Obsessively Yours

Ghostwritten Medical Articles Cast Doubt on Reliability of Psychiatric Drugs

Lennard J. Davis — Wed, 05 Aug 2009 17:31:22 +0000

The New York Times reported on Wednesday that Wyeth, the drug company that made Premarin used in estrogen replacement therapy, commissioned 26 ghostwritten articles that appeared in major medical journals. The articles hyped the value of estrogen replacement and downplayed the negatives. Evenutally, this therapy was discontinued as a routine way of treating menopausal women because of the dangers involved. The ghostwritten articles were actually not written by the doctors whose names appeared on the articles, and for the most part those doctors seemed to have played no major roles in the production of these articles other than endorsing a paycheck. Further, the journals were not informed that those doctors whose names appeared did not write these works,

This fact is a scandal in itself, but the idea of ghostwriting articles has been well documented earlier. Particularly in the hype around Prozac and similar SSRI's, scholars have called our attention to the fact that many articles were ghost written and published in prestigious journals to make it seem as if those drugs were incredibly effective in treating depression, OCD, and other difficult to treat disorders. The early days of Prozac were euphoric, with statistics indicating that over 70 per cent of people taking those drugs were helped dramatically. While there were very few randomized, double-blind experiments with such drugs, anecdotal and other types of articles appeared that touted these high rates of cure. Instrumental in this mix were the ghost-written articles with the names of well-known experts in the field published in significant and prestigious journals.

Now that the dust has settled, the New York Times and other journals have pointed out that the early estimates of the efficacy of SSRI's was skewed by over-eager researchers. The actual efficacy rates for Prozac-like drugs is more like 37 percent, a thirty percent drop from the initially enthusiastic rates. It's worth noting that 37 percent is only four points above the placebo effect, which is generally agreed on as being about 33 per cent effective. This fact, of course, doesn't discount the beneficial effects of SSRI's to those individuals for whom they work.

My point is that we need to be extremely careful when we read that "experts have said" or that "experiments have shown"-particularly when we are looking at difficult-to-treat affective disorders. Even when we note that articles have been peer-reviewed (and all these ghostwritten articles had been peer-reviewed) we are still dealing with human being capable of making flawed judgments. Herd mentality exists not just in bovine groups but even in academic and scholarly ones as well. Some studies have shown (caveat emptor) that almost 50 per cent of peer-reviewed articles eventually turn out of be wrong. Science attempts to reach certainty, but certainty never attempts to reach science.

OCD and Swine Flu--disorder or survival technique?

Lennard J. Davis — Sun, 03 May 2009 19:25:57 +0000

In my book Obsession: A History, I argue that much of what we call Obsessive Compulsive Disorder is dependent on the social-cultural surround. Swine flu or H1N1 virus provides us with a real-time way of proving my point.

If you believe that washing your hands a lot, avoiding contact with other humans, wearing a mask, and the like are useful behaviors, at this moment you will be seen as a good citizen aiding in the stopping of the flu and protecting yourself and your family. If it turns out that the swine flu is an overblown media phenomena, then your behavior will suddenly revert to being compulsive and your thinking about the spread of disease will be seen as obsessional. You will be seen as the problem, especially by members of your family.

Everything depends on the context.

If we want to argue that OCD is a brain disease or a neurochemical disorder and we can spot with fMRIs or PET scans where in brain it lives or which neurotransmitters govern the OCD response, then how can the very same activity--protecting against contamination-- be pathological in one instance and normal in another in the very same brain?

The arguments that I make in the book suggest that complex human behaviors like those found associated with anxiety disorders like OCD have a strong social, political, and historical grounding. While it is obviously true that people who are washing their hands, refusing to touch other people, and other such behaviors are suffering, it is not entirely clear, I would argue, whether the source of the suffering is the person alone or society at large.

Obsession: A History

Lennard J. Davis — Thu, 29 Jan 2009 20:34:45 +0000

I've been generally happy with the reviews of my new book Obsession: A History but a recent one requires a response. Dag Agins in The Huffington Post writes that when someone tries to cross the line between science and the humanities, that person ends up pleasing neither side of the divide. He particularly criticized my effort to show a continuity between obsession in the culture at large and obsession in a person. Agins tells us that we must never blur the clinical with the cultural and he ratifies the idea that diagnoses have to be somewhat rigid to clearly demarcate the pathology from the sociology. Yet, he ends up making contradictory remarks about diagnoses, saying that they are just labels and strategies, but then asserts that they are necessary.

I want to respond to his objections. There has for too long been the feeling that only people "in" the sciences can critique the sciences. This is a strange point to make since science prides itself on being an unbiased search for truth with all parties allowed to make inquiries and subject results to strict oversight. The objection that only scientists are allowed to criticize scientists is therefore a violation of the claim to objective truth. In fact, the role of the humanities is not simply to provide novels and poetry for doctors to read, but to teach and explore the use of language, the logic of an argument, and necessary grounds for rhetorical persuasion. No one disputes that the data are the data, but interpretation always intervenes between data collection and scientific conclusions.

So we need to look at Agins's language and reasoning itself: "...psychiatric categories are merely labels for clusters of symptoms, but it's also true that psychiatric categories of some kind are absolutely necessary in the clinic as a guide for what sort of behavior to expect from a patient. A psychiatric label is simply a practical device to assist in treatment." The summarization of his own data here isn't even logical. If diagnoses are "merely labels for clusters of symptoms," or "practical devices", then how can they be "necessary" in any scientific or rigorous way? If we said that "electrons" or "super novas" are only labels or devices, we would no longer be in the realm of science. If we are to examine such a cluster of symptoms as if it were a real thing, as we might in analyzing the neurochemistry or brain structure of people with OCD, then shouldn't we have a stronger sense that a diagnosis described a real thing rather than a cluster of symptoms?

Agins goes on to explain that although there isn't very good science now to explain what OCD is or how it works, nevertheless "people who are distressed by psychiatric symptoms do want and need treatment" and therefore "diagnostics and treatment must be constrained by pragmatism, by what seems to work." So in the end, Agins is saying in effect, "OK, we don't know what causes OCD or how the brain works in this disorder, but we have to do something since people come to us for help, and so we are forced to invent diagnoses that aren't proven by any rigorous system so that we can try treatments that ‘seem' to work." But the reality in OCD is that not only is there no diagnostic rigor but there are poor outcomes for patients who face a lifelong battle with the disorder. The best controlled statistics show that a third of patients get better, a third get worse, and a third remain the same. Anecdotal evidence is much more enthusiastic on the part of practitioners, as one would assume it would be with many websites for clinics claiming, without any controlled evidence, that their success rates are close to 70 per cent. Is that science?

Just because clincians are in the trenches doesn't mean they have the clearest view of what they do. Sometimes an educated observer from outside the specific profession can fly over the battlefield and get a better sense of the lay of the land. In fact, scientists are very good at one thing, detailing the increasingly narrow and specific mechanisms they study. What science isn't very good at, and where it needs people from the humanities-historians and sociologists of science, is in articulating the big picture and making logical claims about the implications of their particular discoveries.

Don't be fooled when a scientist tells you to keep out of his backyard. It's not done in the interest of science. It's done to protect the backyard.

The New York Times on the DSM V

Lennard J. Davis — Thu, 18 Dec 2008 16:46:39 +0000

The New York Times today carried a story about the machinations and politics behind the DSM V, the diagnostic and statistical manual used by therapists and medical doctors to assign diagnoses to patients seeking treatment.

What strikes us is that the DSM is one of the most obsessive works to come out in the long and obsessive history of psychiatry and psychotherapy. It catalogues in scrupulous detail the symptoms needed to achieve a diagnosis of a particular disease entity (that's a term I use to indicate that in the case of affective disorders symptoms can be organized in different ways and produce different diagnoses). The point is that many of the illnesses listed are made by committees that have to determine which symptoms, how many, and how frequently they occur can tip the balance and produce the diagnosis. Obsessive physicians and researchers are obsessively studying people who may themselves be labeled as obsessives.

Interestingly, the DSM IV TR says quite specifically that the purpose of the work is to "enhance agreement" among practitioners. This agreement, like other forms of consent, is manufactured, as we see with the NY Times report. Various groups are lobbying for and against the inclusion of new illnesses. So disease entities are more properly regarded as constructs created by obsessive cataloguers and researcher. This doesn't ‘mean that people can't suffer from such "diseases," but the etiology and the dispersal of these categories needs more scrupulous (I guess more obsessive) study themselves.

And if we look at OCD, we'll see a meteoric rise in the number of cases from the 1960's to now. Back in the day, OCD was an extremely rare disease, now the World Health Organization ranks it number four of all mental disorders. How did that rise come about? As with other disorders like bipolar depression and ADD, and now perhaps "shopping addiction," a complex mix of the social, cultural and economic have come into play and a mixed group of players like the writers of the DSM, the drug companies, and whatever zeitgeists are floating around-all have produced a social reality.

Axl Rose: Obsessive Monomaniac Perfectionist

Lennard J. Davis — Tue, 09 Dec 2008 23:32:21 +0000

The 15-year run of suspense is over. Guns N' Roses fans, and anyone who has followed the release of "Chinese Democracy," Axl Rose's grand obsession, can now buy the album. But the general consensus is that after all the obsessive work, perfectionism, and endless tinkering Rose has brought forth an over-worked, over produced, hash of lyrics with every instrument and style in the world rolled into one not-very-good album. In the course of his compulsive perfectionism, Rose went through three recording studios, four producers, and a slew of musicians. In doing so he ran up more than $13 million in production costs, making his album the most expensive recording never released.

In some ways, we might regard this as the latest act of a tortured genius in the great tradition of other tortured geniuses. The nineteenth century abounded with them, from Captain Ahab and his obsessive quest of his white whale to Frenhofer, Balzac's tortured painter and to Claude Lantier, Emile Zola's novelistic representation of Cezanne. What these driven people have in common is the desire to create, to capture, to produce something extraordinary. And yet all end up ruining the thing they want and destroying themselves in the process.

Balzac describes Frenhofer who works laboriously and endlessly on one painting in secret for very many years. He even manages to get a student to force his unwilling wife to pose nude for the great painter. Yet finally when the painting is revealed, it is so overworked that the central image of the nude beauty can't be seen by anyone except the deluded artist himself

Zola's Claude Lantier in the novel The Masterpiece paints his nude with such fury and determination that it takes over his life. He alternately falls in love with it, hates it, gouges the painting, scrapes it, tears it with a knife, and finally in an act of desperation and love, hangs himself in front of it.

Is there something inherently obsessive and self-consuming about creating art, and especially trying to create the ultimate work? If you aim high and pledge yourself to perfection, can you in fact destroy perfection? Axl Rose seem to have found the fatal flaw of failed art-the belief that you can force a work into being by sheer persistence over time.

Bob Dylan often wrote his songs in one sitting, while Axl took years. Is there a split between those artists who create effortlessly and those who labor unto death to produce something? In the former case, artists rely on that intuitive and obsessionless state called "flow" in which creativity happens effortlessly. But in the latter case creating can be excruciating and endless-and only obsession and compulsion can carry them through.
But in the case of Rose, his obsessive-compulsive nature didn't produce a masterpiece, it produced a disaster.

Obama erotomaniacs become stalkers?

Lennard J. Davis — Thu, 20 Nov 2008 15:19:26 +0000

During this election, frequently sighted at Obama rallies were women falling into a faint. These occurrences became so common that Obama would throw a bottle of water to the woman or routinely ask for medical care. Women weren’t just fainting from the heat or dehydration—they were fainting with love.
   Obsessive love for someone you don’t know is called “erotomania.” This is a longstanding category that dates from the time of the ancients. It was known as unrequited love or erotomania (“raving love”). Love sickness of this sort was linked to physical ailments and psychic distress. Called amor heroes in the 12th century by physicians, and “erotic melancholy” by Robert Burton, by the Renaissance it was seen as “a somatic disease of inflamed and congested genitals leading to disordered fantasy.” As André Du Laurens wrote in the sixteenth century, “the sillie loving worme cannot any more look upon any thing but his idol: al the functions of the bodie are likewise perverted, he becommeth pale, lean, souning.”
   Has a considerable portion of the US and world become enamored with Barack Obama? Our craze for celebrity is in many cases a form of erotomania, with many of us having crushes on people that we have never met and never will meet.
   But what happens when our obsessive love object begins to disappoint us? Stalkers can be erotomaniacs whose objects of desire reject them. Then obsessive love turns to obsessive attempts to get the attention of the lost object. Admiration can turn to hostility.
   In the past few days, there has been a new emotional theme in the opinion pieces about Barack Obama and his choice of cabinet staff. Is Barack beginning to disappoint us by picking former Clinton appointees who are not connected with the message of “change?”
I’ve noticed in political writing the faint beginnings of what might become stalker rage. I am wondering if we need to wonder what happens when the fainting women turn into disappointed erotomaniacs who begin to haunt our President-elect in less supine and more actively angry ways. Can a fainting erotomaniac turn into a devoted voter wronged? Hell hath no fury, apparently.

Sex Addiction? An Obsession? A Disease?

Lennard J. Davis — Tue, 04 Nov 2008 21:06:42 +0000

Actor David Duchovny, who plays a sex-addicted writer in the TV series Californication, had recently checked himself into and now out of Meadows Rehab in Arizona for being, well, sex addicted in real life. This story is more than just one about life imitating art, it is also about sex addiction imitating drug and alcohol addiction.

While there are a growing number of people who believe you can be addicted to sex-just as you can be addicted to shopping or to work-many psychological practitioners would disagree. Indeed, sex addiction is not currently in the DSM, the standard diagnostic manual for psychiatric disorders. Addiction, according to that guide, has to be an addiction to a substance. If you're an alcoholic, it's booze; if you're a drug addict, it's heroin or Percodans. But if you're addicted to sex, what exactly is the substance?

In this age of brain chemistry, some argue, without any serious laboratory proof, that you are addicted to your own neurotransmitters. They claim that sex produces dopamine, serotonin, and oxytocin-and some people get addicted to those chemicals. But the argument is specious-is someone who is happy addicted to their own seratonin? Or are nursing mothers addicted to prolactin? Can you be addicted doing, as the song says, "what comes naturally?" To understand the craze to explain behaviors like infidelity, sex with multiple partners or prostitutes, or simply serial one-night stands as medical phenomena, you need to take a long look at how America deals with obsessive behavior.

In order know if a behavior is obsessive or excessive, you have to come up with what normal sex might look like. There is a long and hopeless history of specialists trying to establish those norms-from Victorian ideas about the dangers of masturbation and promiscuity to statistical analyses by Masters and Johnson to a late 20th century notion that anything between consenting adults is normal. But throughout, in repressive or progressive times, people have tried, and failed, to come up with what would be sexually normal-normal in terms of frequency, object of desire, and intensity.

Somewhere in the post-sixties world, sex addiction was invented. The founders of the idea were called, and still are, Sex and Love Anonymous. For them sex addiction is a "progressive illness" that cannot be cured but only be arrested. Using the language of Alcoholics Anonymous they want to remain sexually "sober." If you read through their forty questions for self-analysis, you'll find it hard to understand where the line is drawn between the cultural goal of being in love and having a lot of sex and the medical goal of cure or 12-step aim of sobriety.

The Meadows Rehab, where Duchovny is now getting sexually sober, is the end result of a popular movement to define and treat sex addiction. Its senior fellows are listed as: Pia Mellody, author of Facing Love Addiction and Breaking Free, Claudia Black, author of It will Never Happen to Me and Changing Course, and Patrick Carnes, author of Out of the Shadows and The Betrayal Bond. None of them are medical doctors but what they all share in common is that they wrote best-selling books on addiction, sex addiction, and co-dependency. In other words, sex addiction was invented by a self-help group aided by popular books. It is trying now to move over into a medical condition. One way is to abandon the addiction model and move over to a compulsion model. Compulsive behavior is listed in the DSM as part of OCD. And new journals in the field combine both as in Sexual Addiction and Compulsivity: the Journal of Treatment and Prevention. Compulsivity gets the issue out of the demotic 12-Step programs where it began and into the psychiatrist, therapist, and mental-health practitioner's office.

But is sex addiction a real thing? It's real in the sense that people say they have it. But it is invented in the sense that how much sex you have, how happy you are with that, how guilty you feel about what you do in the dark with whom are all heavily subject to culture and morality. Our culture is, after all, obsessed with sex, and obsessed with controlling sex. Sex addiction is the perfect poster boy to embody that dichotomy.