and graphics, hand-drawn by Japanese artists, were top-notch. But in addition to these basic features shared with most games, PAD has many mechanisms that increase its ability to grab ahold of players’ attention, time, and money, and these psychological manipulations are very clear for me to see in retrospect.

Left: Narrowly escaped death from the enemy's attack. Right: My team doing some serious damage to Kali.

The game frequently gives away magic stones and other goodies for free, using reciprocity to make a player feel motivated (or obligated) to keep playing. Also, you get more rewards the more consecutive days you log in, which helps players make the game a daily habit à la Snapstreaks. The most powerful cards, of course, are very rare, so there’s intermittent variable interval reinforcement when you get lucky and land a good card. There are special events every few weeks called “Godfests,” which are the only times players can get certain rare cards, creating some serious FoMO. Once you’ve invested time and energy to assemble a nice collection, there’s a strong tendency towards loss aversion, as no one wants to feel like they’ve wasted all this time for nothing. Since most of PAD’s players are young men, many of the most desirable cards feature scantily-clad female characters, a.k.a. “waifus.” And there’s a community aspect as well, with multiple forums devoted to the game where players share their accomplishments and good Godfest luck, leading to upward comparisons and social reinforcement.

Despite all that, I’m not sure I would say that I was addicted to the game in a clinical sense. I was spending ~30-60 minutes a day playing the game, and maybe another half hour a day reading about it. My personal relationships and work did not suffer, as far as I can tell. Over the course of 2 years, I spent a grand total of $10 on in-app purchases of magic stones. On PAD forums there are reports of “whales” who've spent upwards of thousands of dollars on the game, so I got off relatively easy, at least in a financial sense.

Still, how PAD affected my mind is undeniable. Instead of reading blogs related to psychiatry and mental health, I was reading blogs and watching YouTube channels related to PAD. I stopped even thinking about my blog, and every time I had a spare moment, I would open the PAD app instead of taking in my surroundings or reading a book. In fact, I read far fewer books in 2016 and 2017 compared to any other year in my life since I learned to read, though part of that may be due to reading more on the web. It wasn’t all bad, though. I wasted far less time on Twitter, and I was no longer waking up in the middle of the night with ideas for blog posts. I had a convenient and pleasant distraction from politics. And I’ve spent much less mental energy these last 2 years obsessing about my fantasy football teams than I have in previous years.

So what finally made me stop? A part of it was the fact that PAD’s creators are constantly adding more difficult dungeons, which in turn require ever more powerful (and rare) monster cards to deal with. Playing the game started to feel increasingly like a Sisyphean task. I’d also like to think that a part of me missed blogging and reading books. Recently, I came across the philosophically-oriented Slate Star Codex blog, written by a young psychiatrist, and I thought, “If he can write several 2000 to 5000-word blog posts in a week, then why can’t I be even 3% as productive (i.e. roughly a 1000-word post per month)?”

Lastly, some advice for parents out there: as fun as Super Mario Bros was for us in our youth, it does not remotely compare to the reinforcement mechanisms that today’s microtransaction-driven mobile games employ. I’ve heard multiple stories from parents about their kids stealing their credit cards to spend hundred of dollars on in-app purchases for games like Clash of Clans and Clash Royale. I now believe that parents should not be letting their kids play games like these, which all tend to use similar attention and money-grabbing tactics. As a general rule, this applies to any of the mobile games that you see advertised on TV; how else would those game companies have so much money to spend on prime time ad spots? Recently, regulators in The Netherlands have started investigating whether games that have “loot boxes” (a similar idea to the Rare Egg Machine) are a form of gambling and should be regulated as such. In my mind there is no doubt that these games can work very similarly to gambling, except you can’t actually win any money, so it’s in a way worse than gambling.

Even if there are kids who can responsibly play these games without spending too much time or money, I would still strongly suspect that these games have an outsized influence on what their players think about—and stop thinking about—even when they’re not playing. And for me, that was ultimately the biggest negative impact.

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.

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:

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?

Like Water

The flustered mother told me this about how difficult it was to get her school-aged son to do what she wanted: "He's like water. Whatever I try to do, whatever rules I set up, he finds a way around them."

I said, "Well, that must be very frustrating."

Here's what I wish I had been clever enough to say to her instead: 

"You're right. Kids are a lot like water. The harder you try to grab them, the more they slip through your fingers.

Like water, kids can mirror their surroundings. They are given shape by their environment, while over time they are also shaping the environment.

Similar to water, kids can exist in different states. Too much heat or too much cold, and they may become explosive or get more rigid and brittle.

Water is very resilient. Most of the time, like water, kids can return to their previous state after a perturbation if the environment allows it.

It always takes energy to change the flow, the direction, the trajectory of water. Otherwise it just follows the path of least resistance.

Just as you can make water move against gravity through capillary action, giving the right scaffolding for a child can make all the difference. 

While water running rampant can be destructive, water put to purpose can do immeasurable good.

So you're absolutely right: your child is very much like water. Now what shall we do about it?"

My Favorite Blog Posts From 2013

As we approach the new year, I would like to reflect on some of my favorite posts from 2013. If you're new to this blog, I think these articles should hopefully give you a sense of what I enjoy writing about. Here they are, in chronological order:

A Most Influential Professor (5/19/13)
I probably would not have become a psychiatrist if not for how my undergrad Abnormal Psychology professor made the class so fascinating. And yet, the more I learn, the more I feel he had a very limited perspective.

Psychiatry Leadership: Uneasy Lies the Head that Wears a Crown (6/7/13)
I was disappointed — but not all that surprised — by how much more cogent psychologist Gary Greenberg was compared to APA president Jeffrey Lieberman and NIHM director Thomas Insel during an NPR Science Friday debate about the DSM-5.

A Chilling Encounter (6/11/13)
A story about interviewing a teenage psychopath in the psych ER. I hope I was able to convey why I felt chills down my spine during the encounter.

Movie Review: The Bling Ring (7/12/13)
I really enjoyed this movie and found it to be a funny satire of adolescent vanity and vapidity. I was surprised that some reviewers thought Sofia Coppola took a neutral stance toward her subject matter. I thought she was anything but neutral, and I even found some YouTube evidence supporting my view.

Hmm…looking at this list, perhaps I should stick to blogging during the spring and summer months…

Thanks to everyone for visiting this blog, and I wish you all a Happy New Year!

The Wizard: Psychopharmacology Magic?

One of the most memorable psychiatrists that I worked with as a trainee is someone I think of as The Wizard. He specialized in treating some the most difficult behavioral manifestations of autism and other genetic conditions like Fragile X syndrome. He had a magical ability to calm even the most agitated children and adolescents and seemed to inspire reverence and awe in their parents, who kept voting him to the top of various "Best Doctor" lists.

What most amazed me about The Wizard was his Zen-like serenity. Regardless of how much noise the patient was making or how many toys went flying around the room, he would be like the calm eye of the storm, holding still while everything else moved around him. His gaze was remarkable, intense yet warm and soft, like a bright candle. He would focus intently on whoever he was talking to, making that person feel important and special. His voice was smooth and soothing, almost soporific; perfect for those in emotional distress.

He took no notes during the appointments. His dictated progress notes were usually just a couple of paragraphs long, without pesky details like what medications the patient was taking and what medication changes were made during the visit. However, he did not have to remember those things. During the visit, he would shine his bright gaze upon the parents and say, "So tell me, what did we decide to do with the medications last time?" And the parents always provided the details. Maybe they knew that they would be quizzed this way, so they prepared so as to not be embarrassed. More likely, I think the parents were pleased that this eminent psychiatrist trusted them enough to empower them in this way.

The Wizard was an expert psychopharmacologist, often prescribing medications that I've seen no other psychiatrist prescribe. Things that may have had success in case studies, but no positive clinical trials (and maybe even some negative ones). Yet for him, he was able to get results using those medications. Perhaps he was lucky, or with his experience he was able to intuit the right medication for a certain patient. However, I firmly believe that just being in his presence was one of the major therapeutic interventions that he provided for his patients and their parents.

I attempt to channel him during every patient encounter. But try as I may, I can't help but continue taking notes while talking to patients and then writing overly detailed progress notes.

Losing the White Coat Part 1: Medical School

This is part 1 of a series on the evolution of my approach to psychiatry. For background, I recommend reading A Most Influential Professor, which is essentially part 0 of this series.

Just about every medical school has a traditional white coat ceremony, during which the incoming class of medical students get their shiny new white coats that they will then wear throughout the rest of medical school during clinical experiences. At my school, the ceremony came with a recitation of a modified Hippocratic oath, adding to the gravitas of the day and helping us reflect on our future roles as healers and doctors.

The psychiatry faculty and residents at my school made it a point to insist that they were “doctors first." As medical students, we were repeatedly told about the contributions our institution made to modern biological psychiatry, and how it was a bastion of biologically-minded psychiatrists even during the era when psychoanalysts dominated psychiatry.

It was not surprising, then, to see psychiatry attendings walking around the hospital and lecture halls wearing their long white coats. Even the lone psychologist that taught some medical student lectures wore a white coat when he was in the hospital.

However, something always felt amiss with this biomedical aura. The psychiatry attendings were very quick – too quick – to defend the medical-ness of their specialty. I was told on multiple occasions that the arbitrary diagnostic criteria used in the DSM-IV are no different than the cutoffs used to define blood pressure in hypertension or glucose levels in diabetes. However, despite the prominent role the school's psychiatry department made in establishing biological psychiatry, physicians in other specialties there did not seem to respect the psychiatrists very much. The psychiatry interns took care of fewer patients on their Internal Medicine rotations than the medical interns, yet the psychiatry program director always insisted that the psychiatry interns performed just as well as the medicine ones.

As a third year medical student, I did my psychiatry rotation in a publicly-funded mental hospital, wearing my white coat just like the residents and attendings. There certainly were cases in which something clearly biochemical was going on in the brain of my patients, such as when a young man came into the ER hearing voices and feeling very paranoid after using a large amount of cocaine. I got to see antipsychotic medications help some patients with schizophrenia, but only so much, and with obvious side effects. There was clearly a vast gulf in understanding between the psychiatrists and patients, with the psychiatric residents spending minimal amounts of time with their patients and going home by 3pm each day. I was not sure how much wearing a white coat contributed to this distance or if it was mostly due to the culture of the place, but it certainly did not help foster empathy.

There were many other cases that left me feeling uneasy. As a fourth year medical student on the consult service, I accompanied a psychiatry resident when he evaluated a patient for suicidal thoughts. Afterwards, he told the primary team, "Don't worry, he's just a boy borderline." The attitude seemed to be that this patient would not actually harm himself because he was just "being manipulative," or that personality disorders somehow were not real, perhaps because there was nothing "biological" that could be done.

I did have a great experience working with the child psychiatrists at my medical school, who because of their specialty necessarily had to take a more holistic view of things. But even so, they tended to focus on the children as individual entities, without deep thought given to how interactions with parents influenced the children's behaviors.

When I asked the program director about learning psychotherapy as a resident there, I was told by that they don't really teach psychotherapy, because that is not going to be part of the job of a psychiatrist going forward. I would learn enough to know what kind of psychotherapy to refer a patient for, if it were necessary. Talking to the psychiatry residents though, some of them clearly wished that they had more psychotherapy training, so they could be more complete and competent clinicians.

I knew as a medical student that this approach to psychiatry was not for me. I would go elsewhere to continue my training.

A Most Influential Professor

On the first day of Abnormal Psychology class, The Professor sat on stage, just him with his cane, no notes or Powerpoint. His jowls hung low, giving him a bulldog look. Instead of appearing mean, however, he seemed almost bored, in a wizened sort of way. The Professor began by asking the class to come up with all of the different names that exist in our culture for someone who is "crazy." Students got into it, enthusiastically shouting out dozens of nouns, ranging from the clinical (psychotic, delusional) to the pejorative (nutso, wacko). A graduate assistant wrote all of the words down on a chalkboard while The Professor continued to sit, expressionless. There were almost 50 words on the board by the time people started running out of ideas. "What is the purpose of all these words," The Professor asked us, before answering himself that they are labels, used by those who were "well" or "normal," to define those who were "not normal."

He proceeded to launch into an explanation of his background. "I am an insight-oriented object-relations psychodynamic psychotherapist," he began, and while I had no idea what that actually meant, I was impressed by his certainty. Mental illnesses, he explained, are nothing like physical illnesses. Psychiatric labels are cultural inventions, a "word game" that cannot be separated from the time and the place in which those words originated. "I do not believe in biological reductionism or determinism," he continued, speaking in composed paragraphs to students who were used to hearing bullet points. He lamented how biological treatments have taken over much of mental health, and he told us that we would spend little class time covering conditions like depression, anxiety, or schizophrenia. Instead, he focused on conditions for which there were no medications (at least at the time): Conversion and other somatoform disorders, dissociation, addictions, eating disorders, and of course, personality disorders.

Over the course of the semester, The Professor repeatedly emphasized to us that human traits are on a continuum, even though the DSM tried to fit everything into discrete categories. He used his own dimensional scale to rate each patient on various traits such as impulsivity, neuroticism, and even adaptive regression in the service of the ego. He staged live demonstrations in front of the class in which he interviewed actors trained to portray patients with various psychopathologies; the auditorium was so crowded on those days that I'm convinced he could have sold tickets.

The Professor told us many stories, colorful and memorable. He mesmerized us with tales of 18th century mass hysteria. He lectured authoritatively on the superego lacunae present in those with narcissistic and antisocial personalities, and I could not help but visualize Swiss cheese. He recounted many of his own experiences with patients, especially those with histrionic and borderline personalities, whom he described as very "kiss kiss bang bang." Though I missed the James Bond reference (there was no Google back then), that description still strikes me as particularly apt.

Of course, The Professor was far from infallible. Humility and self-doubt were not part of his repertoire. He was prone to broad generalizations, delivered matter-of-factly: Bulemics were histrionic and attention-seeking, while anorexics had more severe super-egos and conflict with their mothers. Women who were sexually abused as children became obese as an unconscious defense against further advances. People who suffered severe enough abuse could develop multiple personalities as a way of coping. The Professor, after the first day of class, never stooped to acknowledge any other perspectives besides those which he knew to be true.

A friend of mine, who took Abnormal Psychology with a different professor, hated the class because his professor treated the DSM diagnoses as if they were naturally-occurring phenomena like planets or animal species. Looking back on my journey through psychiatry, this was often the perspective of the teachers I had from medical school onward. Therefore, I'm especially glad I had The Professor so early on. He was not a big name at the university, as a clinical psychologist in a department filled with researchers and "cognitive neuroscientists." Yet he has influenced me more than anyone else with regard to how I think about psychopathology and psychiatric diagnosis. In particular, the dimensional system just made sense. The DSM-5 even incorporates some dimensional scales to rate symptom severity, though I was disappointed when the APA Trustees voted down efforts to add a dimensional element to personality disorders in DSM-5.

I also learned from The Professor the importance of recognizing the limits of our knowledge and perhaps why psychoanalysis had fallen out of favor, even though those were not lessons he was explicitly trying to teach.

Challenges of Psychiatry Blogging: Why Start? Why a Pseudonym?

This is part 4 of my series on the challenges of psychiatry blogging. Previous posts covered content, audience, and design.

Why Start?

I'm sure everyone who blogs does so for intensely personal reasons; thus, I will not speculate on anyone's motivations but my own here. I've always enjoyed writing but have not done much of it since college. I enjoy reading other psychiatry and neuroscience-related blogs, and I've long wished that there were more blogs focused on the many important issues related to child psychiatry. Eventually, I decided to start a blog myself for that niche. I hope to be critical in the sense of "involving skillful judgment as to truth, merit, etc.; judicial," rather than being "inclined to find fault or to judge with severity, often too readily." Though I've focused a lot on the DSM thus far, it is no accident that my first post was a movie review, and I hope to write about a broad range of topics, including vignettes from my own clinical experiences.

Why Now?

Why did I choose to start the blog last month, instead of at some other time? This question is harder to answer, and so let me examine it as I would any complex human behavior. Could it be that some life change increased the free time I have? Could I have been inspired by reading other blogs and being caught up in the zeitgeist with the DSM-5 about to be released? Is it that I finished writing a self-reflective piece offline, and encouraged by how rewarding it felt, managed to overcome previous inertia? Does it have anything to do with the fact that, after having knee pain for the last few years, I finally found a way to deal with the pain in April, thus allowing me to run again (and I'm getting good ideas while running)? Could it be the increased daylight and seasonal change helped me be more alert and focused? Is it that I've been drinking stronger coffee? I can't give you a simple explanation for why now, except to say it's likely a combination of several of those factors.

The Name Thing

Why am I using a pseudonym instead of my real name? Well, first let me say it's not so that I can vent my frustrations or write mean things. I'm more likely to use profanity in real life than on this blog. I'm fully aware that there is no true anonymity on the Internet, so I write everything as if it were under my actual name. I treat a blog post like I would an essay, refining each one until I am somewhat satisfied with the result.

Neuroskeptic has actually written a paper on the topic of anonymity in science, and how it can "facilitate the free expression of interpretations and ideas, and can help to ensure that suggestions and criticisms are evaluated dispassionately, regardless of their source." I'd like to think that's one of the main reasons why I use a pseudonym. Another reason is simply convenience. It's much easier for someone to Google "psycritic" to look up my blog (as well as my comments on other blogs), than to search for a name that belongs to many people. It helps me compartmentalize; though my patients are unlikely to bring up this obscure blog, I would still prefer to not have to chat about the blog during our sessions, and instead focus on what is going on in their lives.

Lastly, we come to the name itself. Why Psycritic? Well, as I said on Twitter:

Hoping to have a productive time blogging, emulating @neuro_skeptic & @neurocritic, with an emphasis on child & adolescent psychiatry.
— Psycritic (@psycrit) April 28, 2013

What can I say? It's certainly not original, but the domain name was available. Now, we just need a psychskeptic who blogs, and we'll have a complete tetrarchy!