In Practice

Nobelobama: Yes, You Can!

Peter D. Kramer — Fri, 09 Oct 2009 15:41:48 +0000

What do these Scandinavians have in mind?

I heard the news this morning as I drove out to my usual bicycling route. On NPR, Elie Wiesel was sounding gracious but befuddled, as if it were he who had been wakened with incomprehensible news. Then I was off pedaling, so I got to digest the announcement without exposure to commentary.

With patients who are indecisive about commitment, I find myself asking them what a given act means. Moving in, buying a house together, marrying - do these choices say that you must enter a fixed gender role, live forever in the same city, agree to sex on demand, enjoy the same movies? I think about language and Wittgenstein's example of the game, a seemingly straightforward concept that eludes explicit definition, because as humans we play with concepts, use them in all sorts of ways. They may have core functions and meanings, but finally institutions are tools that serve our purposes.

What is an award? Today, it seems a means for calling out to a powerful man surrounded by advisors, immersed in daily negotiations, caught up in the confusion that is America. The Committee (in my imagination) was offering pointed reminders: "Remember where you come from." "We, the wider world, are your constituents, too." The members seemed also to be giving encouragement: "Be the person we hope you are." And, "Stay the course."

Implicitly, the award is a rebuke to George W. Bush and the Republicans. In a strange way - can an award serve this function? - it acts as a rebuke to Obama as well. The Scandinavians know that he is committed to waging war in Afghanistan, to renewing the Patriot Act, to behaving altogether like a cautious American politician. An award can stand as congratulations for attempts and achievements. Here, it seems a gesture pointing in a direction: Yes, you can.

Due for a Comeback?

Peter D. Kramer — Sat, 03 Oct 2009 19:06:39 +0000

I see that I have been remiss in not alerting PT readers to my recent book review (of Generosity: An Enhancement, by Richard Powers) in Slate. In it, I refer to changing assessments of the much-discussed serotonin transporter gene and the ability of favorable variants to protect against the effects of stress.

As I indicate in the essay, from the start I had doubts that a strong version of the finding - two long alleles provide absolute protection against stress-induced depression - would hold up. I made this point both in Against Depression and in an op-ed in the New York Times. But I would like to underscore what I suggest only in passing in Slate: Neither am I fully convinced by the recent debunking of the stress-protection hypothesis. Many minor studies, at the periphery of the depression literature, suggest that variants of the gene do confer partial immunity from the lingering effects of adversity. My own guess is that in time variants of the serotonin transporter gene will be found to play protective and permissive roles with regard to mood disorders but that the effects will be more subtle or limited than enthusiasts had at first anticipated.

No Joints: How Psychiatry Carves Up Nature

Peter D. Kramer — Wed, 22 Jul 2009 15:30:07 +0000

Just a note to say that I have a piece posted at double X on the latest dust-up about DSM-V. My topic is the blg-picture question, whether we can "carve nature at the joints." I'm reseaching a book-in-progress on diagnosis and its counterpart, normality, so there will be more notes along these lines. My prior entry on double X, also about diagnosis, focused on Sarah Palin and narcissism.

Nice Work If You Can Get It

Peter D. Kramer — Sat, 20 Jun 2009 22:46:59 +0000

Just a note to say that I have an essay in the Wall Street Journal "Culture" section about good work and its effect on identity and private life. Although her name is not mentioned (as it was in a longer, earlier version of the essay that did not make it into print), it is Arlie Russell Hochschild and her theories about the commercialization of the family inspired the piece; in effect, I am responding to Hochschild's (and before her, Karl Marx's) writing, not from within sociology, but from the viewpoint of a practicing psychiatrist.

I am convinced that Hochschild is right, that the private sphere has been commercialized and the work sphere made (sometimes falsely) intimate. And surely Marx was on target: workers can be alienated from what they produce; and marriage suffers from its economic burden and its divisions of labor. But it also seems to me that capitalism evolves (Hochschild says as much) and that the modern workplace, at least for knowledge workers, satisfies some of the requirements of the "early Marx," providing good variety and interest on the job. As psychiatrists, we take the world as we find it. If the office or factory is now a place to learn the social skills everyone needs at home, then our patients can take advantage of that opportunity.

I should add that hearing about people's jobs is one of the special privileges inherent in the practice of psychotherapy.

FWIW

Peter D. Kramer — Wed, 17 Jun 2009 11:36:19 +0000

I'm always curious about what the New York Times considers news. Today it features a debunking report based on a JAMA overview piece that undercuts a famous study, by Avshalom Caspi, of what the press dubbed the "depression gene." That research had found that different variants of the (to use its prior sobriquet) "Woody Allen gene" made people more or less liable to the effects of stress, and thus more or less vulnerable to depression and suicide. Time magazine has comparable coverage as does the Wall Street Journal.

Seeing the news stories, I went back and looked at how I had assessed information about the gene in Against Depression, in 2005. In part, I wrote: "If the same gene plays a more direct role in the shaping of personality — if it leads to neuroticism — then people with the short version of the gene will have a slightly greater liability to moodiness, from early in life, as well as a greater tendency to contract depression in the face of stress.It is almost the rule in behavioral genetics for later studies to weaken or complicate early findings. The New Zealand study has raised eyebrows on a number of grounds. Competing studies had found a less dramatic level of stress immunity in people with the protective variant of the gene. . . . . the heritable part of depression is almost certainly mediated by a variety of mechanisms shaped by a variety of genes — and most likely by different combinations of genes in different people. [Kenneth] Kendler’s statistical analysis indicates that there must be genes that influence depression and do not give rise to the neurotic personality style."

So,not perfect, but not a bad guess either, well in advance of the current meta-analysis . . . assuming that that study holds up.My own doubts and caveats were based on my conversations with Ken Kendler, as well as on earlier reports about the same alleles of the same gene that had found only very weak correlations with depression and stronger ones with anxiety and neuroticism.I don't imagine that I was the only commentator to use the initial Caspi study carefully. In effect, the current meta-analysis gives a formal shape to what the literature already suggested when the Caspi research appeared and so what any careful journalist could have reported all along.

Postscript: I should add (and the press reports should have made this point as well) that the new meta-analysis says nothing about the overall heritability of depression. Caspi and his colleagues may not have identified a gene that makes a major contribution to mood disorder, but depression is as "genetic" as it ever was — that is, at about the level of many other multi-system diseases. The major research on heritabiity comes from the very people the news reports quote, Ken Kendler and Kathleen Merikangas.

One Patient, One Doctor, One Year

Peter D. Kramer — Mon, 30 Mar 2009 14:24:01 +0000

I'm back to recommend another book by a medical colleague who is also a good friend. Today sees the publication of The Addict, by Michael Stein. Michael is an internist specializing in the treatment of infectious disease, but his work with drug addicts displays the sensitivity and insight of the best psychotherapy. Most of The Addict concerns a year in Stein's treatment of a single patient, Lucy, whose attachment to the prescription pain-killer Vicodin, and to addiction itself, has pulled her from a middle-class life to a daily round of abuse and degradation. Better than any therapist writing today, Stein depicts how good doctors think in the course of intimate work with patients. You can find an excerpt and early review at Stein's website.

Ave atque Vale

Peter D. Kramer — Wed, 11 Mar 2009 16:06:29 +0000

I have received a number of emails from readers asking about the disappearance of my postings to "In Practice." I am grateful for the expressions of concern and encouragement, but I have decided to set this blog aside - at the least, to stop contributing to it regularly. From the start, the blog was a one-year experiment. The year is up, and I have had to weigh the effects of my participation.

It's been a good run. I've enjoyed the chance to comment on events as they occur and to hear back from readers. To my regulars especially: thanks. On the downside, blogging intruded on my long-term writing projects as other activities, like hosting a weekly radio show, had not.

Blogging can be relentless. You're your own producer, setting your own topics and doing your own research. The temptations are something like addictive. You can think about postings every day. Also, I had a habit of refining essays once they were up. A piece I had online by ten AM was still not in final form at noon. And then I was always taking on other journalistic projects, like book reviews for Slate and the Washington Post. In the wake of the recession (I think that's the cause) my clinical practice expanded, generally through the return of patients who already had a claim on my attention. Increasingly, solid blocks of time for planned books became hard to find.

That's my main reason for pulling back - to give my other writing space. The Website has made organizational changes as well, but that factor is less critical. I urge my patients to take control of their schedules. I have wanted to "do as I say."

The end of a project is an occasion for assessment. I have not been fully satisfied with my performance as a blogger. In an opening essay, I wrote "The best blogs, it seems to me, have a personal voice and an element of edge, part humor, part grumpiness." I committed myself to "a certain looseness of focus, as regards subject matter" and a tolerance for variety and idiosyncrasy. I don't know that I got there. Many of my blogs were as carefully researched as my print essays, and more conventional in their form. I rarely got loose - nor did I have a sense that my audience wanted me to. When I strayed, into notes about Alain Robbe-Grillet or bicycling or my experience as a cub writer for Newsweek, those postings attracted fewer readers. The highest click rates were for essays about brain biology.

Invariably, posts about psychotherapy, the field I have taught (and written about) the longest, were less popular than ones about drugs. I wondered about my audience. In effect, readers wrote to say, "You overemphasize psychopharmacology" - but would they spend time with my postings about alternative treatments, such as talk, bright lights, and exercise? Mostly, no.

I sensed, and sometimes read explicitly of, resistance to my approaching health care politics, medical ethics, public health, and the history of psychiatry. Here, I sometimes thought it was a matter of my having failed to introduce myself properly: I should have detailed my prior work in those arenas. (And - my own training and background aside - what is the basis of the objection to doctors' discussing medical ethics? Philosophers are the johnnies-come-lately. From Hippocrates through Osler and on, doctors have debated the proper use of their techniques.) Perhaps some more formal process was called for - when I was aiming for more informality.

Looking at my list of postings, I see that my most frequent function was correcting science writing by the mainstream media, often reporters' sloppy readings of new research. I criticized big Pharma often; but because debunking drug companies is a comfortable activity for journalists, generally when I clarified research results, the reassessment was in the direction of saying, no, that practice was not deceptive, and, yes, that positive effect was more marked than has been reported. I saw my role as merely corrective. I would have undertaken it as gladly for a psychotherapy or form of meditation not given its due. But because the press was so one-sided, often I found myself defending ordinary psychiatric diagnosis and the like.

To clarify science, its tools and its categories, is to protect patients and to strenghthen certain useful cultural perspectives as well. That stance is honorable and necessary. But the role conflicts with my sense of myself as a maverick commentator whose hope is to stand apart and, on occasion, to make radically original observations. Yes, as the writerly consensus moves to oppose industry and the professions, conventionality becomes rebellious - but finally the paradox does not satisfy me. I might leave that honorable undertaking to someone else and move on to other causes. Also, I worry over a word that has recurred in this overview, clear, or clarity; in other writing, my additional aim has been to leave room for paradox, ambiguity, uncertainty, and double-mindedness; short pieces are ill-suited to that posture.

As for achievements: when I look over the list of my postings, I find that what I like resembles what I have just worried over. I seem steadily to have emphasized the importance of depression as a diagnosis and to have wrestled with questions of what treats it well. I worked to keep everyone's hands on the table: drug and psychotherapy researchers, science reporters, sociologists, and philosophers. I returned repeatedly to the (vaguely psychoanalytic) point that what is true can differ from what we wish were true. I did stray into distant territory, the films of Jules Dassin, the art of Robert Rauschenberg, and the pleasures of alpine skiing. I contributed, if in minor fashion, to the rescue of the Frank Lewis weekly crossword in The Nation. The reader is free to browse as I did. I hope we've had fun together.

I will miss the opportunity to speak my mind, miss it already. Women and heart disease, job loss and mood disorder, Mike Leigh's "Happy-Go-Lucky," which I just saw on DVD . . . so many topics left untouched . . . But I hope that I will also regain the opportunity to speak my mind, in less compact and more roundabout fashion. I've just had my first literary short story accepted for publication. It should appear this fall, in TriQuarterly. I'm back to novel writing.

Who knows? Perhaps, like any addict, I will break my vows. But it's goodbye for now. I hope we'll meet at other times, in other forums.

Fuhgeddaboudit

Peter D. Kramer — Thu, 19 Feb 2009 15:28:33 +0000

If we had a drug that could erase bad memories, should we use it? That was the question the press extracted from an arguably limited set of observations reported in an on-line article in Nature Neuroscience.

You've probably heard about the experiment. A trio of Dutch researchers showed normal subjects photos of spiders, accompanying one image with an electric shock. The next day, the scientiest re-presented the images, with or without pre-administering the subjects an anti-adrenalin drug, propranolol. Down the road, those who had taken propranolol were less likely to startle when exposed to a loud noise in the presence of an offending picture. The conclusion was that the drug interfered with the consolidation of the emotional memory, stripping it of its fear element.

This finding is a slim reed on which to rest a philosophical inquiry, but in truth the medical ethics field has been debating the broader question for the better part of a decade, based on earlier, similar suggestive research involving propranolol. In 2003, the President's Council on Bioethics weighed in, arguing that the modification of emotional memory was a worrisome alteration of personhood, one that risked trivializing signal forms of pain that compose a complex self. In 2007, the American Journal of Bioethics devoted most of an issue to discussions of an essay that argued in favor of choice in the matter of muting disabling fear.

Yesterday, for better or for worse, I represented the bioethics community when AirTalk with Larry Mantle, a public radio show, took up this issue, under the heading "The Spotless Mind." The broadcast does a fair job of presenting the issues — those who are interested should give a listen.

I want here only to clarify a single point - one that was at the heart of Listening to Prozac. When we wrestle with an ethics question in neuroscience, often it is important to ask what worries us: Is it that we disapprove of the goal of an intervention, or that we dislike the intervention itself.

Do we really, for the most part, worry about the attenuation of fearful memories? Let's say that a patient comes to a doctor and says, "I had a terrible experience yesterday, and I'm worried that it will haunt me. Can you help prevent the fear from lingering?" That's the set up.

Now imagine that the doctor prescribes "tincture of time," that is, she reassures the patient: "Don't worry. I know you. That memory will fade." No one, I would guess, has moral worries about that scenario. Yes, there will be a change in the self, but so what? The content in our library of memories shifts all the time. If the self is continuous, that's not because our emotions are always identical.

What if the doctor says, "You're adept at meditation. Tomorrow, when you recall the event, enter into a relaxed state. Later, the memory will upset you less." Do we object to that prescription? If not, then in truth we do not fret about the result, a muted emotional response to a real stimulus.

How about a more mechanical behavioral prescription? Let's say we believe in the efficacy of "Eye Movement Desensitization and Reprocessing," or EMDR, in its simplest form. The doctor trains the patient to recall the trauma while moving his eyes this back and forth. The memory loses its force. Are we alarmed? Well, perhaps this approach does seem a bit eerie.

Now think of an ingested substance, chocolate or green tea. The doctor has the patient call up the memory while enjoying a soothing snack. Do we object to that sort of interference with reconsolidation?

My point is a simple one. We only initiate an ethics debate when the intervention is a medication - here, one with a complex name, propanolol. (In truth, the consolidation of anxiety may be a fairly easy target; it looks as if steroids, opiates, benzodiazepines, and anesthetics might do the job, along with beta-blockers.) That category, medication, seems to bring into play technology, doctors, patient status, and drug companies, and therefore hierarchy, social coercion, and communal norms. Now we worry, if we do, about altering the self in ways that the culture favors.

There's much more to say on this topic, but for the moment, I think I'll stop with this question: Why is it that we debate the ethics of muting anxious memories now, in the years since it's seemed propranolol can do the trick, when we never argued over that capacity before? Like everyone else, I understand the dystopian science fiction scenario of "eternal sunshine," but to undertake a serious philosophical discussion we need to do better of specifying what's at issue. Why precisely do we worry over a drug's doing a job we are happy to see accomplished by any number of other means?

As They Say on Facebook: Status Update

Peter D. Kramer — Wed, 18 Feb 2009 18:28:20 +0000

Just a note to let readers know that shortly (morning West Coast, afternoon, East) I will be participating in "AirTalk with Larry Mantle," on public radio. The topic is the ethics of memory modulation - via medications, such as propranolol, that may be able to interfere with the consolidation of fearful associations. (One British headline for a story on the topic reads: "Pill to erase bad memories: Ethical furore over drugs 'that threaten human identity.'") The show is carried on a number of stations, including, in Southern California, 89.3 KPCC, 89.1 KUOR, and 90.3 KPCV. I plan also to address the memory topic in future blog postings.

While I'm on the ether: The current and, sadly, final issue of the Washington Post Book World features my review of two books, one focused on neurology and one on psychology, related to the ways we make good and bad decisions. Again, I may return to this topic here, particularly the question of whether neuroscience has any help to offer to people faced with tough choices.

Note:The KPCC memory discussion is up on line as Hour 2 for February 18, at the AirTalk Website.

Why Ski

Peter D. Kramer — Tue, 17 Feb 2009 16:08:01 +0000

The family took a trip to the mountains this weekend. Skiing is an impossible sport. From where we start, the drive north takes four and a half hours, if you don't hit bad weather or traffic, but you always do. This time, on our way up black ice slowed the interstate to thirty, allowing for a leisurely view of the spinouts. Then there's the equipment. Once, when the kids were young, my wife and I started listing items that needed to make it to the slopes; we stopped counting when we reached on one hundred. The expense, the risk - who needs any of it?

Yesterday, on the ride home in the van, someone asked, "What do we like about skiing?" The question was friendly, and it elicited a serious first answer, concerning the beauty of the surroundings. Soon we were on to the usual jockeying based on roles, parent and child, brother and sister. Consensus was that the last day had been the least thrilling, with scratchy surfaces, blown snow on ice.

Annoyingly for all present, I was euphoric. Monday had been magnificent! Because of the tough conditions, groomers had smoothed out some difficult trails, and although the mountain is one we've visited often, I had been able to take runs I'd never tried before.

I am - I have confessed as much - a fanatical mediocre skier. Surely, an attraction of the sport for the kids must be that by age six you're better at it than your father is. Someone asked how I'd managed to make it down a particular double black diamond slope. The immediate answer, volunteered by our resident wiseacre, was "stubbornness."

That quip strikes me as about right. I have some sense of "why I ski," and here, too, the list could be a long one. One reason must be the incongruity of the act. I don't belong on the mountain. I'm urban, cerebral, unathletic, uncoordinated, not at all handy, and reasonably comfort-loving. Carved turns and I make a beautiful-woman-with-Woody-Allen mismatch. But don't we aspire to the very grace we lack?

Stubbornness explains a lot. I'm damned if I won't make my way down, and not just sideslipping either. I'd prefer to answer "why ski" in terms of exhilaration or the conquest of fear, but my persisting with the sport bespeaks a certain obstinacy; when I succeed (in limited fashion) that same trait must count among the explanations.

It's not that I like to think of myself as rigid. Much of what I value - creativity, empathy, problem-solving - depends on flexibility or multiplicity of viewpoint. But cussedness can be a virtue, or so I remind myself when dealing with patients who show that side first. Stubbornness gets you stuck in tight places, yes, but it gets you out of some, too.