Losing the White Coat Part 2: Residency

This is part 2 of a series on the evolution of my approach to psychiatry. Part 1 was about my medical school experience, and A Most Influential Professor described a key experience I had in college.

I went into psychiatry because I was fascinated by the variety of human emotions, behavior, and psychopathology, and I wanted to explore the plethora of influences (cultural, social, psychological, and biological) on those aspects of humanity. My medical school emphasized the biological approach, so I decided to continue my training elsewhere for residency.

At my residency program, while there was more of an emphasis on psychotherapy compared to my medical school, the biological psychiatrists still reigned supreme. The university had some well known psychotherapists, but they tended to have titles such as "emeritus professor" or "clinical professor," meaning that they were not around very much. And I doubt they would have felt welcome, with the residents' main jobs being completing paperwork and adjusting medications during the majority of their rotations, rather than running groups or conducting therapy.

It was easy to see who the big money-makers of the department were: the researchers who focused on the neural basis of mental disorders while providing biological treatments in their clinical practice. There was a bipolar disorder expert, who once had a patient on 10 different medications, to the point that it was impossible to tell what was the patient's "disease" and what were the side effects. There was the schizophrenia expert who headed the locked inpatient unit, who frequently gave talks to psychiatrists in the community advertising the newest antipsychotic medications. She claimed that because she was on the speaker bureau for all the big pharma companies, she was unbiased in her assessment of the medications. And then there was the renowned depression expert, who once told us, "Even if the medications are no more effective than placebo, it doesn't mean that you shouldn't treat the patients." Make of that what you will.

However, the experience that opened my eyes most to the flaws of a purely biological approach to psychiatry was what I saw happening with Dr. Z, one of the psychiatrists on the electroconvulsive therapy (ECT) service. He gave great lectures, drawing up pretty diagrams of the circuits in the brain believed to underly mood and depression. Unlike most psychiatrists, he often walked around in scrubs, and he had a confident charm to go along with a cheerful disposition. Perhaps appropriately so, since he offered a treatment unparalleled in its effectiveness for patients with severe psychotic depression and bipolar disorder.

The problem, though, was that the bipolar disorder diagnosis (and its attendant "treatment resistant depression") became so loosely applied that practically anyone with mood swings was being diagnosed with "bipolar II," and Dr. Z fully embraced this trend. His evaluations for whether a patient was a good candidate for ECT were thorough, to a point. There was meticulous documentation of the medications that the patient has tried and the inadequate response to them. Mostly ignored, however, were details about what the patient's life was actually like and what factors may have been influencing their symptoms. Thus, plenty of patients who clearly had borderline personality disorder (BPD) were deemed "excellent candidates" for ECT; none of the depression medications that they had tried ever did lasting good, since their moods would turn depressed or irritable in response to interpersonal stress, regardless of what meds they were taking.

I remember hearing two stories in particular about his patients (details altered to protect anonymity). One day, a patient of Dr. Z's arrived in clinic holding a knife to her chest after her boyfriend broke up with her. She told the astounded clinic receptionist that she would stab herself if she did not see Dr. Z right away. Dr. Z was not in, and the patient ended up walking into the office of another psychiatrist, who managed to calmly talk her down while security was notified. Another time, a patient was dragged kicking and screaming into the ER after swallowing a handful of pills during an argument with her husband. She was heard yelling, "I'll only talk to Dr. Z! Where is he? I know he's coming because he loves me!" Dr. Z clearly had a profound effect on his BPD patients, even if the benefits of ECT for those patients was very temporary.

Recently, I read Dr. David Allen's post on the difference between the symptoms of major depression and the depression often seen in BPD. But even back then something felt off to me about doing ECT on patients who had "treatment resistant depression" because of a personality disorder, which brings me back to the title of this post. At the institutions where I trained, the psychiatrists who wore the white physician's coats, not surprisingly, tended to be the more biologically-oriented ones. Thus, in my mind the white coat became associated with their view of psychiatry, one that I did not share.

Thankfully, my mind was already set on being a child psychiatrist. At least in the world of child psychiatry, despite the influence of biological psychiatrists like Harvard's Biederman, many (I don't dare to claim "most," given the direction things seem to be heading) child psychiatrists still consider the influence of things like family, parenting, and developmental trauma on behavior, rather than just focusing on figuring out the black box of the brain.

Putting a Dent in the Universe, One Way or Another

The two men's personalities were more similar than different: both were temperamental, easily slighted. They had similar views of themselves, believing that they had a special purpose in life. Both clearly burned with a desire to shape history.

As young men, both embraced alternatives to mainstream culture: one became a hippie, the other a Marxist. One travelled to India looking for enlightenment, while the other went to the U.S.S.R. in search of a communal utopia. They both returned to the U.S. somewhat disillusioned. 

They could both be quite cruel and controlling: one was known for tearing down subordinates and once implied that the mother of his child was a slut, saying "28 per cent of the male population in the United States could be the father." The other one beat his Russian wife and refused to allow her to learn English.

They both ignored reality, but whereas one was famous for his "reality distortion field" in which he would convince not only himself but also everyone around him that the impossible could be achieved, the other only distorted reality for himself: upon returning from Russia, he was surprised that the press was not waiting for him at the airport to hear his story. His wife later told investigators about "his imagination, his fantasy, which was quite unfounded, as to the fact that he was an outstanding man."

One of these men founded a company by the time he was 21 and became a multi-millionaire at the age of 25. He then went on to reshape the personal computer, animated film, music, and telephone industries. The other also made his mark, on a tragic day in November, and would be dead at the age of 24 fifty years ago today.

So what made their life stories so different? Was it because one of them was more intelligent than the other? Was born with more innate charisma, a better aesthetic sense? Or was it parenting and the environment where each grew up? One was adopted shortly after birth and raised by middle-class parents in a stable home, while the other's father passed away 2 months before he was born. His overwhelmed mother put him and his siblings in an orphanage, then later moved with him across the country, worked long shifts, and left him to fend for himself. He went to juvenile hall for truancy, and his social worker there thought he conveyed "the feeling of a kid nobody gave a darn about."

Looking back on history, one can never be sure of causation. But I can tell you with certainty that childhood matters. Growing up in a safe environment with loving family matters. Having nurturing adults who support a child's interests matters. I wish that all of the attention given to Lee Harvey Oswald and the Kennedy assassination in recent weeks had focused less on the final act of the shooter and more on the formative years that shaped him. As Steve Jobs once said:

I'm 100% sure that if it hadn't been for Mrs. Hill in fourth grade and a few others, I would have absolutely have ended up in jail. I could see those tendencies in myself to have a certain energy to do something. It could have been directed at doing something interesting that other people thought was a good idea or doing something interesting that maybe other people didn't like so much. When you're young, a little bit of course correction goes a long way.

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."

A Chilling Encounter

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

Late one afternoon, I got a page from the emergency room about a 14-year-old male who was in for a suicide attempt, who was medically stable and ready to be interviewed by a psychiatrist. When I arrived at the tiny conference room adjacent to the ER, I was expecting the typical morose teenager, full of emotional turmoil. Instead, this young man looked at me calmly and nonchalantly, smiled, and said hello. He was thin and looked like he could be 12 or 13, dressed in a polo shirt and khaki shorts. He would not have seemed out of place in a Boy Scout uniform.

I started with the obvious. How did you end up in the ER today? He told me that he had tried to end his life earlier in the day by hanging himself, only to be discovered when his father got home early from work. Has there been anything stressful going on in your life? Yes, he said. Several weeks ago, a little boy had reported him for molesting him. When the police investigated, they eventually discovered several other young boys in the neighborhood with similar stories. Somehow, a judge had allowed the teen to remain in the custody of his parents while he awaited his sex offender psychological evaluation.

He seemed at peace, and neither the crowded space nor the noisy environment fazed him in the least. I tried my best to keep a poker face as I continued asking the standard questions. Have you been sad or depressed? No, he said. He'd been in a good mood all summer, even after the accusations surfaced. He has not lost any interest in enjoyable activities. How's your sleep? He slept very well, at least 8 hours a night. Appetite? Good. Any guilty feelings or negative thoughts? Nope. So how did you decide that today was the day to die? He had just finished the last book of a popular young adult series. "I finally got to see how that story ended, and it was very satisfying. Then I decided, I might as well kill myself so I don't have to go to jail."

I kept searching his face for any sign of tension, doubt, or guilt. There was none; he might as well have been chatting with a friend about his favorite video game. In the back of my mind, I wondered if he could detect that I was more uncomfortable than he was.

He told me that he had a normal childhood, that he got along with his parents, and that he was never mistreated or abused in any way. Do you have any friends your age? Instead of answering the question, he mentioned that he was on the golf team for his school and he got along fine with his peers. Are you attracted to males or females your age? "No, I only go for the younger ones." Any reason you targeted those particular children? He looked straight at me and said, "I take whatever I can get," sending shivers down my spine.

Later, I interviewed his mother and father, who seemed like nice, normal suburban parents. They both appeared stunned, uncomprehending. I felt sad for them, yet I was also glad that their son was caught when he was 14, rather than when he was 40 or 75. I could not decide whether it was a good thing or a horrendous thing that he made no effort to deny what he did. Or perhaps he just wanted to appear honest to hide even greater atrocities.

Did I end up admitting this "patient" to the psychiatric unit? I would have preferred to send him straight to juvenile detention, but the hospital had a protocol: A serious suicide attempt like his had to be admitted if there were beds available. As a service to the community, of course. Even better, I had to admit him under a diagnosis of "depression not otherwise specified," since the hospital could not get reimbursement for an admission diagnosis of pedophilia. Walking out of the hospital that evening, I was glad to see the sun still visible low on the horizon, and that the darkness had not quite set in yet.

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.