Monday, May 23, 2011

Infertile mothers becoming pregnant after adopting a baby

In my practice I have come across two women who could not conceive for a very long time until, giving up all hopes, they adopted a baby, and lo and behold, within months found themselves pregnant.

The immediate explanation that comes to mind is that taking care of a baby aroused their maternal instincts and changed their hormonal status and made them more pliable to conceive.

But there was something else, at least in one of them for sure, that raised questions in my mind whether in some women psychological, and not biological, factors do not play more important role as to why they cannot conceive.

The person whose case I am describing had been infertile all her life, and had adopted a new born, her nephew, in early forties, and after doing so, had become pregnant in matter of months.

Observing her I sensed that she had not conceived all her life because she greatly doubted her ability to be a mother. She grew up in a very stressful household where both parents suffered from mental illnesses. This factor though spurred her to become a successful show woman, it, at the same time, implanted self doubts as to her ability to be emotionally available to others, other than as a performer on stage. She feared she will be detached from her child, will not be able to give emotional warmth, will not develop tender bonds, and may actually hurt it. She had many traits of obsessional neurosis.

None of these fears proved to be true with her adoptive child. Perhaps because she did not feel any special obligation to be the perfect mother with someone who was not biologically hers and in whose case she felt she was doing a favor to someone else by taking care of him.

I have often wondered whether it is not such obsessive self doubt about one's ability to control hostile impulses towards one's children that lies behind so many women's inability to conceive. This factor also may be present in those men who never venture into parenthood or at least postpone it till late in life.

Only when they adopt a child and find how joyful parenthood is and that the thought of hurting the child is hardly present when interacting with the baby, and how happy the baby is from the attention and love it is receiving, that many women become fertile and conceive a child.

In olden days people lived in extended families or at least close knit communities and girls grew up taking care of relatives and friends children. This melted away their exaggerated fear of their destructiveness towards their helpless baby. It should not surprise in past centuries infertility was rare.

I wondered too if such obsessive doubts about being a good parent does not lie behind Post Partum Depression. Here of course the baby is one's own and already born, nevertheless, the fear that one could harm it prevents one from taking up the role of motherhood. The psychodynamics of post partum depression is, of course, more complex and the factor of sacrificing one's child to one's own mother - here one is reminded of the Hindu practice of sacrificing one's child to Kali, the mother goddess, for propriation and prosperity- for getting something even more precious in return, comes in as well. Nevertheless the fear that one may harm one's child lies behind post-partum depression too. The depression is triggered by unconscious defense mechanism to put a lid upon the impulse to harm.

Sunday, May 22, 2011

Stomach grumbling [borborygmi] not an indicator of hunger but nerves/somatic anxiety

My stomach often rumbles, grumbles, gurgles, growls, the choice of verb depends upon who is listening and how he or she wants to describe it. Medical people pompously call it borborygmi. There is lots of money in converting simple words to medical tongue twisters.

If this happens while I am seeing patients, it generally causes mild amusement and sometimes uneasiness. For Americans find the rumbling of stomach as something to be embarrassed about. No doubt, because the noises are emerging from the GI tract, and that naturally arouses associations with other functions of that organ which must be hidden from the public. To cover up this embarrassment, patients invariably remark, jocularly of course, that they need something to feed their stomach. It is interesting in this context they usually talk about their stomach as a separate entity and in the third person. As if something you are embarrassed about you want to disown and not be a part of.

For example, yesterday, a patient remarked with considerable consternation at his rumbling stomach , "Man, this stupid thing is growling like a dog that just got a beating."

When I tell them that the stomach growling has very little to do with hunger and is actually the result of nerves which are finding discharge for the tension through [involuntary] muscles of the intestines, they do not believe me. Even if I tell them I just had my meals, and in my case the stomach growling occurs more often after a meal than before, they don't readily accept it.

For the belief that stomach rumblings are due to hunger is part of the American folk wisdom.

But an occasional patient will show courage, and go beyond her belief system, and rely upon her observations to come to the right conclusion. An obsessional neurotic lady, who must apologize for everything as a compensation for her obsessive acts and as a means to allow the pangs of her conscience to emerge as pangs of intenstinal contractions, could not tell me enough in the session as to how embarrassing those sounds were. "I don't understand why I am having this when I could swear to you that I just ate. It shouldn't be doing that. My stomach has no business going to town like that."

["Going to town" phrase specifically arose in her mind because her unconscious wish, the chief factor behind her neurosis, is to have sado-masochistic tryst with whoever crosses her path in the streets of her town. She suffers from agoraphobia as a consequence of this unruly impulse, though she is completely unaware of such a tendency in her in her conscious mind.]

Another patient had it clearly figured out that her stomach noises were a reflection of anxiety. "I get frank anxiety attacks over it. When the gurgling is going on, I feel nauseous, my stomach feels tense as a drum and I worry if my appendix is going to burst. I can tell when my panic attack is about to occur. I feel its aura in my stomach."

It is interesting when one person's stomach is making noises, the person hearing it often responds to it by starting the same reaction in her intestines; like an involuntary sympathetic response to the nervousness of the other person. Not unlike how if one person yawns the ones watching him start doing the same.

One of my patients when I told her that stomach rumblings is due to anxiety, vigorously disagreed, and insisted that it is due to hunger, but confirmed the correctness of my observation by starting the rumblings of her own stomach, about which she felt very embarrassed, for she had to admit that whatever was causing it was not so much an organic process as psychogenic, for not a trace of it was present till we began talking on the topic.

On reading the Wikipedia I find that this noisy behavior of intestines is attributed to normal aspect of digestion.

I beg to differ. I think all that loud noises the stomach makes has less to do with digestion than an increase in intestinal motility due to nerves. We do know that when a person is highly anxious it gives him the "runs". In fact there are all kinds of colitis from Irritable Bowel Syndrome to Ulcerative Colitis which have at its root an attempt to symbolically get rid of whatever is causing the stress. The movement of intestine which goes beyond the function of digestion is primarily an attempt to get rid of stressful people, who are active in one's life at that point, by unconsciously treating them as pieces of shit which need to be evacuated out of the system via the excretory organ.

Depending upon how much stress one has, one can have a continuum of GI irritability - from simple borborygmi to deathly ulcerative colitis.

In this context one way mention that human flatulence also often is a symbolic attempt to blow away the hated stress-producing objects. People who complain of "gastric trouble" and are full of gas are really using the GI tract to get rid of stress. They constantly produce gas which causes discomfort - symbolic of the distressful stress in their lives - and then release it in flatulence, which gives relief - symbolic of getting rid of the stressors. It should not surprise us that a person in stress often has more urgent and more smelly flatulence. As if more stressful the world quicker and stinkier is our response to it.

It may not be inappropriate to add here that the relief from such a self created intestinal bloating through flatulence produces pleasure and release of dopamine in the reward centers, which must reduce the pain of the stress that one is experiencing in some other part of the brain. So the reason d'etre of this psychogenic overactivity of the GI tract is to produce pleasure to counter the harmful effects of stress. The whole process is not too different from how under stress we eat to produce pleasure, dopamine release and reduction of stress.

This role of flatulence as a stress reliever I can frequently confirm in my own self. I have found that if someone cuts me off on the road, or irritates me in some other way, and I can do nothing about it, like give him the "finger" - the jerks make sure to avoid your gaze after intruding into your space behind the safety of their car - after a little while, I develop a slight discomfort in my chest which rapidly changes in to a queasiness in my intestines. The psychological feeling accompanying it is as if I am bloated and carrying excessive baggage. Then I perceive the urge for flatulence, which when indulged in, takes away the discomfort and along with it the perturbed mood, anxiety and the anger towards the piece of shit who had cut me off. The whole process seems to me as a method which my system utilizes to take away the tension off my chest back to the outside world from where it came, accomplishing it through the medium of my bowels .

So intestines play a huge role in us to discharge anxiety through somatic means. And it is not just from lower GI tract. The upper GI tract with churning and butterflies in the stomach does the same thing. And they all make a racket while doing it, which we euphemistically believe is taking place due to simple hunger.

Saturday, May 21, 2011

Schizophrenia a disorder of complexity that is showing disintegration

Over the years after seeing thousands of schizophrenic patients, I feel it is less of an illness and more of a disintegrative process where the person ceases to be a unit. Living organisms are basically conglomerations of ever smaller entities that have their own goals, side by side with the goals of the being as a whole. In schizophrenia the various components of a person start going their own merry way regardless of what is good for him as a whole. It appears that humans once they cross a threshold of complexity cannot prioritize and organize the demands of their various components effectively and a disintegrative process sets in. Schizophrenia appears to be the such a disintegrative process in the mental sphere.

Living organisms constantly, as an evolutionary process, try to accumulate new attributes for better survival. This is done primarily by entering into symbiotic relationship with other living entities. For biological survival is not just about strife with other living organisms but also, when strife with another organism turns into a stalemate, about entering in to cooperative relationships with them, sometimes permanent ones that makes one out of the two. But this cooperative complexity of a living unit can only go to point before the disintegrative process sets in. Schizophrenia appears to be a disorder where due to generations of natural selection the person is born with so many mental drives [attributes] that he fails in the task of giving them proper sequential expression and lets them go their own way.

In a living organism, with increasing complexity, the co-existing subunits have to progressively relinquish, or at least dampen, their own priorities to accommodate the urgency of the entire organism. Without such cooperation and order there would not be harmony in the functioning of the organism as a whole.

An example would be of the digestive and muscular systems. While an organism is hunting a prey, or escaping a predator, the digestive system comes to a standstill. Everything is then about the muscular system; there is no hunger, no thirst, only running and running. After the kill and a satisfying meal, the blood is now primarily directed towards the intestinal tract and the voluntary muscles lose not just their tonus but do so to an extent that immediately after the meal the animal falls asleep.

Even within a system there are subsets which have to accommodate each others' quasi-independence. When the blood flow is to the mouth, gullet and the stomach, during the process of chewing, swallowing and emulsifying food, the lower intestinal tracts come to a standstill. And as a corollary while the person is excreting it has no hunger. This kind of commensalism or mutualism extends to even individual cells. Different parts of a cell must aid and inhibit the functions of cell organelles.

Does such mutualism and what must go necessarily with it, antagonism, exist in the functioning of the mind/brain as well? Since all biological functions are organized on a pyramidal system where even the most refined operations are nothing but a higher complexity of the more fundamental ones, we have to take it as a given that neurological and various mental functions also operate through mutual aiding and inhibiting.

And mental illnesses can be conceptualized as a disturbance in regulation between different mental impulses/functions where some become excessively strong and put undue inhibitions upon others to the detriment of the organism as a whole. That may explain why alteration in the absolute levels of some neurotransmitters brings temporary relief in patient's misery and symptoms without altering the fundamental disease process.

And a little reflection confirms this viewpoint.

In obsessions the sadistic/gouging impulses, executed by the motor system, become predominant, putting inhibitions on other manifestations of libido, while in hysterics other sensory surfaces than the genitals take the center stage in person's love life.

In depression there is general inhibition of all libidinal outlets - which the person had habitually used for finding satisfaction - and he is forced to go in to mourning to put a permanent stop on old ways of satisfaction and find new outlets for his love needs. In mania, the yoke of all the inhibitions is thrown aside - at least temporarily - and all the libidinal outlets become capable of giving satisfaction and the person rushes from one place to another to find objects for his pent up needs - from the earlier period of depression - like a mad man.

It is more interesting as to what happens in schizophrenia.

But before we do that we will have to examine more closely the problem of mania which is most akin to schizophrenia; but easier to understand because a person in its grip is not totally incoherent. The undertaking will come in handy when we finally tackle the more inscrutable schizophrenia.

In mania an attempt is made to allow all of one's needs satisfaction by lifting all inhibitions at once. But on second thought perhaps not all inhibitions. For the manic, despite appearing more crazy than schizophrenic or at least more noticeable - because of his intrusiveness, his great energy that allows him to be all over the place and his desire for attention - is still not quite out of touch with reality. The ego - the central organizing agency - still makes attempts to own up to the person's actions, and still tries to put some order to the expression of the needs of individual components, and still wants to take responsibilities for his actions, and still allows emergence of some guilt over what he is doing, when confronted. The manic's sense of self may become very inflated and megalomaniacal because he is undertaking so many projects at the same time, but it still is there. If the mania causes disorganization beyond a point, the neurochemicals responsible for initiating depression - in all probability acetylcholine - are finally unleashed, and the disintegrative process is reined in by putting a damper on all of one's needs.

In schizophrenia too there is an overwhelming emergence of the pent up needs, but unlike in mania, the ego, the central organizing agency, struggles against them in a most haphazard fashion, and in the end, more or less gives up the struggle, letting the needs aid and inhibit each other more or less independently from the inputs from the ego, which are there, but haphazardly placed, and often contradictory. Schizophrenic has no orderly strategy against the pell-mell emergence of psychic needs. The hurry and the rush of mania is not there because the subunits are pursuing their own course and there is little desire to prioritize. In mania there is still a sense of timing and the person still attempts to go from one need to another, even if he keeps leaving things half done to rush to another project.

The strategy of reining in the excessive satisfaction of needs through depression/inhibitions seen in mania is not done in a sequential manner in schizophrenia. Instead the ego sends the inhibitions in a haphazard fashion and not quite to those precise neuronal activities that would put inhibitions upon the cortical representation of the unruly needs. Acetylcholine, which through its activation of GABA inhibits the cortical activity, in schizophrenia seems to target the wrong areas of cortex. It appears that in schizophrenia an attempt is made to control the excessive demands of the needs by inhibiting not the cortical areas where the memory images of the objects that are required for fulfillment of the need and the motor images of the actions that would get the needs fulfilled are stationed, but by inhibiting the word images that correspond to these objects and these motor actions. Schizophrenia is a disorder where excessive demands are dealt by putting inhibitions upon the cortical areas where word symbols of objects are stationed - the cortical centers of language.

And here lies the essential difference between manic-depressive illness and schizophrenia. In the latter the formation of language itself comes under repression.

I think in those who are destined to turn schizophrenic instead of manic-depressive, the problem lies in the language apparatus. In mania even at the very height of illness, with flight of ideas, klang associations and rapid speech where the words just merge into each other, the words still correspond to the concepts they represent. Words continue to correctly symbolize the "things" they are meant to. Manic person never quite gives up his grip upon the world and the words he uses to understand it. His words do correspond to the ideas he has in his mind and they do correspond to what others believe those sound symbols (words) stand for.

In schizophrenia the language is used in such a manner that there is a disconnect between the words used and the concepts/things they are conventionally meant to represent. There is a modification of the language itself to give into excessive satisfaction of needs. It is a kind of psychogenic aphasia that makes a person behave gibberishly in the social dimension of his life.

Development of the language undoubtedly has played the most important role in making us humans. Language arose as an expansion of auditory signals that evolved to indicate danger. Sounds that dangerous animals or competing humans made, and which spelled danger, began to symbolize these feared objects, and making of these symbolic sounds through the motor apparatus of speech by one person to another could evoke their image in the consciousness even when the feared object was not around. This was the beginning of thought consciousness which makes humans different from other animals. It may be worthwhile in future for me to write here how the sound symbols soon began to be applied from dangerous objects to friendly ones, and then to the objects' actions and their positions in space and time, to their emotional expressions, and finally to abstract notions about them. The latter occurred by doing away their particular attributes and putting them in classes based upon their common attributes. But we will resist here the temptation to get sidetracked into the origin of language itself and limit ourselves to examine as to how language ceases to operate as it should in the disorder of schizophrenia.

And to do that we will have to examine the raison d'etre of mental illnesses itself. It appears that mental illnesses arose because evolutionary pressures forced humans to live in company of those whom they loved and hated at the same time. The object they loved often was the object they hated and hence feared. It is to defend oneself against the fear of those whom we hated but could not get away from because they were the only ones who could satisfy our love needs and who we loved at the same time, did humans develop mental illnesses.

It is our relationship with parents that we first experienced the paradox of having to live in a social milieu where we have to satisfy our love need from the same people who also correct us and who quite often behave punitively and dangerously.

It is the fear of danger to our love life - in boys primarily the fear of castration in hands of the father and in girls the loss of love from the mother - that initiates mental problems. And these adverse consequences from parents, the child senses, would become reality if he or she indulges in unrestrained satisfaction of needs.

There are various ways this fear is nullified, or rather displaced and muted, so the child can continue to love the parents without fearing them. In obsessional neurosis and hysteria the genital activity becomes of secondary importance - comes under inhibition/repression - and the love needs are primarily expressed through prominence of anal-sadistic activities, and sexually loaded exhibition of other parts of the body, respectively. As long as the child does not indulge in the forbidden genital activity that would put him or her in conflict with the parents he need not fear.

But the affect of fear persists. The fear of the father gets displaced upon fear of objects that symbolize him such as thunderstorms or dangerous animals while fear of mother get displaced upon things like closed spaces or witchcraft. The fear is there nevertheless, though in check. As long as the objects and situations that symbolize once feared parents and the circumstances surrounding that fear respectively are not directly faced or reenacted, the fear is under control. And the language apparatus is left undisturbed in these disorders. One person may substitute another in one's thinking, but words continue to symbolize the objects they represent.

In manic-depressive illnesses this imbalance between allowing some needs to be expressed excessively at the expense of others which are inhibited takes on an added dimension. During the depressive phase there is excessive fear and all the needs are suppressed while in mania there is very little fear and an attempt is made to satisfy every possible need. But here too the language is left undisturbed. Words that one uses do not have idiosyncratic meaning, and they mean the same thing to others what they mean to oneself.

Only in schizophrenia the early childhood fears are dealt with by making the words not quite correspond to the objects they represent, and in bringing about other subtle disturbances in the use of language and all because the fear was most profound in this disorder in childhood years when the neuronal tracts of the disorder were laid. Language plays a central role in helping ego put correct inhibitions upon some activities in order to facilitate others. In schizophrenia the yoke of inhibitions falls upon distortion of language areas of cortex.

Why does the language itself becomes the target of inhibition in schizophrenic in contrast to obsessional neurosis and hysteria where other cortical representations of the forbidden objects come under repression instead of just the auditory symbols?

It appears that when an organism reaches a certain degree of complexity it enters into the mode to divide into two separate units. In human this division has to take place by involving another person and via the sexual act. If the complexity becomes too great in a human, due to generations of natural selection, there is increased pressure to prematurely divide and a corresponding premature strengthening of sexuality, and as a consequence greater fear and greater counter measure of repression during the Oedipal phase.

My experience with schizophrenics and those who suffer from schizoptypal speech, they have the greatest difficulty when it comes to talking about sexual processes. The disorganization of language appears to be be some special inhibition in making connections between word representation of sexual organ - the penis - which generalizes to all spheres of language. Yes, once they have psychotic breakdown, or when they are trying to deny the existence of this difficulty, they may be able to bring the words that symbolize these organs without a problem. But even here the proper affect that should emerge when using these words is absent. As if the repression upon the affect of fear gets generalized to all affective expressions.

It appears that the person who is destined to become schizophrenic has disproportionately stronger genital sexual drive at the Oedipal period, causing a massive premature repression that specially falls upon words that symbolize genital organs and the affects associated with it. And this repression gradually generalizes to a whole range of words directly or indirectly connected to the genital organs, causing the language to become highly dysfunctional, finally affecting all those mental functions that must use language areas of the cortex to function in an organized manner.

After such a dry discussion, if anybody has been able to follow the essay this far, he will be glad to get a clinical example of what I am claiming to be the central feature of schizophrenia - a repression of the language areas of the cortex.

A young girl in her twenties who has made a schizophrenic withdrawal from the world due to extreme fear of sexual relations was told in a session that she always sits on the edge of the chair in the office and what could lie behind such vigilance.

It was an indirect broaching of the subject of her extreme caution in giving up her mother - she still lived with her parents - and embracing an extra-familial sexual object. She had dated very briefly in college, and at first hint of having to submit herself sexually, had stopped all interest in men. In fact had dropped out of college.

"Why have you become so cautious?"

The patient thought for some time and when did not reply and was egged to make a response said, "I am questioning about the caution."

After a pause added, "I am wondering about the caution." Then, "I am thinking about the caution." And after another long pause, "I have become so cautioned."

When asked, "What do you mean I have become so cautioned?" She replied, "I am thinking as to what caution is." Then added, "Maybe caution was enlisted by them."

"What do you mean caution was enlisted by them?"

"They saw the caution sign on the road and thought they must be cautioned."

One can see how her sensing that I was broaching the topic of sexuality led this girl to immediately block out the correct meaning of the word 'caution'. By getting confused about the word caution she blocked any further exploration of her conflicts.

A hysteric with a fear of genital sexuality would not have sat so cautiously, but would have been doing just the opposite - acting flamboyant and flagrantly exhibiting her non-genital sexuality. If she had to distort the word caution to avoid further discussion on genital sexuality, she would have either blocked out the word entirely in further conversation, or lisped on it, or mispronounced it, but would have never been confused as to what the word actually means, and how it must be used in understanding complex concepts.

But in my patient, the fear and caution over genital sexuality, when she was confronted about, was handled by getting confused over the meaning of the word 'caution' itself. Under stress, the word had ceased to symbolize the concept which it was supposed to. When words do not symbolize the underlying concepts but become rather fluid in representing a range of related but irrelevant concepts, the patient's grip of reality is grossly affected. For in humans the reality is primarily comprehended by the language system. And this is what happens in schizophrenia, patient gets lost in words when trying to convert experiences into abstract concepts by the aid of language.

Here is another example from the same patient on how language is distorted in schizophrenia. She had an obsession to look inside purses and was creating problem for the family in department stores where she would constantly open every purse she could get hold of and examine minutely what was inside. She even tried to shoplift a couple of specially attractive purses.

As to what lay behind, unconscious to her, was not difficult to decipher. Purse symbolized female genitals and she was looking inside for the missing penis. If it was true that women - at least superior women like mothers - had penis, which was hidden, but could be accessible, then there was no need to take interest in men to get one. One could continue to be attached to the mother and avoid entering into heterosexuality.

One day when I asked her as to how obsession with purses was coming along. Instead of saying I have given it up or it is under control she said, "I lean towards looking at something else."

When asked what do you mean you lean, she said, "If I am attracted towards purses I lean towards looking at something else."

A hysteric would control the impulse to touch the purses by making body movement of leaning away when in the store, or adorn herself with jewelry or other trinkets to compensate for the shiny purse. But in schizophrenic the language itself becomes flowery and elaborate. The world is changed to fulfill ones desires and fantasies not by actual action but by changing the words corresponding to those actions.

Tuesday, May 17, 2011

DSM of APA an Ivory Tower monstrosity that harms more than helps in conceptualizing and treating mental illnesses

I had submitted the following article to a mainstream psychiatric journal, pointing to how conceptualizing and treating mental illnesses through the use of rating scales and DSM diagnostic criteria hinders more than aids treatment. As expected it was rejected. So I am putting it on the blog. It is rather long but anybody who is seriously interested in psychiatry will find plenty of meat in it.

Do the “Real-World” Field trials of DSM diagnostic categories have anything to do with the Real world of Psychiatry?

Recently I read in Psychiatric News (1) that Dr. David Kupfer, the chairman of the DSM V task force, is now conducting “Real-World” Field Trials of DSM diagnostic categories to test whether they are useful to clinicians, and it will be done through questionnaires and rating scales.

I hate to say it but it is a slap on the face of real world clinicians. In real world of psychiatric practice anybody who wants to make sense of his patients’ complaints rather than cataloging them to reach a critical threshold to clinch a diagnosis does not use rote questionnaires, does not use rating scales, and does not use the DSM system of classification.

Mental illnesses should not be conceptualized the way we do with physical illnesses and should not be approached using structured formats and should not be put in rigid diagnostic categories the way DSM does. Furthermore, using rating scales to elicit and judge the intensity of patient’s symptoms is a sure way to ruin any prospect of understanding as to what the patient is trying to say through them and how they fit in with his overall mental world. The DSM system starts with the presumption that patients’ report of their nebulous and ever changing mental states alone is enough to rely upon as to what is wrong with them. In reality it is very difficult for patients to report their problems with any degree of reliability. The problem becomes even more complex when we observe that while patients when reporting about physical illnesses do their utmost to have their verbal reports correspond to what is ailing them, mental patients are as likely to use their words to hide and mislead you as to what is emotionally and behaviorally troubling them. They are as committed to hiding from themselves as from their doctors as to what are their mental issues. To base a diagnostic system of mental illnesses solely upon what the patient reports, accepting everything on face value, is like building a Taj Mahal on a foundation of shifting sands. No wonder the size of the DSM diagnostic categories is going through the roof.

Unlike physical problems, mental complaints are exceedingly context laden and cannot be understood without paying attention to the continuity of thoughts processes, the emotional nuances accompanying these thoughts, and the non-verbal cues the patient gives while reporting. A clinician cannot attend to these if his attention is divided between reading aloud the questions from his rating scales, selectively listening to patient’s responses to fit in with what the rating scale expects, making up his mind when to cut short the patient to proceed to the next question, and trying to decide with every answer as to what quantitative option between 1 to 6 best fits the qualitative utterances of the patient. Structured formats by their very nature discourage open-ended narration by the patient and without there is little possibility of going in to the deeper structures of the mind where the meat of the real world of psychiatry lies.

A movement started in the early 1960s, beginning with Present State Examination (PSE), and which was quickly followed by Research Diagnostic Categories (RDC) and the Third Diagnostic and Statistical Manual of American Psychiatric Association (DSM III) that ad hoc decided that mental illnesses in essence are not different than physical illnesses.

Unfortunately there are several fundamental differences between mental and physical illnesses. Only two can be taken up here. When a person reports a physical problem to the physician there is little disagreement between the two as to what constitutes the illness and what should be the treatment. If there is a fracture of the foot the doctor and the patient will rarely disagree over the X-ray findings and even more rarely disagree over the advisability of treating it. But the matter is quite different with mental illnesses. Not only as to what is wrong with the patient, but how to approach it. Take for example a young patient of mine who suffers from obsessional neurosis and is plagued with images of harm coming to her sister such as seeing her younger sister falling off the edge of her school playground. One day she said that from henceforth she will communicate with me only in writing and that too by email and I could just call in to the pharmacy her prescriptions. When told that this decision is another attempt to prevent her hostility to show itself in her communication in my office and should be viewed as a symptom, she got very upset and claimed that communicating through writing instead of speaking is not a symptom but a more reliable and objective method of describing her problems. She would undoubtedly love structured formats especially if she can do them through the anonymity of the Internet.

The above is an extreme case but it appears that when it comes to reporting mental problems our mind is divided. One part wants to reveal the facts and join hands with the doctor’s endeavors, while the other does it’s utmost to maintain the status quo and does so by distorting the true state of affairs. This is because our desires and impulses that make us mentally sick [by becoming pathologically strong] are generally anti-social in their aim, while from earliest childhood we are taught to put our best foot forward when talking and revealing about ourselves to others and we loath to reveal the unacceptable aspects of our mental life. Any psychiatric interviewing technique that ignores this fundamental “hypocrisy” of human mind when reporting about itself that makes our speech as much an instrument of accurate communication as an instrument of deception e cannot go beyond scratching the surface.

To make matters more complicated mental diagnostic categories unlike physical disorders have no independent existence. They are inexorably intertwined. Mental complaints do cluster. But while individual complaints are pregnant with meaning, the clusters have little clinical usefulness. As soon as you give a name to one such cluster of your patient’s problems, and gear up to resolve it en masse, say depression, you find that there is another cluster lurking right behind which warrants putting the patient in to another category like obsessive compulsive. It you listen some more you may find he is hysteric in his body aches and pains and anxious in his chronic expectation of harm, paranoid in his belief that people are always ill about him, sociopath in the way he files his taxes , pervert in his fantasies, and an outright psychotic in his nightmares. And even these clusters may be just scratching the surface. One often finds even more clusters, which the patient was barely aware of when he first came to you, that he is willing to examine once his thoughts and emotions were allowed freer expression in a carefully nurtured therapeutic alliance.

Now if one starts using rating scales for all these clusters, as our colleagues from their Ivory Towerswould like us clinicians to do, our therapy sessions would comprise of nothing more than running ragged from one rating scale to another for the clusters of these patients have no beginning or end.

One can understand why researchers love rating scales. They need symptom clusters to correlate with their “biological markers”. They would give anything for these clusters to appear in isolation and be ironclad entities. Presence of multiple clusters is a nuisance, or at least an unwelcome confounding variable, to their work. So they have a natural bias to ignore the existence of clusters which they are not looking for to correlate with their “biological marker”. And of course rating scales are indispensable for epidemiological and pharmaceutical studies where the whole objective is to crunch out numbers and not understand the meaning behind patient’s complaints.

For the clinician, however, the problem is very different. As soon as he pays attention to symptom from one cluster, the patient tends to make a getaway into another cluster. Let me illustrate this with an example.

A woman, who was hypochondriacally preoccupied with breast cancer, on being confronted that it is a punishment for death wishes against her mother - who did have breast cancer when the patient was a teenager and which she survived – stopped her obsession with cancer and went into a panic attack. When the panic was interpreted as an attempt at flight from dealing with her ambivalence towards her mother with whom she still lives at the age of 51 despite having a boyfriend she developed a migraine headache – a hysterical somatization. Along with headache came another somatic symptom – an attack of colitis – a conversion of her psychic anxiety into an autonomic somatic behavior. When she came out of the restroom she claimed could no longer drive home because her agoraphobia has come back with a vengeance and she cannot be trusted not to hurt somebody on the street. On receiving alprazolam she felt confident about driving, but only when her original hypochondriacal preoccupation with breast cancer returned and blocked out all other “clusters” from her consciousness.

Can such a patient’s problems, and virtually all patients are as complex when examined closely, be really handled with the medium of rating scales or can be even rightly viewed as clusters of illnesses that should be handled en masse? If one still says yes, he is either a hypocrite or has no feel for the real world of mental illnesses.

The trouble with ivory tower folks who spend most of their time doing biological research, collecting data through the medium of rating scales, and teaching residents journal knowledge is that the pride they feel in their lofty mission often misleads them into believing that the average private practitioner is too ill trained to correctly assess whether the patient is improving or worsening without the help of rating scales.

This is preposterous. Even a marginally good clinician within minutes of listening to his patient, whether done with or without the help of rote questions, can tell if the illness is getting better or worse. There are of course bad clinicians, and plenty of them, and they do have vested interest in seeing the patient the way he is not, usually to justify keeping them on unnecessary medications and treatment, but such doctors will make such errors of judgment with or without rating scales.

Judging patient’s improvement or worsening is not a rocket science, and the last thing we clinicians need is to have these rating scales become mandatory in assessing progress or lack of it in approaching psychiatric problems which ivory tower folks cannot emphasize enough is the wave of the future. It will be the final nail in the coffin of qualitative approach in treating mental problems. And the irony is how little these rating scales enhance our clinical judgment. Psychiatric symptoms move in tandem. If a patient’s anxiety lessens generally his depression will too and if an antipsychotic is effective in a patient is will be as much with positive as with negative symptoms. It is simply impractical, and outright counterproductive to approach these patients with stack of rating scales and rob oneself of the valuable clinical time to decipher the displacements that underlie mental symptoms before they emerge in consciousness.

Another problem with using rating scales is that it starts with an a priori assumption as to what kind of complaints the patient is going to bring to a session and what rating scales one should take out of the drawer to do the job. A person who gets diagnosed as Major Depression or OCD will session after session will get assessed with HAM-D and Y-BOCS respectively. But is this fair? By using such stock questionnaires one may very accurately assess the intensity of a few symptom clusters but in the process one may completely miss out on seeing the uniqueness of the patient’s illness. The approach is truly the proverbial case of missing the forest for the trees. Structured approaches simply do not create the right ambiance for capturing the vastness, as well as the deeper strata, of patient’s mental world. For example a patient of mine who was initially diagnosed as suffering from Major Depression and Generalized Anxiety Disorder and should have been approached with the rating scales for these two disorders per current academic recommendations under the grip of severe resistance which had to be carefully dealt with told me that every night he must open and close his refrigerator, and flush his toilet, four times each, before he can fall asleep, because the alternative would be the death of all the four members of his family - his parents, his sister and himself, while he lays sleeping.

Most of the meat in psychiatry lies in such subtle details, which have little to do as to which diagnostic category the patient belongs to. Also such subtleties, the patient will never let you in if he senses that the primary agenda of the session is for the doctor to rush from one question to the next to get over with his rating scales. One of course can argue that the therapist can first rate the symptoms and then go on with the business of dealing with them per his theoretical persuasion. But in practice this never works. The shallow interpersonal connection that exists between the patient and the therapist when the therapeutic alliance is established through reading of the questions out of a manual of rating scales mars the completely non-judgmental open-ended ambiance that must develop in the session before the patient will take courage to tell you something as complex as the meaning of an obsessive act of closing and opening of the refrigerator four times “magically” averts the death of the four members of his family in his psychic world. A long time back Madagascar (2) did some interesting research and showed that what a patient will tell in a therapeutic session depends highly upon the degree of affect-laden empathic connection that develops between him and the therapist. Reading questions out of rating scales is no way to develop any such affect-laden empathy. It is easy to get on the same page of the rating scale manual but a lot harder to the same pages of mental complexes where the patient’s psychic blocks exist.

Since mental symptoms when viewed as clusters and dealt with en masse tell us so little about the patient’s real difficulties in his psychic and real world and lend themselves so meagerly for resolution respectively, is there any benefit to giving diagnostic labels to mental patients?

Yes, there are benefits. Not great benefits now, but certainly there are some. First of all we have no choice but to use diagnostic rubrics to make a crude working categorization of patient’s overall difficulties, and not only just for our own thinking but to communicate with other professionals and third parties and to a minor extent with the patient who, more familiar with the world of physical illnesses, would like a diagnostic label as to what is wrong with him. Our reimbursement depends upon billing with succinct medically sounding diagnoses with their own diagnostic codes. Then there is the real world of other medical specialists, primarily family practitioners and internists, who want to have an elementary working knowledge of psychiatry without any interest in the metapsychology of these illnesses, so they can prescribe half a dozen or so psychotropic medications that they are familiar with. Let us not forget treating mental problems constitutes a significant portion of their income. One may mention in passing though that such a superficial and drug -oriented quasi-psychiatric practice is usually substandard care, and in my experience these non-psychiatric physicians more often than not give either too little or too much psychotropic medications and by their ignoring of the psychological dimension, in long run, they do more harm than good for psychiatric. Training more good psychiatrists instead of training non-psychiatrist physicians to treat via using psychiatric rating scales is the more correct approach to the overwhelming presence of mental illnesses. The legal system, including disability determination and workmen compensation organizations, and Managed Care behemoths all need diagnostic labels to do their work. However, let us not fool ourselves that these people have any real interest in finding out as to what is really wrong with these patient and their love for ironclad diagnoses and the multi-tiered axes of DSMs arises because it makes it easier to deny benefits, joust with adversaries, and hone out deals and quick judgments with such a simplistic diagnostic approach.

While we cannot do away with diagnostic labels we can certainly do away with pretending that arriving at such diagnoses is a very important part of psychiatry. The hoopla that has been created around the development of DSM V and how the task force participants are fighting tooth and nail as to which symptom clusters deserves distinction of full fledged diagnosis – and now there are about 500 of them – and which should be denied access to the schema reminds one of congressional infighting over different pork in passing bills and give a wrong impression to trainees and even trained psychiatrists that arriving correctly at these DSM based diagnoses is the crux of psychiatry. But in the real world we could care less as to what diagnoses our patient has garnered. For we know that once treatment proceeds symptoms from across the board of those diagnostic categories will start emerging with their own contextual logic without any regard for the diagnostic categories.

As for the other Axes of DSM their usefulness is even more suspect. There is no real justification to give personality disorders a separate axis. It saw the light of the day to create niche for a few chosen psychiatric researchers who were big in the field in the late Seventies. But they are now gone, or have turned quite old, and the Axis’s usefulness has now fallen to just denigrating difficult and irritating patients as borderline or histrionic or sociopath, with other personality disorders almost never getting mentioned. Furthermore real clinicians don’t approach patients’ personality disorders with one set of therapeutic method and his other psychiatric problems with another. The third axis is a joke as well. Psychiatrists add one or two of them as an afterthought, without doing any physical examination. They are, in the real world, to use the vernacular, half-ass impressions about patient’s physical illnesses. The imprecision with which these diagnoses are arrived at without any clue as to how many of them should be mentioned behooves that such an approach towards physical illnesses should be abandoned by psychiatrists. Just like an orthopedician feels no compulsion to put the patient’s cardiac or dermatological illnesses on a separate axis, though he would not operate on a patient in an advanced Congestive Cardiac failure or on a psoriatic joint, I see no need for a special axis for physical illnesses for psychiatrists. If a physical illness requires major psychiatric intervention it can be as easily listed as another diagnosis alongside others ones which are outright psychiatric. The fourth and fifth axes are quantitative measures to assess the strength of the stressors and the gravity of patient’s illness respectively. But in practice they have become a cat and mouse game between psychiatrists and third party payers for only a fool will not give his patient very high scores in the beginning and then show gradual improvement to keep getting more sessions authorized. It may be worthwhile mentioning here that it is not just playing games with the last two Axes, but the entire psychiatric documentation has become a rote game. One is expected to do two, or at most three, pages long initial evaluation and then two or three line perfunctory mental status statements on subsequent visits, all done mechanically with the sole purpose of protecting oneself from potential lawsuit and giving justification to write prescriptions.

The multi-axial system makes the profession look very good and one has to concede that if it does not dazzle the outsiders it at least baffles them to wonder if our field is not more complex than any rocket science. However, the truth is that the multiaxial fanfare is a weird imposition upon the practitioners with no practical benefits.

It is time we move away from considering making correct categorical diagnoses using the DSM system as a very important aspect of psychiatry and the first step in this direction would be the doing away for good the last four axes. It will be the first blow on our pretensions that by writing those pompous multi-axial diagnoses we have written something very useful about the patient.


1. Kupher D. Read-World field trials: Next step in DSM-5 process. Psychiatry News. Oct. 1 2010, 45: 19, 2.

2. Matarazzo, JD: Prescribed behavior therapy: Suggestions from interview research. In A.J. Bachrach,ed., Experimental Foundations of Clinical Psychology. New York :Basic Books. 1962: 471-509.

Wednesday, May 11, 2011

Nervous stomach, bruxism, OCD, death wishes and the mechanism of action of the SSRIs

A man in his late twenties who for years suffered from "nervous stomach" and who gnashed his teeth in sleep (bruxism), and who frequently got in to trouble with the law for petty transgressions, declared that the reason he is addicted to narcotic pills is because they control his anxiety.
For his narcotic dependency he was put on Suboxone which stopped his abuse of Hydrocodone and Oxycodone. In psychotherapy, it emerged that his penchant for getting into trouble with the law was a form of self-punishment for harboring unconscious evil thoughts towards his father. These two interventions: substitution of Suboxone (Bupronorphine) for street narcotics, and a realization that his ambivalence towards his father, for he loved his father very much too, was emerging against the local police, straightened his life considerably.
Once he squared up with the probation department and the court, and started showing up at his work reliably, he wanted some medication to straighten out his other problems - the teeth-grinding and the stomach churning. He bemoaned that the former kept him awake at night with sore jaws and the latter had him in knots during the day.
He was put on Zoloft (Sertraline). A SSRI (selective serotonin reuptake inhibitor) was chosen because he attributed his anxiety to excessive worrying. As a psychoanalyst I had to correct him that it is not worrying that causes anxiety but anxiety that causes the person to find one reason or another to worry about. The affect of anxiety makes the person restlessly scan for dangers in the environment and if there is no real danger he is left with no choice but to make mountains out of a molehills. Anxiety can pick up the most trivial danger to mull over.
The patient admitted that he is always taking precautions to avert lurking dangers. Though, he admitted, it is ludicrous to even label them as dangers.
For example he worries almost every day as to who will give him ride to work - he had lost his license to drunk driving - even though he knows his girlfriend faithfully will. Or he'll worry that she will be late, which she never is. Or he will go into deep consternation over having wasted his money on paying rent all these years instead of buying a house which would have built equity, even though he knows that his brother and his friends had lost their houses to foreclosure due to housing-bubble collapse and he had done better by renting.
The Zoloft dramatically eased his queasy stomach, teeth grinding, and petty worrying.
But what emerged in its place were classic compulsive rituals. He began checking and rechecking the stove and the press iron to make sure they had not been left on by mistake which would burn down his apartment.
The anxious worrying was replaced by obsessive daydreaming. He would play scenarios in his mind of his house catching on fire due to a careless mistake of his causing his pet cat to get roasted.
Couple of other interesting compulsions which I made a note of were his great discomfort at the slightest hint of growth of his facial hair and the immediate need to shave and getting gripped with a compulsion to clean his house. He called it his "cleaning mania" and it came in waves. First would be the impulse to mess up things which most of the time he could successfully avoid giving in to. After the urge to mess would come the wave to clean.
The only explanation he could give for his fear that his house will burn down was that his uncle and his wife had actually burnt down their house to ashes due to carelessness. They had then moved to his grandparents - uncle's father's house - and had burnt that one too, a few months later.
Patient claimed that his fear of his burning down the apartment was justified because it had happened to his family twice.
This explanation did not sound sufficient enough to produce the whole range of his obsessive symptoms. People witness fires destroying houses all the time yet it does not lead to their getting obsessively preoccupied with their own house burning down.
Also it fails to explain the roots of his bruxism, stomach pangs, anxious worrying that some harm will come from his surroundings.
The primary pathology in this young man was a legacy of an excessively strong Oedipal struggle - an early and strong flowering of love impulses directed towards the mother accompanied by equally strong destructive impulses directed towards the father. Because of his great love for his father, the destructive impulses had gotten prematurely suppressed and could never emerge as such in the consciousness. Willy-nilly they had found an outlet but not against his father but against the law enforcement folks of his city. His father was General Manager of an auto plant and his authoritative persona, with which the boy had gripe, had got displaced on to the authority of his city's police force.
But not all his aggression towards his father had found this unadaptive outlet. Some of it had found expression in ego-syntonic and socially rewarding endeavors of beating the competition. He became a star athlete. And once when he was shipped off to Tennessee to live with his relatives to keep him out of the hair of the city's police department, he had gotten so good at baseball that his coach thought he would one day be a Major League player. Away from his father he could dare outshine him, at least on the baseball diamond. But something soured this healthy outlet for his aggression, and he started getting in to trouble in Tennessee too and had to return to Michigan. Back in his father's house where he had to abide by the latter's rules, he gave up baseball and was back on the streets challenging the police and getting arrested for speeding and doing drugs.
The analysis of his bruxism showed it to be the same aggressive streak emerging in sleep. It was an attempt to chew and spit out his father/authorities. The churning of the stomach was continuation of the oral aggression lower down the GI tract.
How did the Zoloft (SSRI) took away these two somatic symptoms of anxiety? Here one has to get speculative because we know so little about how the neurochemicals modulate our behavior.
One thing for certain is that the SSRI ended the somatic anxiety of bruxism and stomach- churning and replaced it with checking and rechecking rituals, the cleaning mania, and daydreams of destructive scenarios.
So the SSRI had shifted the mode of expression of his aggression - from the soma to the psyche.
Does this tell us something about how SSRIs work?
Perhaps they work by taking away the aggression from destroying one's own body - in this case through unnecessary grinding of the teeth and excessive acid secretion of the stomach - to the mental sphere and directing upon others. Instead of moving the muscles of the jaw (bruxism) and the involuntary muscles of the stomach which was destroying his own body, now the movement had shifted to producing obsessive thoughts of burning the house down and roasting the cat and in the rituals of checking and rechecking and endlessly cleaning the house to prevent others from coming to harm.
Along with the disappearance of bruxism and the overactivity of the stomach the SSRI also improved his affective status. He was no longer as anxious, worrisome and inhibited. So with the shift of the problem - discharge of aggression from somatic to the psychic sphere - the affects lessened too.
This throws light upon the obscure problem of the generation of affects.
Affects appear to be internal sensations/perceptions generated in the psychic sphere when there is anticipation of some physical harm coming to the body. Originally the affect was a psychic reaction to some actual physical harm that had occurred to the organism - either phylogenetically or ontogenetically. Later the affect began to be generated even before the harm occurs just at the anticipation of harm. As if the organism senses something is about to happen to the body, generates the appropriate affect to deal with it which guides the organism to take appropriate motor action to get out of harms way and to start releasing stress hormones/chemicals/antidbodies in case actual injury occurs.
So are SSRI the ultimate answer to dealing with somatic anxiety and affects?
Not really.
For the man reported that the cure of his somatic problems and lessening of anxiety came with a price. He stopped feeling things deeply, his affective response to people and situation became flat and he felt like he was not quite in touch with the world. So one cannot do away with affects without taking away the feeling of being alive and human. As if the right combination and strength of affects gives us the sensation of being ourselves and as if each person has his own unique repertoire of affects which give him his individuality.
And there was another disadvantage. While the anxiety and pain in the jaw and stomach had him hobbled in his pre-SSRI days, the appearance of checking and rechecking, the cleaning mania, and the daydreaming wasted his time no less. So in some sense all the antidepressant did was to replace one set of problems with another.
Even the somatic problem of stomach churning and teeth gnashing were not just wiped away. Some very deep somatic problems emerged in their place. The patient began gaining weight and began sleeping 10 to 12 hours a day. Granted they were not very painful but perhaps in the long run as destructive. It was surprising that he did not develop loss of libido, which is a frequent somatic problem with SSRIs.