Paul J. Fink

Exposure to violent media results in brain changes that might desensitize teen boys to aggression. Should we advise patients in therapy to stay away from violent media?

Research tends to narrow a question to a researchable conclusion. The question above is not only of concern to those of us in psychiatry; it worries parents and teachers alike.

The question refers to an article published last month (“On-Screen Violence May Desensitize Teen Boys”).

Instead of approaching the issue from a biopsychosocial point of view, it is immediately medicalized, and conclusions and solutions are derived from the major premise.

I am a great believer in the biopsychosocial ethos and our need to rise above the rest of medicine.

Even if these researchers are correct in their findings, this is just a tiny corner of the data we have on the causes of adolescent violence. Desensitization is important, but its causes are many. One example is growing up in a house devoid of empathy, so that the child has no one to whom he can talk and receive an empathetic response. Empathy is learned and only can be achieved through love. If the child has not felt love, he cannot be empathic. It is a critical factor when we try to understand how an adolescent could take the life of another. He has no ability to put himself in the other person's shoes.

This area of youth violence is one that I have been working in for almost 2 decades, and I am pleased to have some biological evidence about aggression. Experiments using neuroimaging are always engaging, but they still leave many psychosocial discoveries as peripheral to the central biological theses.

For example, we have discovered markers for murdering someone or getting murdered. These include bullying; dropping out of school; being a chronic truant – often leading to illiteracy; and getting suspended from school multiple times. None of these markers correlate with parts of the brain underlying these kinds of behaviors.

Perhaps researchers in the future will be able to trace each of these markers to functional magnetic resonance imaging (fMRI) changes, which, in turn, could help develop methods for reducing these behaviors. But I doubt it.

Bullying has recently received much attention, especially the phenomenon of cyberbullying, which has resulted in numerous suicides across the country. In each of the markers I have mentioned, multiple factors are driving the child to make them happen.

Negative self-image is a major factor that causes adolescents to strike out, retaliate, take action to preserve their manhood, and find ways to feel better about themselves.

A young man went to apply for a job and kept saying to his mentor after the interview: “They'll never hire me,” over and over again. It was an inappropriate reaction, but his self-esteem was so poor that he could only have a negative response. Feeling worthless is not a genetic trait. It is imbued in the child from early life. If a mother tells her son: “You can't do it”; “You're worthless”; “Everything you touch is ruined,” the child's sense of value is permanently damaged.

Many aggressive adolescents are angry – very angry! The most important reason for their anger is the absence of a father in their lives. They feel it keenly. If their father was never there, is in jail, or is on the streets, the child feels it. The key is the absence of a relationship or interaction between the two. I recommend that every psychiatrist see an outstanding documentary called “Oh Father…Where Art Thou?” It is a provocative movie filmed across two continents that demonstrates the value of a father or male mentor in the life of a young boy.

Another reason for the anger is the continual punishment a child receives, perhaps for an aggressive act. The failure on the part of the adult to understand why the child did what he did is a key factor that stimulates anger. I have written many times about the negative effects of corporal punishment and physical abuse. I am saddened to report that 95% of American children experience hitting. Many children expect to get beaten and talk about it as adults with a sense of pride. But it carries a price (as does verbal shaming).

Punishment in the home is only part of it. Punishment in school also is quite common: In many U.S. states, corporal punishment remains legal and acceptable in schools. About 25% of adolescents continue to absorb blows from adults – which singularly is a humiliation that is antagonistic to the child's developmental goal of autonomy. Unfortunately, suspension is used as punishment, and, as I stated earlier, multiple suspensions from school are markers for getting killed. In Philadelphia, a 17-year-old boy accumulated 57 suspensions from school before he was murdered.

The street also is a place where children are punished by bullying from their peers and “older heads”; they also are chased by neighbors and others who do not want “bad kids” crowding their streets.

Another cause for adolescent male aggression involves their continual search for respect, which I interpret as a search for someone – a peer, adult, mentor, teacher – with whom they can talk. It is imperative that we adults learn how to talk to young people.

We are frightened of them. We don't listen to them or even express curiosity about their feelings – assuming that they have none. This is an enormous flaw in our society when it comes to our children.

Another locus for punishment is the public-safety sector – lawyers, courts, judges, police – where the right questions are not asked and punishment is the end point. Whether it's jail, probation, rough treatment, or whatever the adults want to do or say, the child is subject to them.

Much more important than these violent videotapes is the failure to engage the child and make him feel like he matters. There is an element of ageism here that I find troubling, too. Adults think: “He's the child; I'm the adult. I'll straighten him out.” In these situations, the adolescent comes out feeling badly treated and needing, and practically pleading for an adult who will talk to him. I can't tell you how many times I've heard a young person say: “It's not fair.” The thing is, when they describe what happened, it sounds unfair, indeed. Our society needs to change our attitudes toward and treatment of our young people.

When thinking about youth violence, we first must consider the psychological, familial, environmental, as well as biological factors that can come together in one child to take him down the road of aggression and violence, often landing him in a morgue or behind bars.

So many young men end up in jail for life with no opportunity to get anywhere near their goals, use their natural talents and skills, or speak out on their own behalf. When we deal with a young man who is caught up in either the courts or the mental health system, we must first ask: “What happened to you?” We must find out about the traumas, abuses, losses, and punishments he has endured, and help him forgive himself.

And we must remember to treat him with respect, an act that can open up the door to trust. These are children who never trusted anyone – let alone an adult. To reverse that, we need to look at all of the factors in their lives that led to their current predicament.

Too often, we jump to conclusions and end up oppressing the child because of our prejudices.

The current movie, “Conviction,” is a perfect example of these dynamics. Our young people need an even playing field – and a chance.

Exposure to violent media results in brain changes that might desensitize teen boys to aggression. Should we advise patients in therapy to stay away from violent media?

Research tends to narrow a question to a researchable conclusion. The question above is not only of concern to those of us in psychiatry; it worries parents and teachers alike.

The question refers to an article published last month (“On-Screen Violence May Desensitize Teen Boys”).

Instead of approaching the issue from a biopsychosocial point of view, it is immediately medicalized, and conclusions and solutions are derived from the major premise.

I am a great believer in the biopsychosocial ethos and our need to rise above the rest of medicine.

Even if these researchers are correct in their findings, this is just a tiny corner of the data we have on the causes of adolescent violence. Desensitization is important, but its causes are many. One example is growing up in a house devoid of empathy, so that the child has no one to whom he can talk and receive an empathetic response. Empathy is learned and only can be achieved through love. If the child has not felt love, he cannot be empathic. It is a critical factor when we try to understand how an adolescent could take the life of another. He has no ability to put himself in the other person's shoes.

This area of youth violence is one that I have been working in for almost 2 decades, and I am pleased to have some biological evidence about aggression. Experiments using neuroimaging are always engaging, but they still leave many psychosocial discoveries as peripheral to the central biological theses.

For example, we have discovered markers for murdering someone or getting murdered. These include bullying; dropping out of school; being a chronic truant – often leading to illiteracy; and getting suspended from school multiple times. None of these markers correlate with parts of the brain underlying these kinds of behaviors.

Perhaps researchers in the future will be able to trace each of these markers to functional magnetic resonance imaging (fMRI) changes, which, in turn, could help develop methods for reducing these behaviors. But I doubt it.

Bullying has recently received much attention, especially the phenomenon of cyberbullying, which has resulted in numerous suicides across the country. In each of the markers I have mentioned, multiple factors are driving the child to make them happen.

Negative self-image is a major factor that causes adolescents to strike out, retaliate, take action to preserve their manhood, and find ways to feel better about themselves.

A young man went to apply for a job and kept saying to his mentor after the interview: “They'll never hire me,” over and over again. It was an inappropriate reaction, but his self-esteem was so poor that he could only have a negative response. Feeling worthless is not a genetic trait. It is imbued in the child from early life. If a mother tells her son: “You can't do it”; “You're worthless”; “Everything you touch is ruined,” the child's sense of value is permanently damaged.

Many aggressive adolescents are angry – very angry! The most important reason for their anger is the absence of a father in their lives. They feel it keenly. If their father was never there, is in jail, or is on the streets, the child feels it. The key is the absence of a relationship or interaction between the two. I recommend that every psychiatrist see an outstanding documentary called “Oh Father…Where Art Thou?” It is a provocative movie filmed across two continents that demonstrates the value of a father or male mentor in the life of a young boy.

Another reason for the anger is the continual punishment a child receives, perhaps for an aggressive act. The failure on the part of the adult to understand why the child did what he did is a key factor that stimulates anger. I have written many times about the negative effects of corporal punishment and physical abuse. I am saddened to report that 95% of American children experience hitting. Many children expect to get beaten and talk about it as adults with a sense of pride. But it carries a price (as does verbal shaming).

Punishment in the home is only part of it. Punishment in school also is quite common: In many U.S. states, corporal punishment remains legal and acceptable in schools. About 25% of adolescents continue to absorb blows from adults – which singularly is a humiliation that is antagonistic to the child's developmental goal of autonomy. Unfortunately, suspension is used as punishment, and, as I stated earlier, multiple suspensions from school are markers for getting killed. In Philadelphia, a 17-year-old boy accumulated 57 suspensions from school before he was murdered.

The street also is a place where children are punished by bullying from their peers and “older heads”; they also are chased by neighbors and others who do not want “bad kids” crowding their streets.

Another cause for adolescent male aggression involves their continual search for respect, which I interpret as a search for someone – a peer, adult, mentor, teacher – with whom they can talk. It is imperative that we adults learn how to talk to young people.

We are frightened of them. We don't listen to them or even express curiosity about their feelings – assuming that they have none. This is an enormous flaw in our society when it comes to our children.

Another locus for punishment is the public-safety sector – lawyers, courts, judges, police – where the right questions are not asked and punishment is the end point. Whether it's jail, probation, rough treatment, or whatever the adults want to do or say, the child is subject to them.

Much more important than these violent videotapes is the failure to engage the child and make him feel like he matters. There is an element of ageism here that I find troubling, too. Adults think: “He's the child; I'm the adult. I'll straighten him out.” In these situations, the adolescent comes out feeling badly treated and needing, and practically pleading for an adult who will talk to him. I can't tell you how many times I've heard a young person say: “It's not fair.” The thing is, when they describe what happened, it sounds unfair, indeed. Our society needs to change our attitudes toward and treatment of our young people.

When thinking about youth violence, we first must consider the psychological, familial, environmental, as well as biological factors that can come together in one child to take him down the road of aggression and violence, often landing him in a morgue or behind bars.

So many young men end up in jail for life with no opportunity to get anywhere near their goals, use their natural talents and skills, or speak out on their own behalf. When we deal with a young man who is caught up in either the courts or the mental health system, we must first ask: “What happened to you?” We must find out about the traumas, abuses, losses, and punishments he has endured, and help him forgive himself.

And we must remember to treat him with respect, an act that can open up the door to trust. These are children who never trusted anyone – let alone an adult. To reverse that, we need to look at all of the factors in their lives that led to their current predicament.

Too often, we jump to conclusions and end up oppressing the child because of our prejudices.

The current movie, “Conviction,” is a perfect example of these dynamics. Our young people need an even playing field – and a chance.

Exposure to violent media results in brain changes that might desensitize teen boys to aggression. Should we advise patients in therapy to stay away from violent media?

Research tends to narrow a question to a researchable conclusion. The question above is not only of concern to those of us in psychiatry; it worries parents and teachers alike.

The question refers to an article published last month (“On-Screen Violence May Desensitize Teen Boys”).

Instead of approaching the issue from a biopsychosocial point of view, it is immediately medicalized, and conclusions and solutions are derived from the major premise.

I am a great believer in the biopsychosocial ethos and our need to rise above the rest of medicine.

Even if these researchers are correct in their findings, this is just a tiny corner of the data we have on the causes of adolescent violence. Desensitization is important, but its causes are many. One example is growing up in a house devoid of empathy, so that the child has no one to whom he can talk and receive an empathetic response. Empathy is learned and only can be achieved through love. If the child has not felt love, he cannot be empathic. It is a critical factor when we try to understand how an adolescent could take the life of another. He has no ability to put himself in the other person's shoes.

This area of youth violence is one that I have been working in for almost 2 decades, and I am pleased to have some biological evidence about aggression. Experiments using neuroimaging are always engaging, but they still leave many psychosocial discoveries as peripheral to the central biological theses.

For example, we have discovered markers for murdering someone or getting murdered. These include bullying; dropping out of school; being a chronic truant – often leading to illiteracy; and getting suspended from school multiple times. None of these markers correlate with parts of the brain underlying these kinds of behaviors.

Perhaps researchers in the future will be able to trace each of these markers to functional magnetic resonance imaging (fMRI) changes, which, in turn, could help develop methods for reducing these behaviors. But I doubt it.

Bullying has recently received much attention, especially the phenomenon of cyberbullying, which has resulted in numerous suicides across the country. In each of the markers I have mentioned, multiple factors are driving the child to make them happen.

Negative self-image is a major factor that causes adolescents to strike out, retaliate, take action to preserve their manhood, and find ways to feel better about themselves.

A young man went to apply for a job and kept saying to his mentor after the interview: “They'll never hire me,” over and over again. It was an inappropriate reaction, but his self-esteem was so poor that he could only have a negative response. Feeling worthless is not a genetic trait. It is imbued in the child from early life. If a mother tells her son: “You can't do it”; “You're worthless”; “Everything you touch is ruined,” the child's sense of value is permanently damaged.

Many aggressive adolescents are angry – very angry! The most important reason for their anger is the absence of a father in their lives. They feel it keenly. If their father was never there, is in jail, or is on the streets, the child feels it. The key is the absence of a relationship or interaction between the two. I recommend that every psychiatrist see an outstanding documentary called “Oh Father…Where Art Thou?” It is a provocative movie filmed across two continents that demonstrates the value of a father or male mentor in the life of a young boy.

Another reason for the anger is the continual punishment a child receives, perhaps for an aggressive act. The failure on the part of the adult to understand why the child did what he did is a key factor that stimulates anger. I have written many times about the negative effects of corporal punishment and physical abuse. I am saddened to report that 95% of American children experience hitting. Many children expect to get beaten and talk about it as adults with a sense of pride. But it carries a price (as does verbal shaming).

Punishment in the home is only part of it. Punishment in school also is quite common: In many U.S. states, corporal punishment remains legal and acceptable in schools. About 25% of adolescents continue to absorb blows from adults – which singularly is a humiliation that is antagonistic to the child's developmental goal of autonomy. Unfortunately, suspension is used as punishment, and, as I stated earlier, multiple suspensions from school are markers for getting killed. In Philadelphia, a 17-year-old boy accumulated 57 suspensions from school before he was murdered.

The street also is a place where children are punished by bullying from their peers and “older heads”; they also are chased by neighbors and others who do not want “bad kids” crowding their streets.

Another cause for adolescent male aggression involves their continual search for respect, which I interpret as a search for someone – a peer, adult, mentor, teacher – with whom they can talk. It is imperative that we adults learn how to talk to young people.

We are frightened of them. We don't listen to them or even express curiosity about their feelings – assuming that they have none. This is an enormous flaw in our society when it comes to our children.

Another locus for punishment is the public-safety sector – lawyers, courts, judges, police – where the right questions are not asked and punishment is the end point. Whether it's jail, probation, rough treatment, or whatever the adults want to do or say, the child is subject to them.

Much more important than these violent videotapes is the failure to engage the child and make him feel like he matters. There is an element of ageism here that I find troubling, too. Adults think: “He's the child; I'm the adult. I'll straighten him out.” In these situations, the adolescent comes out feeling badly treated and needing, and practically pleading for an adult who will talk to him. I can't tell you how many times I've heard a young person say: “It's not fair.” The thing is, when they describe what happened, it sounds unfair, indeed. Our society needs to change our attitudes toward and treatment of our young people.

When thinking about youth violence, we first must consider the psychological, familial, environmental, as well as biological factors that can come together in one child to take him down the road of aggression and violence, often landing him in a morgue or behind bars.

So many young men end up in jail for life with no opportunity to get anywhere near their goals, use their natural talents and skills, or speak out on their own behalf. When we deal with a young man who is caught up in either the courts or the mental health system, we must first ask: “What happened to you?” We must find out about the traumas, abuses, losses, and punishments he has endured, and help him forgive himself.

And we must remember to treat him with respect, an act that can open up the door to trust. These are children who never trusted anyone – let alone an adult. To reverse that, we need to look at all of the factors in their lives that led to their current predicament.

Too often, we jump to conclusions and end up oppressing the child because of our prejudices.

The current movie, “Conviction,” is a perfect example of these dynamics. Our young people need an even playing field – and a chance.

A recent study shows that dysthymic disorder leads to more disability than major depressive disorder. How should we think about dysthymic disorder?

Dysthymic disorder is one of those diagnoses in the DSM-IV that seems to be characterized by ambiguity. I think that many psychiatrists like me do not use this category very often because we see it as a fall-back diagnosis. For example, if you don't think that the patient has a serious depression, you might call it dysthymic disorder.

The finding of Dr. Jonathan W. Stewart and his colleagues that dysthymic disorder causes a “significant public health burden” that carries with it a significant amount of disability (“Dysthymic Disorder Causes More Disability Than Major Depression” ) is in line with what I've seen over the years. Coming up with effective treatment for these patients is particularly challenging.

My approach is to do a careful assessment of a patient who complains of depression. If I don't believe that supporting evidence of major depressive disorder exists (MDD), I will call it dysthymic disorder and look for a “major” diagnosis for the patient. I always use dysthymia as a secondary condition. The patient talks depressed but doesn't look depressed. Since the entire category of depression is under affective disorders in the DSM-IV, I expect a great deal of affective symptomatology for MDD and still some in dysthymic disorder.

Inability to Work Is Key

An important component is the degree of impairment in these patients. They can't get to work and are inconsistent. According to Dr. Stewart, “dysthymia is what ruins people's lives.” Work history, history of success, and failure in social settings are clearly part of dysthymic disorder. These patients also consume more Medicare, Medicaid, and Social Security Disability Insurance than do people with other forms of depression. These patients also had fewer full-time jobs than did those with other diagnoses.

These objective findings are important, because patients with dysthymic disorder do not have a lot of symptoms. They know they do not feel good; instead they are sad, not joyous, and have a lot of self-blame and guilt. The patient's failure in social engagement and poor work history are important factors to note. The patient rarely has a lot of vegetative signs. Sleep is the exception. The dysthymic disorder patient has some sleep disturbance, but not of the degree found in MDD or bipolar illness.

I was trying to provide a case history for this essay and couldn't come up with a patient who had a pure DD. As I said in the beginning, the diagnosis reminds me of “not otherwise specified” or the way in which the ER physician decides that the patient has a psychiatric illness–he can't find anything physiologically definitive to affirm a diagnosis in his mind.

When I interview a patient who has been on the inpatient service, there is a group of them who respond to my question, “When did you first become depressed,” with a quick, “I've been depressed all my life.” When I get that answer, I search for a history of physical, sexual, and/or emotional abuse early in that person's life. The person sitting in front of me might not be clearly depressed, but between major depressions–the sense of a lifetime of depression might actually be dysthymic.

If we were to plot the illness, perhaps it would look like a sine curve graph. This is just a conjecture, but it might look like this: dysthymic–MDD–suicide attempt–dysthymic disorder–MDD–suicide attempt, and so on. We have all seen patients like this. Nothing is accomplished; the patient has no job and usually no attachments; the family is not interested. I would like to hear from others who have seen this kind of syndrome or life history. We know that when a patient says she has been depressed her whole life, that is that patient's impression retrospectively to what happened between major episodes. I have found that major depressive episodes are aborted by a suicide attempt, usually with hospitalization and a discharge. But discharge to what?

The dysthymic patient needs a support system that he usually does not have. And he does not know how to reach out and build such a system.

One man I saw who fit this description had had four intense affairs with women but was unable to consummate any of the relationships into marriage. Of course, he took no responsibility for the breakdown between him and any of the women.

In long-term outpatient cases, we see the diagnosis changing from year to year. In one patient I saw for more than 2 decades, his condition varied over time. He was never free of complaint and sometimes would talk of his depression, which generally was not visible. Yet, there were times in which he became seriously depressed with a lot of crying and discomfort. Again, at other times, his affect was not deeply impaired. Looking back, I would say that this patient had dysthymia at those times.

We have to keep our eye on the diagnostic ball and not feel constrained to keep our original diagnosis as a sacred cow. People change over time and as a result of therapy. We see these changes but usually do not note them. There are numerous anxiety disorders, and we do not find it strange for people to go from one to another. I am suggesting that the same is true of the depressive spectrum.

Dr. Stewart's thesis is that dysthymic patients have more disability than other depressive disorders. We need to assess the psychosomatic symptomatology of these patients and other kinds of psychiatric disability. We already have reviewed some of the major disabling behaviors. What I believe is most disabling is the chronic nature of the illness, the length of time the person feels bad, the complaints, and, in particular, the unhappiness.

Viewing the Illness as Cyclical

I am caring for a patient now with bipolar illness who seemed very depressed for months and then, with a change in medication, became manic–loud, disruptive, very talkative, and filled with complaints. That was a real change from his depressive state. He started going out, seeing people, and was overjoyed with his “improvement.”

Recently, however, this patient has become less joyous, filled with physical complaints of all kinds, and unable to do anything. He quit his part time job and now complains of having nothing to do. He says repeatedly, “I am not depressed,” but he also is not manic. I think he is dysthymic at this time–although the DSM-IV would disagree with me.

On some points, the DSM-IV is clear about dysthymia. It starts early in life, is chronic, and must last for 2 years before one can call a patient dysthymic. Other symptoms include poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.

All of these symptoms also are seen in MDD. This tells us why the diagnosis is so difficult to make. From what I've already said, I don't agree with the DSM-IV about the absence of any full depression in the 2-year period that must precede diagnosis, according to the manual. Most important is the long-term nature of the disorder. For example, the patient who says “I've been depressed all my life” could be a candidate.

The extent to which this diagnosis is related to abuse and trauma in childhood never has been studied. Whenever a person tells me about a lifetime of unhappiness, I inquire about abuse and trauma. What started a life of unhappiness? In the movie “Precious,” the main character says “no one ever loved me,” a pathetic moment in the film but true of many children we see today. Alice Miller, Ph.D., the researcher on childhood, says a child must have one person in his life who gives him unconditional love.

Unconditional love is just what the name implies: no constant criticism (emotional abuse), no constant punishment (physical abuse), and protection from getting hurt or further abused by people, at school, or on the street. Without it, the child might develop dysthymia. I see people gratuitously hitting children in public venues, and being shamed in this way can lead to dysthymia.

Recently, I attended an alternative high school graduation. I was sitting next to a family in which the mother had a 4-year-old on her lap, constantly hit the boy, and yelled “Shut the [expletive] up.” The grandmother eventually rescued the boy, and he ran to her as fast as he could. Later during the program, he ended up back with his mother and she started her admonition again. Finally, she sat the little fellow in her chair and stood right in front of him so that she could see the events. All he could look at was the back of her body. I was very upset by witnessing firsthand what this boy was going through. Of course, I have no way of following up on the child 10 or 15 years from now to see how he is doing. But I can predict that he will either be delinquent or dysthymic.

Those of us who practice in the office each day must be vigilant about identifying dysthymia disorder and finding effective treatments.

A recent study shows that dysthymic disorder leads to more disability than major depressive disorder. How should we think about dysthymic disorder?

Dysthymic disorder is one of those diagnoses in the DSM-IV that seems to be characterized by ambiguity. I think that many psychiatrists like me do not use this category very often because we see it as a fall-back diagnosis. For example, if you don't think that the patient has a serious depression, you might call it dysthymic disorder.

The finding of Dr. Jonathan W. Stewart and his colleagues that dysthymic disorder causes a “significant public health burden” that carries with it a significant amount of disability (“Dysthymic Disorder Causes More Disability Than Major Depression” ) is in line with what I've seen over the years. Coming up with effective treatment for these patients is particularly challenging.

My approach is to do a careful assessment of a patient who complains of depression. If I don't believe that supporting evidence of major depressive disorder exists (MDD), I will call it dysthymic disorder and look for a “major” diagnosis for the patient. I always use dysthymia as a secondary condition. The patient talks depressed but doesn't look depressed. Since the entire category of depression is under affective disorders in the DSM-IV, I expect a great deal of affective symptomatology for MDD and still some in dysthymic disorder.

Inability to Work Is Key

An important component is the degree of impairment in these patients. They can't get to work and are inconsistent. According to Dr. Stewart, “dysthymia is what ruins people's lives.” Work history, history of success, and failure in social settings are clearly part of dysthymic disorder. These patients also consume more Medicare, Medicaid, and Social Security Disability Insurance than do people with other forms of depression. These patients also had fewer full-time jobs than did those with other diagnoses.

These objective findings are important, because patients with dysthymic disorder do not have a lot of symptoms. They know they do not feel good; instead they are sad, not joyous, and have a lot of self-blame and guilt. The patient's failure in social engagement and poor work history are important factors to note. The patient rarely has a lot of vegetative signs. Sleep is the exception. The dysthymic disorder patient has some sleep disturbance, but not of the degree found in MDD or bipolar illness.

I was trying to provide a case history for this essay and couldn't come up with a patient who had a pure DD. As I said in the beginning, the diagnosis reminds me of “not otherwise specified” or the way in which the ER physician decides that the patient has a psychiatric illness–he can't find anything physiologically definitive to affirm a diagnosis in his mind.

When I interview a patient who has been on the inpatient service, there is a group of them who respond to my question, “When did you first become depressed,” with a quick, “I've been depressed all my life.” When I get that answer, I search for a history of physical, sexual, and/or emotional abuse early in that person's life. The person sitting in front of me might not be clearly depressed, but between major depressions–the sense of a lifetime of depression might actually be dysthymic.

If we were to plot the illness, perhaps it would look like a sine curve graph. This is just a conjecture, but it might look like this: dysthymic–MDD–suicide attempt–dysthymic disorder–MDD–suicide attempt, and so on. We have all seen patients like this. Nothing is accomplished; the patient has no job and usually no attachments; the family is not interested. I would like to hear from others who have seen this kind of syndrome or life history. We know that when a patient says she has been depressed her whole life, that is that patient's impression retrospectively to what happened between major episodes. I have found that major depressive episodes are aborted by a suicide attempt, usually with hospitalization and a discharge. But discharge to what?

The dysthymic patient needs a support system that he usually does not have. And he does not know how to reach out and build such a system.

One man I saw who fit this description had had four intense affairs with women but was unable to consummate any of the relationships into marriage. Of course, he took no responsibility for the breakdown between him and any of the women.

In long-term outpatient cases, we see the diagnosis changing from year to year. In one patient I saw for more than 2 decades, his condition varied over time. He was never free of complaint and sometimes would talk of his depression, which generally was not visible. Yet, there were times in which he became seriously depressed with a lot of crying and discomfort. Again, at other times, his affect was not deeply impaired. Looking back, I would say that this patient had dysthymia at those times.

We have to keep our eye on the diagnostic ball and not feel constrained to keep our original diagnosis as a sacred cow. People change over time and as a result of therapy. We see these changes but usually do not note them. There are numerous anxiety disorders, and we do not find it strange for people to go from one to another. I am suggesting that the same is true of the depressive spectrum.

Dr. Stewart's thesis is that dysthymic patients have more disability than other depressive disorders. We need to assess the psychosomatic symptomatology of these patients and other kinds of psychiatric disability. We already have reviewed some of the major disabling behaviors. What I believe is most disabling is the chronic nature of the illness, the length of time the person feels bad, the complaints, and, in particular, the unhappiness.

Viewing the Illness as Cyclical

I am caring for a patient now with bipolar illness who seemed very depressed for months and then, with a change in medication, became manic–loud, disruptive, very talkative, and filled with complaints. That was a real change from his depressive state. He started going out, seeing people, and was overjoyed with his “improvement.”

Recently, however, this patient has become less joyous, filled with physical complaints of all kinds, and unable to do anything. He quit his part time job and now complains of having nothing to do. He says repeatedly, “I am not depressed,” but he also is not manic. I think he is dysthymic at this time–although the DSM-IV would disagree with me.

On some points, the DSM-IV is clear about dysthymia. It starts early in life, is chronic, and must last for 2 years before one can call a patient dysthymic. Other symptoms include poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.

All of these symptoms also are seen in MDD. This tells us why the diagnosis is so difficult to make. From what I've already said, I don't agree with the DSM-IV about the absence of any full depression in the 2-year period that must precede diagnosis, according to the manual. Most important is the long-term nature of the disorder. For example, the patient who says “I've been depressed all my life” could be a candidate.

The extent to which this diagnosis is related to abuse and trauma in childhood never has been studied. Whenever a person tells me about a lifetime of unhappiness, I inquire about abuse and trauma. What started a life of unhappiness? In the movie “Precious,” the main character says “no one ever loved me,” a pathetic moment in the film but true of many children we see today. Alice Miller, Ph.D., the researcher on childhood, says a child must have one person in his life who gives him unconditional love.

Unconditional love is just what the name implies: no constant criticism (emotional abuse), no constant punishment (physical abuse), and protection from getting hurt or further abused by people, at school, or on the street. Without it, the child might develop dysthymia. I see people gratuitously hitting children in public venues, and being shamed in this way can lead to dysthymia.

Recently, I attended an alternative high school graduation. I was sitting next to a family in which the mother had a 4-year-old on her lap, constantly hit the boy, and yelled “Shut the [expletive] up.” The grandmother eventually rescued the boy, and he ran to her as fast as he could. Later during the program, he ended up back with his mother and she started her admonition again. Finally, she sat the little fellow in her chair and stood right in front of him so that she could see the events. All he could look at was the back of her body. I was very upset by witnessing firsthand what this boy was going through. Of course, I have no way of following up on the child 10 or 15 years from now to see how he is doing. But I can predict that he will either be delinquent or dysthymic.

Those of us who practice in the office each day must be vigilant about identifying dysthymia disorder and finding effective treatments.

A recent study shows that dysthymic disorder leads to more disability than major depressive disorder. How should we think about dysthymic disorder?

Dysthymic disorder is one of those diagnoses in the DSM-IV that seems to be characterized by ambiguity. I think that many psychiatrists like me do not use this category very often because we see it as a fall-back diagnosis. For example, if you don't think that the patient has a serious depression, you might call it dysthymic disorder.

The finding of Dr. Jonathan W. Stewart and his colleagues that dysthymic disorder causes a “significant public health burden” that carries with it a significant amount of disability (“Dysthymic Disorder Causes More Disability Than Major Depression” ) is in line with what I've seen over the years. Coming up with effective treatment for these patients is particularly challenging.

My approach is to do a careful assessment of a patient who complains of depression. If I don't believe that supporting evidence of major depressive disorder exists (MDD), I will call it dysthymic disorder and look for a “major” diagnosis for the patient. I always use dysthymia as a secondary condition. The patient talks depressed but doesn't look depressed. Since the entire category of depression is under affective disorders in the DSM-IV, I expect a great deal of affective symptomatology for MDD and still some in dysthymic disorder.

Inability to Work Is Key

An important component is the degree of impairment in these patients. They can't get to work and are inconsistent. According to Dr. Stewart, “dysthymia is what ruins people's lives.” Work history, history of success, and failure in social settings are clearly part of dysthymic disorder. These patients also consume more Medicare, Medicaid, and Social Security Disability Insurance than do people with other forms of depression. These patients also had fewer full-time jobs than did those with other diagnoses.

These objective findings are important, because patients with dysthymic disorder do not have a lot of symptoms. They know they do not feel good; instead they are sad, not joyous, and have a lot of self-blame and guilt. The patient's failure in social engagement and poor work history are important factors to note. The patient rarely has a lot of vegetative signs. Sleep is the exception. The dysthymic disorder patient has some sleep disturbance, but not of the degree found in MDD or bipolar illness.

I was trying to provide a case history for this essay and couldn't come up with a patient who had a pure DD. As I said in the beginning, the diagnosis reminds me of “not otherwise specified” or the way in which the ER physician decides that the patient has a psychiatric illness–he can't find anything physiologically definitive to affirm a diagnosis in his mind.

When I interview a patient who has been on the inpatient service, there is a group of them who respond to my question, “When did you first become depressed,” with a quick, “I've been depressed all my life.” When I get that answer, I search for a history of physical, sexual, and/or emotional abuse early in that person's life. The person sitting in front of me might not be clearly depressed, but between major depressions–the sense of a lifetime of depression might actually be dysthymic.

If we were to plot the illness, perhaps it would look like a sine curve graph. This is just a conjecture, but it might look like this: dysthymic–MDD–suicide attempt–dysthymic disorder–MDD–suicide attempt, and so on. We have all seen patients like this. Nothing is accomplished; the patient has no job and usually no attachments; the family is not interested. I would like to hear from others who have seen this kind of syndrome or life history. We know that when a patient says she has been depressed her whole life, that is that patient's impression retrospectively to what happened between major episodes. I have found that major depressive episodes are aborted by a suicide attempt, usually with hospitalization and a discharge. But discharge to what?

The dysthymic patient needs a support system that he usually does not have. And he does not know how to reach out and build such a system.

One man I saw who fit this description had had four intense affairs with women but was unable to consummate any of the relationships into marriage. Of course, he took no responsibility for the breakdown between him and any of the women.

In long-term outpatient cases, we see the diagnosis changing from year to year. In one patient I saw for more than 2 decades, his condition varied over time. He was never free of complaint and sometimes would talk of his depression, which generally was not visible. Yet, there were times in which he became seriously depressed with a lot of crying and discomfort. Again, at other times, his affect was not deeply impaired. Looking back, I would say that this patient had dysthymia at those times.

We have to keep our eye on the diagnostic ball and not feel constrained to keep our original diagnosis as a sacred cow. People change over time and as a result of therapy. We see these changes but usually do not note them. There are numerous anxiety disorders, and we do not find it strange for people to go from one to another. I am suggesting that the same is true of the depressive spectrum.

Dr. Stewart's thesis is that dysthymic patients have more disability than other depressive disorders. We need to assess the psychosomatic symptomatology of these patients and other kinds of psychiatric disability. We already have reviewed some of the major disabling behaviors. What I believe is most disabling is the chronic nature of the illness, the length of time the person feels bad, the complaints, and, in particular, the unhappiness.

Viewing the Illness as Cyclical

I am caring for a patient now with bipolar illness who seemed very depressed for months and then, with a change in medication, became manic–loud, disruptive, very talkative, and filled with complaints. That was a real change from his depressive state. He started going out, seeing people, and was overjoyed with his “improvement.”

Recently, however, this patient has become less joyous, filled with physical complaints of all kinds, and unable to do anything. He quit his part time job and now complains of having nothing to do. He says repeatedly, “I am not depressed,” but he also is not manic. I think he is dysthymic at this time–although the DSM-IV would disagree with me.

On some points, the DSM-IV is clear about dysthymia. It starts early in life, is chronic, and must last for 2 years before one can call a patient dysthymic. Other symptoms include poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.

All of these symptoms also are seen in MDD. This tells us why the diagnosis is so difficult to make. From what I've already said, I don't agree with the DSM-IV about the absence of any full depression in the 2-year period that must precede diagnosis, according to the manual. Most important is the long-term nature of the disorder. For example, the patient who says “I've been depressed all my life” could be a candidate.

The extent to which this diagnosis is related to abuse and trauma in childhood never has been studied. Whenever a person tells me about a lifetime of unhappiness, I inquire about abuse and trauma. What started a life of unhappiness? In the movie “Precious,” the main character says “no one ever loved me,” a pathetic moment in the film but true of many children we see today. Alice Miller, Ph.D., the researcher on childhood, says a child must have one person in his life who gives him unconditional love.

Unconditional love is just what the name implies: no constant criticism (emotional abuse), no constant punishment (physical abuse), and protection from getting hurt or further abused by people, at school, or on the street. Without it, the child might develop dysthymia. I see people gratuitously hitting children in public venues, and being shamed in this way can lead to dysthymia.

Recently, I attended an alternative high school graduation. I was sitting next to a family in which the mother had a 4-year-old on her lap, constantly hit the boy, and yelled “Shut the [expletive] up.” The grandmother eventually rescued the boy, and he ran to her as fast as he could. Later during the program, he ended up back with his mother and she started her admonition again. Finally, she sat the little fellow in her chair and stood right in front of him so that she could see the events. All he could look at was the back of her body. I was very upset by witnessing firsthand what this boy was going through. Of course, I have no way of following up on the child 10 or 15 years from now to see how he is doing. But I can predict that he will either be delinquent or dysthymic.

Those of us who practice in the office each day must be vigilant about identifying dysthymia disorder and finding effective treatments.

Psychiatrists should not be surprised to learn that many medical interns develop symptoms of moderate to severe depression. A recent study based on a large sample of medical interns found that about 3% of these individuals had depressive symptoms before their internship but over the course of their internship, that number rose to 20%-25%. The factors most closely associated with the onset of depressive symptoms were a perception of medical errors made by the interns and their long work hours. (Arch. Gen. Psychiatry 2010;67:E1-9).

Again, errors by interns should come as no surprise. The most dangerous time to get sick and go to a hospital is the first week in July when medical students begin their internships. Medical schools neither prepare medical students to care for patients with unknown diagnoses nor do they prepare them for the ignominy of internship. And when an intern makes a mistake, he or she is not spared the ridicule or the humiliation that follows. What they bring on July 1 is a great deal of hope, zeal, and empathy–ingredients that are important for a hospitalized patient and often left out of the treatment plan.

The insecurity felt by a fresh intern is palpable. He or she doesn't know where anything is, and is totally dependent on the nurses for guidance and directions. We might chuckle at these circumstances but fail to recognize how devastating it is for the intern who feels ready to conquer the world. The depression, I suggest, comes from the daily humiliating experiences in rounds and work-ups, diagnoses and decisions. A sense of insecurity often leads to feelings of worthlessness, a feeling that one's medical education was wasted, and a fear of doing things that could harm or kill patients.

Day after 12- to 16-hour day, the young doctor suffers through the tasks he so diligently studied for all those years in medical school. These interns are the cream of the crop; they expect to get it right and do it right. The anticipation of failure can be worse than actual failure.

From the moment the intern arrives on the unit until the shift is over, he is bombarded with questions, quandaries, puzzles, and demands for decisions. Each of these challenges triggers anxiety in the intern which, I believe, is what leads to depressive symptoms.

On top of the nonstop demands of patient care is the relentless staff humor that is part of every unit in the hospital. Many articles have been written about the ghoulish humor of interns and residents that is often directed at a member of their group. People wonder why they do it, but it is clearly a defense against the depression and all of the self-deprecation that is unspoken–and often unconscious–going on inside individual members of the group. It can be cruel. It is often directed against patients' imitating them, undermining them, and diminishing them so the intern can feel superior. The humor is part of the fight against the hopelessness of depression.

I can still remember one incident from my own internship. It was late at night and the interns who were on duty were required to draw blood throughout the hospital for the lab the next morning. One of my fellow interns came to me and summoned me to follow him to see a “gomer.” We went to the bedside of an old man (perhaps 90 years old) in an oxygen tent, with deep lines on his face and a towel wrapped around his head. It was difficult to tell whether he was dead or alive. We both thought it was very funny. It was easier to ridicule a patient rather than fall over from exhaustion from phlebotomizing scores of patients after a full day's work.

The sad dénouement to the story occurred about 12 years later. My fellow intern got cancer of the brain, and I went to visit him in a nursing home where he was staying. He was out on the lawn in a wheelchair with a towel wrapped around his head and he looked at me as I approached and said, “Who is the gomer now?” We both laughed–and cried.

The issue of hours on and hours off has been raging in medical education for years. In recent years, the rules and guidelines have been drawn more and more in favor of the interns. But they still might not be getting enough sleep. The authors of the study under discussion found that number of work hours was one factor, along with stress and medical errors.

The study relied on existing research on stress and depression. I suggest that the stress for the intern translates into insecurity, worthlessness, helplessness, and hopelessness. I would add that when you make a mistake in medicine, a lot of guilt emanates from the doctor's feeling of imperfection. Medical training leads students to feel obligated to be perfect, to know everything, and to walk into the hospital on July 1 ready to go! Some personal characteristics were of special significance for depression in interns in the study. Six variables remained significant: neuroticism, personal history of depression, lower baseline depressive symptoms, female sex, difficult early family environment, and U.S. medical education. It is somewhat surprising that the age of the intern or the medical specialty chosen were not factors in the development of symptomatology.

Internship is viewed by many in the medical profession as a rite of passage. Everyone agrees that it is the most difficult year of one's residency. The patients aren't more difficult, although in some programs first-year residents get the most difficult patients, and they are often left to their own devices during their nights on call. The responsibility is great for a fledgling physician, and the entire process can be very depressing. Another important element leading to feelings of depression is the lack of someone to talk to. The tradition of one-to-one supervision in psychiatry is important, because the interns have to have a trusted friend or mentor to whom he/she can unload, and talk about their fears and frustrations. This kind of supervision rarely happens in other programs where it might be even more necessary. Dropping a novice in the emergency room is tough. Self-doubt fills the space, and the need for supervision–backup–by an available senior person becomes vital.

The average intern usually can handle the hazing that he/she gets in the first few months, but the stress can accumulate and, for a few, can become unbearable. It's time for the body politic of medicine to change what are now the norms. For example, a good program might include an orientation period of 3 to 4 weeks, with a lot of lectures and seminars, a few patients, and a lot of supervision. Medical education should not be a source of cheap labor.

The study authors found that an enormous number of interns develop depressive symptomatology. This leads me to believe that we are doing it wrong and that the entire program requires reexamination. In psychiatry, it is traditional for new interns to start on in-patient services and treat the most seriously chronically mentally ill. Years ago, John Nemiah pointed out that this approach was backward. Why have the most inexperienced doctors treat the patients who were the sickest? He suggested we start the other way around–with outpatients, using intensive training in various psychotherapies and lots of supervision. The same thing needs to be done in other medical specialties.

There also would be value in doing encounter group work in the first year. Encounter groups were very popular years ago and should be initiated in all specialties. If surgery or family medicine does not have anyone to do it in the department, they could ask psychiatry whether they could borrow someone to provide the service. It would truly be an innovation to give some thought to the internship.

Finally, we must try to remember that interns have a life–with stressors–outside of their program. Marriage, pregnancy, children, housing, deaths of loved ones, entertainment, sex, and friendships can all be stressors that lead to the development of depressive symptoms. Again, a sympathetic faculty, and attention to the problems and needs of the intern are essential to reduce the amount of depression suffered by them. In particular, we must stop viewing the internship as a rite of passage and look at it as an opportunity for a real alliance between staff and interns.

Psychiatrists should not be surprised to learn that many medical interns develop symptoms of moderate to severe depression. A recent study based on a large sample of medical interns found that about 3% of these individuals had depressive symptoms before their internship but over the course of their internship, that number rose to 20%-25%. The factors most closely associated with the onset of depressive symptoms were a perception of medical errors made by the interns and their long work hours. (Arch. Gen. Psychiatry 2010;67:E1-9).

Again, errors by interns should come as no surprise. The most dangerous time to get sick and go to a hospital is the first week in July when medical students begin their internships. Medical schools neither prepare medical students to care for patients with unknown diagnoses nor do they prepare them for the ignominy of internship. And when an intern makes a mistake, he or she is not spared the ridicule or the humiliation that follows. What they bring on July 1 is a great deal of hope, zeal, and empathy–ingredients that are important for a hospitalized patient and often left out of the treatment plan.

The insecurity felt by a fresh intern is palpable. He or she doesn't know where anything is, and is totally dependent on the nurses for guidance and directions. We might chuckle at these circumstances but fail to recognize how devastating it is for the intern who feels ready to conquer the world. The depression, I suggest, comes from the daily humiliating experiences in rounds and work-ups, diagnoses and decisions. A sense of insecurity often leads to feelings of worthlessness, a feeling that one's medical education was wasted, and a fear of doing things that could harm or kill patients.

Day after 12- to 16-hour day, the young doctor suffers through the tasks he so diligently studied for all those years in medical school. These interns are the cream of the crop; they expect to get it right and do it right. The anticipation of failure can be worse than actual failure.

From the moment the intern arrives on the unit until the shift is over, he is bombarded with questions, quandaries, puzzles, and demands for decisions. Each of these challenges triggers anxiety in the intern which, I believe, is what leads to depressive symptoms.

On top of the nonstop demands of patient care is the relentless staff humor that is part of every unit in the hospital. Many articles have been written about the ghoulish humor of interns and residents that is often directed at a member of their group. People wonder why they do it, but it is clearly a defense against the depression and all of the self-deprecation that is unspoken–and often unconscious–going on inside individual members of the group. It can be cruel. It is often directed against patients' imitating them, undermining them, and diminishing them so the intern can feel superior. The humor is part of the fight against the hopelessness of depression.

I can still remember one incident from my own internship. It was late at night and the interns who were on duty were required to draw blood throughout the hospital for the lab the next morning. One of my fellow interns came to me and summoned me to follow him to see a “gomer.” We went to the bedside of an old man (perhaps 90 years old) in an oxygen tent, with deep lines on his face and a towel wrapped around his head. It was difficult to tell whether he was dead or alive. We both thought it was very funny. It was easier to ridicule a patient rather than fall over from exhaustion from phlebotomizing scores of patients after a full day's work.

The sad dénouement to the story occurred about 12 years later. My fellow intern got cancer of the brain, and I went to visit him in a nursing home where he was staying. He was out on the lawn in a wheelchair with a towel wrapped around his head and he looked at me as I approached and said, “Who is the gomer now?” We both laughed–and cried.

The issue of hours on and hours off has been raging in medical education for years. In recent years, the rules and guidelines have been drawn more and more in favor of the interns. But they still might not be getting enough sleep. The authors of the study under discussion found that number of work hours was one factor, along with stress and medical errors.

The study relied on existing research on stress and depression. I suggest that the stress for the intern translates into insecurity, worthlessness, helplessness, and hopelessness. I would add that when you make a mistake in medicine, a lot of guilt emanates from the doctor's feeling of imperfection. Medical training leads students to feel obligated to be perfect, to know everything, and to walk into the hospital on July 1 ready to go! Some personal characteristics were of special significance for depression in interns in the study. Six variables remained significant: neuroticism, personal history of depression, lower baseline depressive symptoms, female sex, difficult early family environment, and U.S. medical education. It is somewhat surprising that the age of the intern or the medical specialty chosen were not factors in the development of symptomatology.

Internship is viewed by many in the medical profession as a rite of passage. Everyone agrees that it is the most difficult year of one's residency. The patients aren't more difficult, although in some programs first-year residents get the most difficult patients, and they are often left to their own devices during their nights on call. The responsibility is great for a fledgling physician, and the entire process can be very depressing. Another important element leading to feelings of depression is the lack of someone to talk to. The tradition of one-to-one supervision in psychiatry is important, because the interns have to have a trusted friend or mentor to whom he/she can unload, and talk about their fears and frustrations. This kind of supervision rarely happens in other programs where it might be even more necessary. Dropping a novice in the emergency room is tough. Self-doubt fills the space, and the need for supervision–backup–by an available senior person becomes vital.

The average intern usually can handle the hazing that he/she gets in the first few months, but the stress can accumulate and, for a few, can become unbearable. It's time for the body politic of medicine to change what are now the norms. For example, a good program might include an orientation period of 3 to 4 weeks, with a lot of lectures and seminars, a few patients, and a lot of supervision. Medical education should not be a source of cheap labor.

The study authors found that an enormous number of interns develop depressive symptomatology. This leads me to believe that we are doing it wrong and that the entire program requires reexamination. In psychiatry, it is traditional for new interns to start on in-patient services and treat the most seriously chronically mentally ill. Years ago, John Nemiah pointed out that this approach was backward. Why have the most inexperienced doctors treat the patients who were the sickest? He suggested we start the other way around–with outpatients, using intensive training in various psychotherapies and lots of supervision. The same thing needs to be done in other medical specialties.

There also would be value in doing encounter group work in the first year. Encounter groups were very popular years ago and should be initiated in all specialties. If surgery or family medicine does not have anyone to do it in the department, they could ask psychiatry whether they could borrow someone to provide the service. It would truly be an innovation to give some thought to the internship.

Finally, we must try to remember that interns have a life–with stressors–outside of their program. Marriage, pregnancy, children, housing, deaths of loved ones, entertainment, sex, and friendships can all be stressors that lead to the development of depressive symptoms. Again, a sympathetic faculty, and attention to the problems and needs of the intern are essential to reduce the amount of depression suffered by them. In particular, we must stop viewing the internship as a rite of passage and look at it as an opportunity for a real alliance between staff and interns.

Psychiatrists should not be surprised to learn that many medical interns develop symptoms of moderate to severe depression. A recent study based on a large sample of medical interns found that about 3% of these individuals had depressive symptoms before their internship but over the course of their internship, that number rose to 20%-25%. The factors most closely associated with the onset of depressive symptoms were a perception of medical errors made by the interns and their long work hours. (Arch. Gen. Psychiatry 2010;67:E1-9).

Again, errors by interns should come as no surprise. The most dangerous time to get sick and go to a hospital is the first week in July when medical students begin their internships. Medical schools neither prepare medical students to care for patients with unknown diagnoses nor do they prepare them for the ignominy of internship. And when an intern makes a mistake, he or she is not spared the ridicule or the humiliation that follows. What they bring on July 1 is a great deal of hope, zeal, and empathy–ingredients that are important for a hospitalized patient and often left out of the treatment plan.

The insecurity felt by a fresh intern is palpable. He or she doesn't know where anything is, and is totally dependent on the nurses for guidance and directions. We might chuckle at these circumstances but fail to recognize how devastating it is for the intern who feels ready to conquer the world. The depression, I suggest, comes from the daily humiliating experiences in rounds and work-ups, diagnoses and decisions. A sense of insecurity often leads to feelings of worthlessness, a feeling that one's medical education was wasted, and a fear of doing things that could harm or kill patients.

Day after 12- to 16-hour day, the young doctor suffers through the tasks he so diligently studied for all those years in medical school. These interns are the cream of the crop; they expect to get it right and do it right. The anticipation of failure can be worse than actual failure.

From the moment the intern arrives on the unit until the shift is over, he is bombarded with questions, quandaries, puzzles, and demands for decisions. Each of these challenges triggers anxiety in the intern which, I believe, is what leads to depressive symptoms.

On top of the nonstop demands of patient care is the relentless staff humor that is part of every unit in the hospital. Many articles have been written about the ghoulish humor of interns and residents that is often directed at a member of their group. People wonder why they do it, but it is clearly a defense against the depression and all of the self-deprecation that is unspoken–and often unconscious–going on inside individual members of the group. It can be cruel. It is often directed against patients' imitating them, undermining them, and diminishing them so the intern can feel superior. The humor is part of the fight against the hopelessness of depression.

I can still remember one incident from my own internship. It was late at night and the interns who were on duty were required to draw blood throughout the hospital for the lab the next morning. One of my fellow interns came to me and summoned me to follow him to see a “gomer.” We went to the bedside of an old man (perhaps 90 years old) in an oxygen tent, with deep lines on his face and a towel wrapped around his head. It was difficult to tell whether he was dead or alive. We both thought it was very funny. It was easier to ridicule a patient rather than fall over from exhaustion from phlebotomizing scores of patients after a full day's work.

The sad dénouement to the story occurred about 12 years later. My fellow intern got cancer of the brain, and I went to visit him in a nursing home where he was staying. He was out on the lawn in a wheelchair with a towel wrapped around his head and he looked at me as I approached and said, “Who is the gomer now?” We both laughed–and cried.

The issue of hours on and hours off has been raging in medical education for years. In recent years, the rules and guidelines have been drawn more and more in favor of the interns. But they still might not be getting enough sleep. The authors of the study under discussion found that number of work hours was one factor, along with stress and medical errors.

The study relied on existing research on stress and depression. I suggest that the stress for the intern translates into insecurity, worthlessness, helplessness, and hopelessness. I would add that when you make a mistake in medicine, a lot of guilt emanates from the doctor's feeling of imperfection. Medical training leads students to feel obligated to be perfect, to know everything, and to walk into the hospital on July 1 ready to go! Some personal characteristics were of special significance for depression in interns in the study. Six variables remained significant: neuroticism, personal history of depression, lower baseline depressive symptoms, female sex, difficult early family environment, and U.S. medical education. It is somewhat surprising that the age of the intern or the medical specialty chosen were not factors in the development of symptomatology.

Internship is viewed by many in the medical profession as a rite of passage. Everyone agrees that it is the most difficult year of one's residency. The patients aren't more difficult, although in some programs first-year residents get the most difficult patients, and they are often left to their own devices during their nights on call. The responsibility is great for a fledgling physician, and the entire process can be very depressing. Another important element leading to feelings of depression is the lack of someone to talk to. The tradition of one-to-one supervision in psychiatry is important, because the interns have to have a trusted friend or mentor to whom he/she can unload, and talk about their fears and frustrations. This kind of supervision rarely happens in other programs where it might be even more necessary. Dropping a novice in the emergency room is tough. Self-doubt fills the space, and the need for supervision–backup–by an available senior person becomes vital.

The average intern usually can handle the hazing that he/she gets in the first few months, but the stress can accumulate and, for a few, can become unbearable. It's time for the body politic of medicine to change what are now the norms. For example, a good program might include an orientation period of 3 to 4 weeks, with a lot of lectures and seminars, a few patients, and a lot of supervision. Medical education should not be a source of cheap labor.

The study authors found that an enormous number of interns develop depressive symptomatology. This leads me to believe that we are doing it wrong and that the entire program requires reexamination. In psychiatry, it is traditional for new interns to start on in-patient services and treat the most seriously chronically mentally ill. Years ago, John Nemiah pointed out that this approach was backward. Why have the most inexperienced doctors treat the patients who were the sickest? He suggested we start the other way around–with outpatients, using intensive training in various psychotherapies and lots of supervision. The same thing needs to be done in other medical specialties.

There also would be value in doing encounter group work in the first year. Encounter groups were very popular years ago and should be initiated in all specialties. If surgery or family medicine does not have anyone to do it in the department, they could ask psychiatry whether they could borrow someone to provide the service. It would truly be an innovation to give some thought to the internship.

Finally, we must try to remember that interns have a life–with stressors–outside of their program. Marriage, pregnancy, children, housing, deaths of loved ones, entertainment, sex, and friendships can all be stressors that lead to the development of depressive symptoms. Again, a sympathetic faculty, and attention to the problems and needs of the intern are essential to reduce the amount of depression suffered by them. In particular, we must stop viewing the internship as a rite of passage and look at it as an opportunity for a real alliance between staff and interns.

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Yes, the study findings are plausible. Bullying can be the underlying issue in the beginning of substance use. Some children turn to using alcohol and marijuana in their effort to deal with the depression that has developed as a result of being bullied.

The investigation under discussion, published April 27 online by Jeremy W. Luk and his colleagues, found that depression was tied to bullying victimization for adolescent males and females (Prev. Sci. 2010 April 27[doi:10.1007/s11121-0179-0)]. However, they found that only among adolescent females were these associations linked to substance use.

“It is possible that female adolescents were more affected by relational problems that were due to victimization, contributing to the moderation by sex in the mediational pathway from victimization to substance use,” wrote Mr. Luk, of the University of Washington, Seattle.

My own work has found that killing or being killed are serious sequelae of bullying. In addition, this form of victimization can lead to suicide. Add in the devastating impact of cyberbullying and the increasing reports of youth who have been driven to killing themselves, and it becomes clear just how awful this form of schoolyard fun really is (“Fink! Still at Large,” February 2008, p. 30). It is important to point out that bullies also can be victims (“Fink! Still at Large,” December 2003, p. 5). They also are more likely to engage in antisocial behaviors such as drug abuse, and they clearly need our help.

I have worked in the School District of Philadelphia for more than a decade, and despite the establishment of a zero tolerance policy for harassment of any kind, more attention needs to be paid to bullying. Children must feel safe in school, and the child who is being bullied every day is not safe. In addition, there needs to be recognition that children who are being bullied cannot learn.

The bullied child feels worthless and excluded, and often feels as if he/she has no one to turn to for help. When a child screams “leave me alone,” too often, he is met with gales of laughter from his tormentors. Feelings of worthlessness are one of the major symptoms of depression, so it should not surprise us to find that depression and suicide are important sequelae to being bullied.

In addition, as the authors of the article suggest, depression is an entryway to substance abuse. We have known for decades that children as well as adults use alcohol and drugs to self-medicate for depression. Therefore, the findings of the study are all quite logical.

We must reject the notion that children are cruel. Caring for others should be part of the value system that we convey to our children.

I have recommended to the Philadelphia school district that all assertive/aggressive boys in 2nd, 3rd, and 4th grades be placed in groups of 10 children and counseled for a year to try to change their behavior in school. Hitting, hurting, fighting, and assaulting are occurring in our schools regularly. We need to look at preventive models to reduce aggression and bullying. It is my contention that reducing aggression in our elementary schools would lead to fewer arrests in 6th, 7th, and 8th grades and fewer murders at ages 17, 18, and 19.

I have chaired the Philadelphia Youth Homicide Committee for 17 years and have looked for markers that would warn of the potential of young people for either killing someone or being killed. We have found that important markers are serious chronic truancy, multiple suspensions from school, and bullying. We have followed these signs over many years, and they have regularly proven to be valid.

Prevention means we should be addressing these issues and bringing an end to these activities to prevent youth murder. But just like addressing the prevention of bullying, there is an absence of will to prevent truancy and multiple out-of-school suspensions. A movement is afoot, however, to institute in-school suspensions–which I believe would reduce the serious problem of youth murder in our city.

One of the decedents at the Youth Homicide Committee was a 17-year-old who had accumulated 56 suspensions–before he was killed. The schools didn't want him, and suspension was the easiest way to solve the problem. For those of us who provide services to these children, however, suspensions are not the solution because they reinforce the basic idea that these children are worthless and not wanted.

A series of antiviolence programs has been given official sanction because they are effective. One of these is an antibullying program known as the Olweus Bullying Prevention Program. The method requires a paid parent/teacher coordinator at the school who guides the school in its implementation. At a cost of $10,000 per coordinator for each of the 230 schools in Philadelphia, the total would be $2.3 million per school year. Many lives could be saved.

The Olweus program consists of five steps:

▸ Every adult in the school, from the principal to the janitor, must sign on to participate in antibullying efforts.

▸ Assemblies announcing that the school is an antibullying school must take place, in addition to other kinds of marketing to the children–such as signs on the walls–about this designation.

▸ Whenever an adult interrupts a bullying event, the teacher must stop the lesson and take 5–10 minutes to lead a discussion about the incident.

▸ The bully must be made into an antihero.

▸ Parents must become involved.

The last two ideas are the most difficult to implement. Generally, the other children make the bully into a hero by backing him so they, themselves, will not be victimized and/or join the bully in the victimization. Teachers and administrators have to continue to remind the children that bullying will not be tolerated.

Although it is difficult to get parents to come into school for instruction on this issue, parent involvement is key.

Cyberbullying is relatively new horror. After all, it is easier to hurt someone when you do not have to look in their face and can remain anonymous. In one case, an 8th grade girl saw a 7th grade girl talking to the 8th grader's boyfriend. She and several of her friends sent the 7th grader 500 e-mails that were hostile and filled with threats of exclusion. The child hanged herself soon after the harassment. Other cases share similar themes.

Psychiatrists have a huge role to play in getting communities to respond to this problem. Child psychiatrists, in particular, have to make sure to ask about bullying to find out whether it is among the etiological factors in the development of depression and/or substance abuse in a child. Psychiatrists must promote prevention of mental illnesses and sociocultural factors that contribute to the development of mental illness.

The current trend to help patients seek mental wellness is a part of this. We should be the leaders in these events to create healthier communities. It is our duty to help parents to know more about raising children, and helping children deal with traumas and abuses.

[email protected]

Yes, the study findings are plausible. Bullying can be the underlying issue in the beginning of substance use. Some children turn to using alcohol and marijuana in their effort to deal with the depression that has developed as a result of being bullied.

The investigation under discussion, published April 27 online by Jeremy W. Luk and his colleagues, found that depression was tied to bullying victimization for adolescent males and females (Prev. Sci. 2010 April 27[doi:10.1007/s11121-0179-0)]. However, they found that only among adolescent females were these associations linked to substance use.

“It is possible that female adolescents were more affected by relational problems that were due to victimization, contributing to the moderation by sex in the mediational pathway from victimization to substance use,” wrote Mr. Luk, of the University of Washington, Seattle.

My own work has found that killing or being killed are serious sequelae of bullying. In addition, this form of victimization can lead to suicide. Add in the devastating impact of cyberbullying and the increasing reports of youth who have been driven to killing themselves, and it becomes clear just how awful this form of schoolyard fun really is (“Fink! Still at Large,” February 2008, p. 30). It is important to point out that bullies also can be victims (“Fink! Still at Large,” December 2003, p. 5). They also are more likely to engage in antisocial behaviors such as drug abuse, and they clearly need our help.

I have worked in the School District of Philadelphia for more than a decade, and despite the establishment of a zero tolerance policy for harassment of any kind, more attention needs to be paid to bullying. Children must feel safe in school, and the child who is being bullied every day is not safe. In addition, there needs to be recognition that children who are being bullied cannot learn.

The bullied child feels worthless and excluded, and often feels as if he/she has no one to turn to for help. When a child screams “leave me alone,” too often, he is met with gales of laughter from his tormentors. Feelings of worthlessness are one of the major symptoms of depression, so it should not surprise us to find that depression and suicide are important sequelae to being bullied.

In addition, as the authors of the article suggest, depression is an entryway to substance abuse. We have known for decades that children as well as adults use alcohol and drugs to self-medicate for depression. Therefore, the findings of the study are all quite logical.

We must reject the notion that children are cruel. Caring for others should be part of the value system that we convey to our children.

I have recommended to the Philadelphia school district that all assertive/aggressive boys in 2nd, 3rd, and 4th grades be placed in groups of 10 children and counseled for a year to try to change their behavior in school. Hitting, hurting, fighting, and assaulting are occurring in our schools regularly. We need to look at preventive models to reduce aggression and bullying. It is my contention that reducing aggression in our elementary schools would lead to fewer arrests in 6th, 7th, and 8th grades and fewer murders at ages 17, 18, and 19.

I have chaired the Philadelphia Youth Homicide Committee for 17 years and have looked for markers that would warn of the potential of young people for either killing someone or being killed. We have found that important markers are serious chronic truancy, multiple suspensions from school, and bullying. We have followed these signs over many years, and they have regularly proven to be valid.

Prevention means we should be addressing these issues and bringing an end to these activities to prevent youth murder. But just like addressing the prevention of bullying, there is an absence of will to prevent truancy and multiple out-of-school suspensions. A movement is afoot, however, to institute in-school suspensions–which I believe would reduce the serious problem of youth murder in our city.

One of the decedents at the Youth Homicide Committee was a 17-year-old who had accumulated 56 suspensions–before he was killed. The schools didn't want him, and suspension was the easiest way to solve the problem. For those of us who provide services to these children, however, suspensions are not the solution because they reinforce the basic idea that these children are worthless and not wanted.

A series of antiviolence programs has been given official sanction because they are effective. One of these is an antibullying program known as the Olweus Bullying Prevention Program. The method requires a paid parent/teacher coordinator at the school who guides the school in its implementation. At a cost of $10,000 per coordinator for each of the 230 schools in Philadelphia, the total would be $2.3 million per school year. Many lives could be saved.

The Olweus program consists of five steps:

▸ Every adult in the school, from the principal to the janitor, must sign on to participate in antibullying efforts.

▸ Assemblies announcing that the school is an antibullying school must take place, in addition to other kinds of marketing to the children–such as signs on the walls–about this designation.

▸ Whenever an adult interrupts a bullying event, the teacher must stop the lesson and take 5–10 minutes to lead a discussion about the incident.

▸ The bully must be made into an antihero.

▸ Parents must become involved.

The last two ideas are the most difficult to implement. Generally, the other children make the bully into a hero by backing him so they, themselves, will not be victimized and/or join the bully in the victimization. Teachers and administrators have to continue to remind the children that bullying will not be tolerated.

Although it is difficult to get parents to come into school for instruction on this issue, parent involvement is key.

Cyberbullying is relatively new horror. After all, it is easier to hurt someone when you do not have to look in their face and can remain anonymous. In one case, an 8th grade girl saw a 7th grade girl talking to the 8th grader's boyfriend. She and several of her friends sent the 7th grader 500 e-mails that were hostile and filled with threats of exclusion. The child hanged herself soon after the harassment. Other cases share similar themes.

Psychiatrists have a huge role to play in getting communities to respond to this problem. Child psychiatrists, in particular, have to make sure to ask about bullying to find out whether it is among the etiological factors in the development of depression and/or substance abuse in a child. Psychiatrists must promote prevention of mental illnesses and sociocultural factors that contribute to the development of mental illness.

The current trend to help patients seek mental wellness is a part of this. We should be the leaders in these events to create healthier communities. It is our duty to help parents to know more about raising children, and helping children deal with traumas and abuses.

[email protected]

Yes, the study findings are plausible. Bullying can be the underlying issue in the beginning of substance use. Some children turn to using alcohol and marijuana in their effort to deal with the depression that has developed as a result of being bullied.

The investigation under discussion, published April 27 online by Jeremy W. Luk and his colleagues, found that depression was tied to bullying victimization for adolescent males and females (Prev. Sci. 2010 April 27[doi:10.1007/s11121-0179-0)]. However, they found that only among adolescent females were these associations linked to substance use.

“It is possible that female adolescents were more affected by relational problems that were due to victimization, contributing to the moderation by sex in the mediational pathway from victimization to substance use,” wrote Mr. Luk, of the University of Washington, Seattle.

My own work has found that killing or being killed are serious sequelae of bullying. In addition, this form of victimization can lead to suicide. Add in the devastating impact of cyberbullying and the increasing reports of youth who have been driven to killing themselves, and it becomes clear just how awful this form of schoolyard fun really is (“Fink! Still at Large,” February 2008, p. 30). It is important to point out that bullies also can be victims (“Fink! Still at Large,” December 2003, p. 5). They also are more likely to engage in antisocial behaviors such as drug abuse, and they clearly need our help.

I have worked in the School District of Philadelphia for more than a decade, and despite the establishment of a zero tolerance policy for harassment of any kind, more attention needs to be paid to bullying. Children must feel safe in school, and the child who is being bullied every day is not safe. In addition, there needs to be recognition that children who are being bullied cannot learn.

The bullied child feels worthless and excluded, and often feels as if he/she has no one to turn to for help. When a child screams “leave me alone,” too often, he is met with gales of laughter from his tormentors. Feelings of worthlessness are one of the major symptoms of depression, so it should not surprise us to find that depression and suicide are important sequelae to being bullied.

In addition, as the authors of the article suggest, depression is an entryway to substance abuse. We have known for decades that children as well as adults use alcohol and drugs to self-medicate for depression. Therefore, the findings of the study are all quite logical.

We must reject the notion that children are cruel. Caring for others should be part of the value system that we convey to our children.

I have recommended to the Philadelphia school district that all assertive/aggressive boys in 2nd, 3rd, and 4th grades be placed in groups of 10 children and counseled for a year to try to change their behavior in school. Hitting, hurting, fighting, and assaulting are occurring in our schools regularly. We need to look at preventive models to reduce aggression and bullying. It is my contention that reducing aggression in our elementary schools would lead to fewer arrests in 6th, 7th, and 8th grades and fewer murders at ages 17, 18, and 19.

I have chaired the Philadelphia Youth Homicide Committee for 17 years and have looked for markers that would warn of the potential of young people for either killing someone or being killed. We have found that important markers are serious chronic truancy, multiple suspensions from school, and bullying. We have followed these signs over many years, and they have regularly proven to be valid.

Prevention means we should be addressing these issues and bringing an end to these activities to prevent youth murder. But just like addressing the prevention of bullying, there is an absence of will to prevent truancy and multiple out-of-school suspensions. A movement is afoot, however, to institute in-school suspensions–which I believe would reduce the serious problem of youth murder in our city.

One of the decedents at the Youth Homicide Committee was a 17-year-old who had accumulated 56 suspensions–before he was killed. The schools didn't want him, and suspension was the easiest way to solve the problem. For those of us who provide services to these children, however, suspensions are not the solution because they reinforce the basic idea that these children are worthless and not wanted.

A series of antiviolence programs has been given official sanction because they are effective. One of these is an antibullying program known as the Olweus Bullying Prevention Program. The method requires a paid parent/teacher coordinator at the school who guides the school in its implementation. At a cost of $10,000 per coordinator for each of the 230 schools in Philadelphia, the total would be $2.3 million per school year. Many lives could be saved.

The Olweus program consists of five steps:

▸ Every adult in the school, from the principal to the janitor, must sign on to participate in antibullying efforts.

▸ Assemblies announcing that the school is an antibullying school must take place, in addition to other kinds of marketing to the children–such as signs on the walls–about this designation.

▸ Whenever an adult interrupts a bullying event, the teacher must stop the lesson and take 5–10 minutes to lead a discussion about the incident.

▸ The bully must be made into an antihero.

▸ Parents must become involved.

The last two ideas are the most difficult to implement. Generally, the other children make the bully into a hero by backing him so they, themselves, will not be victimized and/or join the bully in the victimization. Teachers and administrators have to continue to remind the children that bullying will not be tolerated.

Although it is difficult to get parents to come into school for instruction on this issue, parent involvement is key.

Cyberbullying is relatively new horror. After all, it is easier to hurt someone when you do not have to look in their face and can remain anonymous. In one case, an 8th grade girl saw a 7th grade girl talking to the 8th grader's boyfriend. She and several of her friends sent the 7th grader 500 e-mails that were hostile and filled with threats of exclusion. The child hanged herself soon after the harassment. Other cases share similar themes.

Psychiatrists have a huge role to play in getting communities to respond to this problem. Child psychiatrists, in particular, have to make sure to ask about bullying to find out whether it is among the etiological factors in the development of depression and/or substance abuse in a child. Psychiatrists must promote prevention of mental illnesses and sociocultural factors that contribute to the development of mental illness.

The current trend to help patients seek mental wellness is a part of this. We should be the leaders in these events to create healthier communities. It is our duty to help parents to know more about raising children, and helping children deal with traumas and abuses.

[email protected]

One of the great misfortunes of aging is the development of Alzheimer's disease. Some of us have patients who either have the illness or are perhaps showing signs of impending impairment because of Alzheimer's. Others have questions about how to best help these individuals.

The study under discussion revealed an interesting correlation between the sense of purpose in life that many elders have and a lowered risk for development of mild cognitive impairment and Alzheimer's. The Rush Memory and Aging Project involved more than 900 subjects who were observed and examined over a 7-year period. The study examined the individuals' cognitive, emotional, and physical changes–and many other aspects of their lives. Purpose in life was measured using 10-item scale derived from Ryff's Scales of Psychological Well-Being (Arch. Gen. Psychiatry 2010;67:304-10).

The concept sounds rational and is in keeping with our best geriatric care practices in which we try to inspire elders to see a purpose in life. Certainly, if the idea of maintaining purpose in life becomes part of how we conceptualize the patient with AD, we will be more vigorous in our efforts to inspire patients to see a value in their lives, to recognize the successes they've had during their lifetimes, and to do more with their hobbies and other social and interactive activities. So, this study could be a stimulus to work harder with elders who are sinking in a purposeless life.

Does Connection Really Exist?

I am skeptical, however, of the notion that purposelessness is an important contributory factor to AD. The concept of “purpose in life” is vague and likely very difficult to measure empirically. I think we would all agree that the feeling of purposelessness is not limited to the elderly. So many young people seem to have purposeless lives. So do others of all ages, such as the addicted, the directionless, the failures, and the abused–many of whom persist in their feelings of worthlessness prompted by their parents. It's a condition that we must recognize and work to change if such a person becomes our patient.

In middle age, we tend to see many people who suffer from depression, because they are confronted with a purposeless life as they review their years. The drab, dull, and useless lives of millions of people who have not fulfilled any of their dreams are a tragedy. Many movies have pursued this theme, and Woody Allen has made a career of portraying such types. All of this explains why it seems implausible that elders who seem to have purposeless lives would be more likely to develop AD.

On the last page of the study, the authors state, “An inherent limitation of this study, as in all epidemiologic studies, is the inability to establish causality with certainty.” I was very glad to read that acknowledgment, because this study reminded me of Dr. I.S. Ravdin, a renowned surgeon in Philadelphia who was considered the “God” of medicine back when I was growing up in that city. He practiced at the University of Pennsylvania and was highly renowned. I recall that when I was a child, there were doctors, diagnosticians, and Ravdin. Later as a medical student, I had the opportunity to make a site visit to a private psychiatric hospital in Philadelphia, and there I discovered Dr. Ravdin.

To my astonishment, Dr. Ravdin was totally lacking cognition during my visit. By that time, he was known to wander the halls of the hospital with the usual absence of the AD patient. I couldn't imagine a man of his stature and fame having no purpose in life. So I must admit to having cognitive interference while reading the study, created by my childhood experiences and Dr. Ravdin–who is long since deceased.

When Age Is Irrelevant

Today, I had an experience which, I think, reminds me of a central purpose in my own life. I was at a conference in which a delegation of 12 people from Ireland came to visit a community-based organization that, I believe, does extraordinary work in reducing youth violence. The Irish visitors were eager to learn about us, and I was there because I am a member of the board of directors and chair of the Oversight Committee of their most successful program.

As I do with most things that contribute to my life's purpose, I spoke with great passion about the program and answered their questions with equal vigor. Just before the meeting closed, one of the visitors asked me, very politely and tentatively, how old I was. They were excited that I was so committed.

As we were leaving the room, I asked that person why he had had asked that question. He said he wanted to know what he had to look forward to. I took the question to indicate that the questioner sensed that I had a purpose in life and that, to me, age was irrelevant.

Reagan Defies the Finding

Perhaps the most well-known person in recent years who had AD was Ronald Reagan. Before his arrival on the national scene, we all joked about the prospects of an actor with the temerity to run for president of the United States. But nothing stopped him. I cannot speak with any certainty about his purpose in life, but he certainly seemed to be a determined man who went after what he wanted and succeeded in getting it. President Reagan is another example of a successful and purposeful man who ended his life with Alzheimer's.

How do we fit President Reagan and Dr. Ravdin into the model suggested by this study's finding? I am neither a researcher nor a statistician, but my own observations and experience offer many examples of purposeful and driven individuals who were nonetheless stricken with Alzheimer's. The authors are honest scientists and offer some concepts suggesting that the association between the sense of purposeless and development of Alzheimer's raises more questions than it offers answers. “Apathy and other lifestyle factors (e.g., exercise and nutrition) may be related to the level of engagement in purposeful behaviors and may have implications for our understanding of the link between purpose in life and cognition,” they wrote.

Cognition is a mysterious part of mental functioning. We hear advice such as “Keep your mind active” and “Do your crossword puzzles” to prevent AD. The aging process is difficult and fraught with many pitfalls, especially physiologic–heart disease, hypertension, and diabetes–to name just a few.

When older people get together, the conversation often turns to the different ailments from which they are all suffering, the vulnerabilities of old age, and the expectation of some disaster lurking around the corner. Elders get used to hearing that a friend or relative developed cancer or has died. We expect it, and these losses only serve to remind us of our own mortality.

As we age and lose those we love, it is painful and might lead to feeling that life no longer has purpose. I have always tended to see these episodes as depressions and not a precursor to AD. I work with such patients to reignite the spark, that is, their purpose in life.

When my first wife died 24 years ago, I went through a very miserable period, and my friends told me in retrospect that I looked awful. But they all inspired me to return to life–to a purposeful life. Fortunately, I had the support of my children and my friends, and 6 months later, I was as busy as I had ever been.

I do know what the authors mean by a purposeless life. It is a very bad feeling. I imagine that when depressed patients say they feel “empty,” that is what they mean, but I agree with the authors of the study that we need to get a better handle on the concept.

If we decided collectively to do an experiment to explore with all of our patients in therapy how they see their life purpose, I think we would be surprised at the variety of answers we would receive. Individuals might have a narrowly focused, highly narcissistic response. A woman might say her purpose is to see her children all grow up and be successful. A man might say his purpose is to earn a million dollars and not have to worry about money. Another man might say his purpose is to give back to society, and a woman might say her purpose was to help poor children learn to read. Among the elderly, there would be a wide range of responses to the question of purpose in life.

The Rush study found an association between purposelessness and mild cognitive impairment or Alzheimer's in later life, but this association is difficult to explain. After all, mild cognitive impairment, a preclinical symptom of Alzheimer's disease, might itself trigger feelings of purposelessness.

Perhaps we as psychiatrists should approach purposelessness in the elderly much as we would that condition in younger people. It is condition that can be addressed psychiatrically, whether or not it has anything to do with Alzheimer's.

[email protected]

One of the great misfortunes of aging is the development of Alzheimer's disease. Some of us have patients who either have the illness or are perhaps showing signs of impending impairment because of Alzheimer's. Others have questions about how to best help these individuals.

The study under discussion revealed an interesting correlation between the sense of purpose in life that many elders have and a lowered risk for development of mild cognitive impairment and Alzheimer's. The Rush Memory and Aging Project involved more than 900 subjects who were observed and examined over a 7-year period. The study examined the individuals' cognitive, emotional, and physical changes–and many other aspects of their lives. Purpose in life was measured using 10-item scale derived from Ryff's Scales of Psychological Well-Being (Arch. Gen. Psychiatry 2010;67:304-10).

The concept sounds rational and is in keeping with our best geriatric care practices in which we try to inspire elders to see a purpose in life. Certainly, if the idea of maintaining purpose in life becomes part of how we conceptualize the patient with AD, we will be more vigorous in our efforts to inspire patients to see a value in their lives, to recognize the successes they've had during their lifetimes, and to do more with their hobbies and other social and interactive activities. So, this study could be a stimulus to work harder with elders who are sinking in a purposeless life.

Does Connection Really Exist?

I am skeptical, however, of the notion that purposelessness is an important contributory factor to AD. The concept of “purpose in life” is vague and likely very difficult to measure empirically. I think we would all agree that the feeling of purposelessness is not limited to the elderly. So many young people seem to have purposeless lives. So do others of all ages, such as the addicted, the directionless, the failures, and the abused–many of whom persist in their feelings of worthlessness prompted by their parents. It's a condition that we must recognize and work to change if such a person becomes our patient.

In middle age, we tend to see many people who suffer from depression, because they are confronted with a purposeless life as they review their years. The drab, dull, and useless lives of millions of people who have not fulfilled any of their dreams are a tragedy. Many movies have pursued this theme, and Woody Allen has made a career of portraying such types. All of this explains why it seems implausible that elders who seem to have purposeless lives would be more likely to develop AD.

On the last page of the study, the authors state, “An inherent limitation of this study, as in all epidemiologic studies, is the inability to establish causality with certainty.” I was very glad to read that acknowledgment, because this study reminded me of Dr. I.S. Ravdin, a renowned surgeon in Philadelphia who was considered the “God” of medicine back when I was growing up in that city. He practiced at the University of Pennsylvania and was highly renowned. I recall that when I was a child, there were doctors, diagnosticians, and Ravdin. Later as a medical student, I had the opportunity to make a site visit to a private psychiatric hospital in Philadelphia, and there I discovered Dr. Ravdin.

To my astonishment, Dr. Ravdin was totally lacking cognition during my visit. By that time, he was known to wander the halls of the hospital with the usual absence of the AD patient. I couldn't imagine a man of his stature and fame having no purpose in life. So I must admit to having cognitive interference while reading the study, created by my childhood experiences and Dr. Ravdin–who is long since deceased.

When Age Is Irrelevant

Today, I had an experience which, I think, reminds me of a central purpose in my own life. I was at a conference in which a delegation of 12 people from Ireland came to visit a community-based organization that, I believe, does extraordinary work in reducing youth violence. The Irish visitors were eager to learn about us, and I was there because I am a member of the board of directors and chair of the Oversight Committee of their most successful program.

As I do with most things that contribute to my life's purpose, I spoke with great passion about the program and answered their questions with equal vigor. Just before the meeting closed, one of the visitors asked me, very politely and tentatively, how old I was. They were excited that I was so committed.

As we were leaving the room, I asked that person why he had had asked that question. He said he wanted to know what he had to look forward to. I took the question to indicate that the questioner sensed that I had a purpose in life and that, to me, age was irrelevant.

Reagan Defies the Finding

Perhaps the most well-known person in recent years who had AD was Ronald Reagan. Before his arrival on the national scene, we all joked about the prospects of an actor with the temerity to run for president of the United States. But nothing stopped him. I cannot speak with any certainty about his purpose in life, but he certainly seemed to be a determined man who went after what he wanted and succeeded in getting it. President Reagan is another example of a successful and purposeful man who ended his life with Alzheimer's.

How do we fit President Reagan and Dr. Ravdin into the model suggested by this study's finding? I am neither a researcher nor a statistician, but my own observations and experience offer many examples of purposeful and driven individuals who were nonetheless stricken with Alzheimer's. The authors are honest scientists and offer some concepts suggesting that the association between the sense of purposeless and development of Alzheimer's raises more questions than it offers answers. “Apathy and other lifestyle factors (e.g., exercise and nutrition) may be related to the level of engagement in purposeful behaviors and may have implications for our understanding of the link between purpose in life and cognition,” they wrote.

Cognition is a mysterious part of mental functioning. We hear advice such as “Keep your mind active” and “Do your crossword puzzles” to prevent AD. The aging process is difficult and fraught with many pitfalls, especially physiologic–heart disease, hypertension, and diabetes–to name just a few.

When older people get together, the conversation often turns to the different ailments from which they are all suffering, the vulnerabilities of old age, and the expectation of some disaster lurking around the corner. Elders get used to hearing that a friend or relative developed cancer or has died. We expect it, and these losses only serve to remind us of our own mortality.

As we age and lose those we love, it is painful and might lead to feeling that life no longer has purpose. I have always tended to see these episodes as depressions and not a precursor to AD. I work with such patients to reignite the spark, that is, their purpose in life.

When my first wife died 24 years ago, I went through a very miserable period, and my friends told me in retrospect that I looked awful. But they all inspired me to return to life–to a purposeful life. Fortunately, I had the support of my children and my friends, and 6 months later, I was as busy as I had ever been.

I do know what the authors mean by a purposeless life. It is a very bad feeling. I imagine that when depressed patients say they feel “empty,” that is what they mean, but I agree with the authors of the study that we need to get a better handle on the concept.

If we decided collectively to do an experiment to explore with all of our patients in therapy how they see their life purpose, I think we would be surprised at the variety of answers we would receive. Individuals might have a narrowly focused, highly narcissistic response. A woman might say her purpose is to see her children all grow up and be successful. A man might say his purpose is to earn a million dollars and not have to worry about money. Another man might say his purpose is to give back to society, and a woman might say her purpose was to help poor children learn to read. Among the elderly, there would be a wide range of responses to the question of purpose in life.

The Rush study found an association between purposelessness and mild cognitive impairment or Alzheimer's in later life, but this association is difficult to explain. After all, mild cognitive impairment, a preclinical symptom of Alzheimer's disease, might itself trigger feelings of purposelessness.

Perhaps we as psychiatrists should approach purposelessness in the elderly much as we would that condition in younger people. It is condition that can be addressed psychiatrically, whether or not it has anything to do with Alzheimer's.

[email protected]

One of the great misfortunes of aging is the development of Alzheimer's disease. Some of us have patients who either have the illness or are perhaps showing signs of impending impairment because of Alzheimer's. Others have questions about how to best help these individuals.

The study under discussion revealed an interesting correlation between the sense of purpose in life that many elders have and a lowered risk for development of mild cognitive impairment and Alzheimer's. The Rush Memory and Aging Project involved more than 900 subjects who were observed and examined over a 7-year period. The study examined the individuals' cognitive, emotional, and physical changes–and many other aspects of their lives. Purpose in life was measured using 10-item scale derived from Ryff's Scales of Psychological Well-Being (Arch. Gen. Psychiatry 2010;67:304-10).

The concept sounds rational and is in keeping with our best geriatric care practices in which we try to inspire elders to see a purpose in life. Certainly, if the idea of maintaining purpose in life becomes part of how we conceptualize the patient with AD, we will be more vigorous in our efforts to inspire patients to see a value in their lives, to recognize the successes they've had during their lifetimes, and to do more with their hobbies and other social and interactive activities. So, this study could be a stimulus to work harder with elders who are sinking in a purposeless life.

Does Connection Really Exist?

I am skeptical, however, of the notion that purposelessness is an important contributory factor to AD. The concept of “purpose in life” is vague and likely very difficult to measure empirically. I think we would all agree that the feeling of purposelessness is not limited to the elderly. So many young people seem to have purposeless lives. So do others of all ages, such as the addicted, the directionless, the failures, and the abused–many of whom persist in their feelings of worthlessness prompted by their parents. It's a condition that we must recognize and work to change if such a person becomes our patient.

In middle age, we tend to see many people who suffer from depression, because they are confronted with a purposeless life as they review their years. The drab, dull, and useless lives of millions of people who have not fulfilled any of their dreams are a tragedy. Many movies have pursued this theme, and Woody Allen has made a career of portraying such types. All of this explains why it seems implausible that elders who seem to have purposeless lives would be more likely to develop AD.

On the last page of the study, the authors state, “An inherent limitation of this study, as in all epidemiologic studies, is the inability to establish causality with certainty.” I was very glad to read that acknowledgment, because this study reminded me of Dr. I.S. Ravdin, a renowned surgeon in Philadelphia who was considered the “God” of medicine back when I was growing up in that city. He practiced at the University of Pennsylvania and was highly renowned. I recall that when I was a child, there were doctors, diagnosticians, and Ravdin. Later as a medical student, I had the opportunity to make a site visit to a private psychiatric hospital in Philadelphia, and there I discovered Dr. Ravdin.

To my astonishment, Dr. Ravdin was totally lacking cognition during my visit. By that time, he was known to wander the halls of the hospital with the usual absence of the AD patient. I couldn't imagine a man of his stature and fame having no purpose in life. So I must admit to having cognitive interference while reading the study, created by my childhood experiences and Dr. Ravdin–who is long since deceased.

When Age Is Irrelevant

Today, I had an experience which, I think, reminds me of a central purpose in my own life. I was at a conference in which a delegation of 12 people from Ireland came to visit a community-based organization that, I believe, does extraordinary work in reducing youth violence. The Irish visitors were eager to learn about us, and I was there because I am a member of the board of directors and chair of the Oversight Committee of their most successful program.

As I do with most things that contribute to my life's purpose, I spoke with great passion about the program and answered their questions with equal vigor. Just before the meeting closed, one of the visitors asked me, very politely and tentatively, how old I was. They were excited that I was so committed.

As we were leaving the room, I asked that person why he had had asked that question. He said he wanted to know what he had to look forward to. I took the question to indicate that the questioner sensed that I had a purpose in life and that, to me, age was irrelevant.

Reagan Defies the Finding

Perhaps the most well-known person in recent years who had AD was Ronald Reagan. Before his arrival on the national scene, we all joked about the prospects of an actor with the temerity to run for president of the United States. But nothing stopped him. I cannot speak with any certainty about his purpose in life, but he certainly seemed to be a determined man who went after what he wanted and succeeded in getting it. President Reagan is another example of a successful and purposeful man who ended his life with Alzheimer's.

How do we fit President Reagan and Dr. Ravdin into the model suggested by this study's finding? I am neither a researcher nor a statistician, but my own observations and experience offer many examples of purposeful and driven individuals who were nonetheless stricken with Alzheimer's. The authors are honest scientists and offer some concepts suggesting that the association between the sense of purposeless and development of Alzheimer's raises more questions than it offers answers. “Apathy and other lifestyle factors (e.g., exercise and nutrition) may be related to the level of engagement in purposeful behaviors and may have implications for our understanding of the link between purpose in life and cognition,” they wrote.

Cognition is a mysterious part of mental functioning. We hear advice such as “Keep your mind active” and “Do your crossword puzzles” to prevent AD. The aging process is difficult and fraught with many pitfalls, especially physiologic–heart disease, hypertension, and diabetes–to name just a few.

When older people get together, the conversation often turns to the different ailments from which they are all suffering, the vulnerabilities of old age, and the expectation of some disaster lurking around the corner. Elders get used to hearing that a friend or relative developed cancer or has died. We expect it, and these losses only serve to remind us of our own mortality.

As we age and lose those we love, it is painful and might lead to feeling that life no longer has purpose. I have always tended to see these episodes as depressions and not a precursor to AD. I work with such patients to reignite the spark, that is, their purpose in life.

When my first wife died 24 years ago, I went through a very miserable period, and my friends told me in retrospect that I looked awful. But they all inspired me to return to life–to a purposeful life. Fortunately, I had the support of my children and my friends, and 6 months later, I was as busy as I had ever been.

I do know what the authors mean by a purposeless life. It is a very bad feeling. I imagine that when depressed patients say they feel “empty,” that is what they mean, but I agree with the authors of the study that we need to get a better handle on the concept.

If we decided collectively to do an experiment to explore with all of our patients in therapy how they see their life purpose, I think we would be surprised at the variety of answers we would receive. Individuals might have a narrowly focused, highly narcissistic response. A woman might say her purpose is to see her children all grow up and be successful. A man might say his purpose is to earn a million dollars and not have to worry about money. Another man might say his purpose is to give back to society, and a woman might say her purpose was to help poor children learn to read. Among the elderly, there would be a wide range of responses to the question of purpose in life.

The Rush study found an association between purposelessness and mild cognitive impairment or Alzheimer's in later life, but this association is difficult to explain. After all, mild cognitive impairment, a preclinical symptom of Alzheimer's disease, might itself trigger feelings of purposelessness.

Perhaps we as psychiatrists should approach purposelessness in the elderly much as we would that condition in younger people. It is condition that can be addressed psychiatrically, whether or not it has anything to do with Alzheimer's.

[email protected]

When I started working in psychiatry 50 years ago, Asperger's disorder was a recognized diagnosis. During that period, the diagnosis drifted into my consciousness through conferences, articles, and discussions with colleagues.

Sometimes, I was asked to evaluate an adult who had difficulty socializing and learning all of his life, and someone had labeled the man with Asperger's disorder. It has become part of the psychiatrist's nomenclature and diagnostic system for a group of patients who otherwise would have been dumped into many other places. The label has provided us with an ability to split and share concepts in a helpful way.

I became very conscious of the illness when we realized that a neighbor's son at 55 years of age had the disorder. He was friendly in a very superficial way; he was peculiar in his looks and manner; and he was the kind of person one might tend to avoid.

He had no friends, no social life, and no seemingly useful activities. We were convinced that he had Asperger's.

He died while in his early 60s, and no one on our street expressed one word of regret that this odd man was no longer on the road. I think that it would have been difficult to call him autistic, so the plan to take Asperger's out and make it part of the autism spectrum disorders will take a great deal of learning on the part of 40,000 psychiatrists and several thousand patients after the DSM-5 is published.

For me, what is most interesting about this is how the diagnosis arrived and might leave in the course of my career. I, like many people in the field, do not understand the rationale of the task force in proposing this change.

Controversy Is Nothing New

I commend the task force members and their efforts, however, in refining this important document. After all, this volume plays a major role in the care and treatment of patients as well as with insurers with regard to getting paid for the work we do.

Each of the previous DSM editions caused much controversy, as this version is doing. Many praise it, and many will be highly critical of the efforts. Preparing a diagnostic and statistical manual takes a great deal of effort, time, and money, and it is one of the most important activities of the American Psychiatric Association. The manual becomes a trusted instrument used by almost everyone after it has been approved and published.

This year, the task force has done something that has never been done before and put a draft outline on the Internet. The APA has invited comments, reactions, and criticism. After the viewing period is over, the final work of editing will begin, and the DSM-5 will be published in 2013.

Psychiatric diagnosis is extremely controversial. I think it is important to say that both Dr. David J. Kupfer nd Dr. Darrel A. Regier are very sincere in their desire to produce a useful volume that will serve both the research and clinical communities well.

Everything I've read leads me to believe that the DSM-5 will be the easiest of all for clinicians to use.

The previous two DSMs were seen as being written for researchers, which made it a little more difficult for the clinician to fit his patient neatly into one of the descriptive groups. Some of the inventions of DSM-III and DSM-IV were thought to be useless by a large number of us who see patients.

And the precision of some of the categories was foolish–at least for me. I saw no value in schizotypal, for example, but I know that younger clinicians found the category very useful.

Calls for Transparency

Both of the previous task force chairs, Dr. Robert Spitzer and Dr. Allen J. Frances, have decried the secrecy of the work of the hundreds of people involved in creating the DSM-5. They kept calling for transparency in a way that brought some discredit on them. Now this entire volume is available for all to see and comment upon.

Transparency might be important to people who played an important role in writing previous DSMs but not to most of us in the field.

Our concerns have been more about how the new DSM will change what we do each day, and how will the manual affect the treatment of people who are very sick, and need correct diagnoses and treatment in order to re-enter life.

We don't want big changes that will have us running to the DSM-5 on a daily basis to be sure that we know what the experts are thinking about a term we've been using for 40 or 50 years.

The power of DSM throughout the world should not be underestimated, and it is the problem for all the psychiatrists of the future–at least until the DSM-6 is written.

But the most important mission of the DSM for me is to identify mistakes and flaws, and correct the concepts that have proven to be incorrect over the last 16 years.

Psychiatric research has continued throughout that time, and new ideas, therapies, and approaches have evolved around specific diagnostic categories.

This evolutionary process is very important for the field and is taken seriously by the new set of authors brought together for the DSM-5.

Importance of the PDM

Several years ago, the Psychodynamic Diagnostic Manual (PDM) was published with Dr. Stanley Greenspan as the primary author (“Manual's Breadth May Aid Diagnosis,” March 2006, p. 1). He recruited many of the senior analysts in America to help in producing the volume. The ostensible reason for all the work was Stan's feeling, shared by many, that the DSM's approach is too mechanical and mathematical, and inadequately describes the mental and emotional functioning of the patient with a given illness.

I think this publication, which was assembled by a committee of leaders within the American Psychoanalytic Association, the International Psychoanalytical Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, the division of psychoanalysis of the American Psychological Association, and the National Membership Comittee on Psychoanalysis in Clinical Social Work, is important.

After all, the PDM opens up a lot of ideas about what a patient with a given illness feels, thinks, and senses, and it provides a great deal of insight into the inner workings of the individual. Its approach to mental illness is dimensional rather than categorical.

I helped write a little of it, and I was shocked by the number of ways we found to describe things that go on inside of a person. None of it is in previous DSMs and most likely will not be in the DSM-5.

I suspect that in some instances, the DSM-5 changes will tighten up areas that have been too vague and difficult to nail down. The concentration on aggressive behaviors is terrific, in my opinion.

We all have evaluated and treated people with various kinds of aggressive behavior with no clear-cut category into which to put them. If the new DSM leads to research that will help us categorize such patients, it will be a blessing.

Many years ago, a couple came in to see me because the wife had taken an ax and destroyed her husband's car. There was no recognized therapy at the time that could guarantee an end to her impulsive outbursts of aggression. The borderline personality disorder diagnosis had not yet come on the scene. Now there are several places to put such patients in the diagnostic scheme, but no real in-depth understanding of why and how the behavior can be treated and stopped.

Role of Politics

What I think is important at this moment in the evolution of the DSM-5 is to realize that many of the controversies are and will be political with proponents on each side of the issue. All of us love rhetoric that seems reasonable to the reader.

One such area is parental alienation syndrome (PAS). I am personally involved in opposing the inclusion of this bit of junk science invented by a psychiatrist in the 1980s, the late Dr. Richard A. Gardner.

All of his books and most of his papers were published by his own publishing company. He protected child sexual abusers in court and was very abusive to the mothers of the children caught up in custody hearings.

Many children and mothers have been hurt by this man's beliefs, but over 15 years, he developed many converts to his beliefs, including judges, lawyers, guardians at litem, and psychologists who liked the neat packaging of his ideas.

In recent years, the ball has been picked up by “father's rights” groups who don't like to be interfered with when they are sexually abusing their children. This group has petitioned the DSM task force to include PAS in the publication.

This is a good example of the political activity into which DSM is drawn. The task force members want to be fair to all parties, so we are now involved in putting together data around this issue to disprove it to the DSM task force.

During the development of the DSM-IV, the question of whether homosexuality was an illness was hotly debated. In that instance, wise heads helped sort out the best route to take, and I am hopeful that the same process will be used with regard to PAS. For more information about PAS, go to the Web site of the Leadership Council on Child Abuse and Interpersonal Violence, which is

www.leadershipcouncil.org

Over the next few months, those of you who are spectators will see many battles taking place on the pages of journals and psychiatric newspapers (such as this one), as we continue to discuss and argue about issues that raise our emotional hackles and require a fight.

[email protected]

When I started working in psychiatry 50 years ago, Asperger's disorder was a recognized diagnosis. During that period, the diagnosis drifted into my consciousness through conferences, articles, and discussions with colleagues.

Sometimes, I was asked to evaluate an adult who had difficulty socializing and learning all of his life, and someone had labeled the man with Asperger's disorder. It has become part of the psychiatrist's nomenclature and diagnostic system for a group of patients who otherwise would have been dumped into many other places. The label has provided us with an ability to split and share concepts in a helpful way.

I became very conscious of the illness when we realized that a neighbor's son at 55 years of age had the disorder. He was friendly in a very superficial way; he was peculiar in his looks and manner; and he was the kind of person one might tend to avoid.

He had no friends, no social life, and no seemingly useful activities. We were convinced that he had Asperger's.

He died while in his early 60s, and no one on our street expressed one word of regret that this odd man was no longer on the road. I think that it would have been difficult to call him autistic, so the plan to take Asperger's out and make it part of the autism spectrum disorders will take a great deal of learning on the part of 40,000 psychiatrists and several thousand patients after the DSM-5 is published.

For me, what is most interesting about this is how the diagnosis arrived and might leave in the course of my career. I, like many people in the field, do not understand the rationale of the task force in proposing this change.

Controversy Is Nothing New

I commend the task force members and their efforts, however, in refining this important document. After all, this volume plays a major role in the care and treatment of patients as well as with insurers with regard to getting paid for the work we do.

Each of the previous DSM editions caused much controversy, as this version is doing. Many praise it, and many will be highly critical of the efforts. Preparing a diagnostic and statistical manual takes a great deal of effort, time, and money, and it is one of the most important activities of the American Psychiatric Association. The manual becomes a trusted instrument used by almost everyone after it has been approved and published.

This year, the task force has done something that has never been done before and put a draft outline on the Internet. The APA has invited comments, reactions, and criticism. After the viewing period is over, the final work of editing will begin, and the DSM-5 will be published in 2013.

Psychiatric diagnosis is extremely controversial. I think it is important to say that both Dr. David J. Kupfer nd Dr. Darrel A. Regier are very sincere in their desire to produce a useful volume that will serve both the research and clinical communities well.

Everything I've read leads me to believe that the DSM-5 will be the easiest of all for clinicians to use.

The previous two DSMs were seen as being written for researchers, which made it a little more difficult for the clinician to fit his patient neatly into one of the descriptive groups. Some of the inventions of DSM-III and DSM-IV were thought to be useless by a large number of us who see patients.

And the precision of some of the categories was foolish–at least for me. I saw no value in schizotypal, for example, but I know that younger clinicians found the category very useful.

Calls for Transparency

Both of the previous task force chairs, Dr. Robert Spitzer and Dr. Allen J. Frances, have decried the secrecy of the work of the hundreds of people involved in creating the DSM-5. They kept calling for transparency in a way that brought some discredit on them. Now this entire volume is available for all to see and comment upon.

Transparency might be important to people who played an important role in writing previous DSMs but not to most of us in the field.

Our concerns have been more about how the new DSM will change what we do each day, and how will the manual affect the treatment of people who are very sick, and need correct diagnoses and treatment in order to re-enter life.

We don't want big changes that will have us running to the DSM-5 on a daily basis to be sure that we know what the experts are thinking about a term we've been using for 40 or 50 years.

The power of DSM throughout the world should not be underestimated, and it is the problem for all the psychiatrists of the future–at least until the DSM-6 is written.

But the most important mission of the DSM for me is to identify mistakes and flaws, and correct the concepts that have proven to be incorrect over the last 16 years.

Psychiatric research has continued throughout that time, and new ideas, therapies, and approaches have evolved around specific diagnostic categories.

This evolutionary process is very important for the field and is taken seriously by the new set of authors brought together for the DSM-5.

Importance of the PDM

Several years ago, the Psychodynamic Diagnostic Manual (PDM) was published with Dr. Stanley Greenspan as the primary author (“Manual's Breadth May Aid Diagnosis,” March 2006, p. 1). He recruited many of the senior analysts in America to help in producing the volume. The ostensible reason for all the work was Stan's feeling, shared by many, that the DSM's approach is too mechanical and mathematical, and inadequately describes the mental and emotional functioning of the patient with a given illness.

I think this publication, which was assembled by a committee of leaders within the American Psychoanalytic Association, the International Psychoanalytical Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, the division of psychoanalysis of the American Psychological Association, and the National Membership Comittee on Psychoanalysis in Clinical Social Work, is important.

After all, the PDM opens up a lot of ideas about what a patient with a given illness feels, thinks, and senses, and it provides a great deal of insight into the inner workings of the individual. Its approach to mental illness is dimensional rather than categorical.

I helped write a little of it, and I was shocked by the number of ways we found to describe things that go on inside of a person. None of it is in previous DSMs and most likely will not be in the DSM-5.

I suspect that in some instances, the DSM-5 changes will tighten up areas that have been too vague and difficult to nail down. The concentration on aggressive behaviors is terrific, in my opinion.

We all have evaluated and treated people with various kinds of aggressive behavior with no clear-cut category into which to put them. If the new DSM leads to research that will help us categorize such patients, it will be a blessing.

Many years ago, a couple came in to see me because the wife had taken an ax and destroyed her husband's car. There was no recognized therapy at the time that could guarantee an end to her impulsive outbursts of aggression. The borderline personality disorder diagnosis had not yet come on the scene. Now there are several places to put such patients in the diagnostic scheme, but no real in-depth understanding of why and how the behavior can be treated and stopped.

Role of Politics

What I think is important at this moment in the evolution of the DSM-5 is to realize that many of the controversies are and will be political with proponents on each side of the issue. All of us love rhetoric that seems reasonable to the reader.

One such area is parental alienation syndrome (PAS). I am personally involved in opposing the inclusion of this bit of junk science invented by a psychiatrist in the 1980s, the late Dr. Richard A. Gardner.

All of his books and most of his papers were published by his own publishing company. He protected child sexual abusers in court and was very abusive to the mothers of the children caught up in custody hearings.

Many children and mothers have been hurt by this man's beliefs, but over 15 years, he developed many converts to his beliefs, including judges, lawyers, guardians at litem, and psychologists who liked the neat packaging of his ideas.

In recent years, the ball has been picked up by “father's rights” groups who don't like to be interfered with when they are sexually abusing their children. This group has petitioned the DSM task force to include PAS in the publication.

This is a good example of the political activity into which DSM is drawn. The task force members want to be fair to all parties, so we are now involved in putting together data around this issue to disprove it to the DSM task force.

During the development of the DSM-IV, the question of whether homosexuality was an illness was hotly debated. In that instance, wise heads helped sort out the best route to take, and I am hopeful that the same process will be used with regard to PAS. For more information about PAS, go to the Web site of the Leadership Council on Child Abuse and Interpersonal Violence, which is

www.leadershipcouncil.org

Over the next few months, those of you who are spectators will see many battles taking place on the pages of journals and psychiatric newspapers (such as this one), as we continue to discuss and argue about issues that raise our emotional hackles and require a fight.

[email protected]

When I started working in psychiatry 50 years ago, Asperger's disorder was a recognized diagnosis. During that period, the diagnosis drifted into my consciousness through conferences, articles, and discussions with colleagues.

Sometimes, I was asked to evaluate an adult who had difficulty socializing and learning all of his life, and someone had labeled the man with Asperger's disorder. It has become part of the psychiatrist's nomenclature and diagnostic system for a group of patients who otherwise would have been dumped into many other places. The label has provided us with an ability to split and share concepts in a helpful way.

I became very conscious of the illness when we realized that a neighbor's son at 55 years of age had the disorder. He was friendly in a very superficial way; he was peculiar in his looks and manner; and he was the kind of person one might tend to avoid.

He had no friends, no social life, and no seemingly useful activities. We were convinced that he had Asperger's.

He died while in his early 60s, and no one on our street expressed one word of regret that this odd man was no longer on the road. I think that it would have been difficult to call him autistic, so the plan to take Asperger's out and make it part of the autism spectrum disorders will take a great deal of learning on the part of 40,000 psychiatrists and several thousand patients after the DSM-5 is published.

For me, what is most interesting about this is how the diagnosis arrived and might leave in the course of my career. I, like many people in the field, do not understand the rationale of the task force in proposing this change.

Controversy Is Nothing New

I commend the task force members and their efforts, however, in refining this important document. After all, this volume plays a major role in the care and treatment of patients as well as with insurers with regard to getting paid for the work we do.

Each of the previous DSM editions caused much controversy, as this version is doing. Many praise it, and many will be highly critical of the efforts. Preparing a diagnostic and statistical manual takes a great deal of effort, time, and money, and it is one of the most important activities of the American Psychiatric Association. The manual becomes a trusted instrument used by almost everyone after it has been approved and published.

This year, the task force has done something that has never been done before and put a draft outline on the Internet. The APA has invited comments, reactions, and criticism. After the viewing period is over, the final work of editing will begin, and the DSM-5 will be published in 2013.

Psychiatric diagnosis is extremely controversial. I think it is important to say that both Dr. David J. Kupfer nd Dr. Darrel A. Regier are very sincere in their desire to produce a useful volume that will serve both the research and clinical communities well.

Everything I've read leads me to believe that the DSM-5 will be the easiest of all for clinicians to use.

The previous two DSMs were seen as being written for researchers, which made it a little more difficult for the clinician to fit his patient neatly into one of the descriptive groups. Some of the inventions of DSM-III and DSM-IV were thought to be useless by a large number of us who see patients.

And the precision of some of the categories was foolish–at least for me. I saw no value in schizotypal, for example, but I know that younger clinicians found the category very useful.

Calls for Transparency

Both of the previous task force chairs, Dr. Robert Spitzer and Dr. Allen J. Frances, have decried the secrecy of the work of the hundreds of people involved in creating the DSM-5. They kept calling for transparency in a way that brought some discredit on them. Now this entire volume is available for all to see and comment upon.

Transparency might be important to people who played an important role in writing previous DSMs but not to most of us in the field.

Our concerns have been more about how the new DSM will change what we do each day, and how will the manual affect the treatment of people who are very sick, and need correct diagnoses and treatment in order to re-enter life.

We don't want big changes that will have us running to the DSM-5 on a daily basis to be sure that we know what the experts are thinking about a term we've been using for 40 or 50 years.

The power of DSM throughout the world should not be underestimated, and it is the problem for all the psychiatrists of the future–at least until the DSM-6 is written.

But the most important mission of the DSM for me is to identify mistakes and flaws, and correct the concepts that have proven to be incorrect over the last 16 years.

Psychiatric research has continued throughout that time, and new ideas, therapies, and approaches have evolved around specific diagnostic categories.

This evolutionary process is very important for the field and is taken seriously by the new set of authors brought together for the DSM-5.

Importance of the PDM

Several years ago, the Psychodynamic Diagnostic Manual (PDM) was published with Dr. Stanley Greenspan as the primary author (“Manual's Breadth May Aid Diagnosis,” March 2006, p. 1). He recruited many of the senior analysts in America to help in producing the volume. The ostensible reason for all the work was Stan's feeling, shared by many, that the DSM's approach is too mechanical and mathematical, and inadequately describes the mental and emotional functioning of the patient with a given illness.

I think this publication, which was assembled by a committee of leaders within the American Psychoanalytic Association, the International Psychoanalytical Association, the American Academy of Psychoanalysis and Dynamic Psychiatry, the division of psychoanalysis of the American Psychological Association, and the National Membership Comittee on Psychoanalysis in Clinical Social Work, is important.

After all, the PDM opens up a lot of ideas about what a patient with a given illness feels, thinks, and senses, and it provides a great deal of insight into the inner workings of the individual. Its approach to mental illness is dimensional rather than categorical.

I helped write a little of it, and I was shocked by the number of ways we found to describe things that go on inside of a person. None of it is in previous DSMs and most likely will not be in the DSM-5.

I suspect that in some instances, the DSM-5 changes will tighten up areas that have been too vague and difficult to nail down. The concentration on aggressive behaviors is terrific, in my opinion.

We all have evaluated and treated people with various kinds of aggressive behavior with no clear-cut category into which to put them. If the new DSM leads to research that will help us categorize such patients, it will be a blessing.

Many years ago, a couple came in to see me because the wife had taken an ax and destroyed her husband's car. There was no recognized therapy at the time that could guarantee an end to her impulsive outbursts of aggression. The borderline personality disorder diagnosis had not yet come on the scene. Now there are several places to put such patients in the diagnostic scheme, but no real in-depth understanding of why and how the behavior can be treated and stopped.

Role of Politics

What I think is important at this moment in the evolution of the DSM-5 is to realize that many of the controversies are and will be political with proponents on each side of the issue. All of us love rhetoric that seems reasonable to the reader.

One such area is parental alienation syndrome (PAS). I am personally involved in opposing the inclusion of this bit of junk science invented by a psychiatrist in the 1980s, the late Dr. Richard A. Gardner.

All of his books and most of his papers were published by his own publishing company. He protected child sexual abusers in court and was very abusive to the mothers of the children caught up in custody hearings.

Many children and mothers have been hurt by this man's beliefs, but over 15 years, he developed many converts to his beliefs, including judges, lawyers, guardians at litem, and psychologists who liked the neat packaging of his ideas.

In recent years, the ball has been picked up by “father's rights” groups who don't like to be interfered with when they are sexually abusing their children. This group has petitioned the DSM task force to include PAS in the publication.

This is a good example of the political activity into which DSM is drawn. The task force members want to be fair to all parties, so we are now involved in putting together data around this issue to disprove it to the DSM task force.

During the development of the DSM-IV, the question of whether homosexuality was an illness was hotly debated. In that instance, wise heads helped sort out the best route to take, and I am hopeful that the same process will be used with regard to PAS. For more information about PAS, go to the Web site of the Leadership Council on Child Abuse and Interpersonal Violence, which is

www.leadershipcouncil.org

Over the next few months, those of you who are spectators will see many battles taking place on the pages of journals and psychiatric newspapers (such as this one), as we continue to discuss and argue about issues that raise our emotional hackles and require a fight.

[email protected]

The incident involving the boy in the balloon is sure to have triggered a lot of concern among psychiatrists who watched the drama unfold.

In my view, the Heene family's misuse of their child is not so different from the drug pusher who recruits a 10- or 11-year-old runner. In the latter case, the child also is put into serious danger–and the adult disregards the needs and interests of the child.

Reportedly, the father, Richard Heene, is a trained actor, and he wanted a job. So, in order to achieve his goal he knowingly endangered helicopter pilots, police, and many others involved in the the search and rescue effort.

One of the most disturbing lessons for the Heene children is that they were made aware that their parents are capable of being less than truthful. Such a lesson might make the boys think that lying is acceptable. After all, many children learn to lie from their parents. “Don't tell your mother” is a common household phrase. Too often, if a child comes home from school and tells mom or dad that they lied, cheated, or hurt another child, the behavior is condoned. This kind of reaction helps the child avoid any pangs of conscience and feel comfortable with psychopathy and sociopathy. At least in the Heene family, the children did not learn that dishonesty pays off.

The Heene family saga also is a reminder of the devastating impact of greed. We have become a nation of cynics, because we expect everyone to cheat. This is expected to such an extent that illegal gains often are worked into the budget, because everyone assumes that someone is bending the rules.

Thirty years ago, I was on my way to New York City to see a show with my wife and 16-year-old son. We got a flat tire, and my son changed the tire while I held an umbrella over his head. The spare was a donut that said on it, “Do not go more than 50 miles on this tire.”

So we drove into a Sunoco station to get the flat fixed. I ran into the station, fell, and broke a leg. Instead of going to New York City to see Amadeus, I went to the hospital to be operated on. Two weeks after the incident, I was at home and received a call from a lawyer for the Sun Oil Co. He asked me numerous questions about grease on the ground or my clothes, and I finally said in an exasperated tone: “I ran, I slipped, and I broke my leg. I am not suing you.” There was a long silence, and he finally said, “Dr. Fink, this is the most unusual conversation I've had in 15 years of practicing law!” He had expected me to sue. But I saw no reason to sue the company, even though I, like everyone else, could have used the money. It just never occurred to me, and I hope that this lesson in honesty was not lost on my son.

The issue of greed is clearly a big part of the balloon boy case. The parents wanted to find an easy way to make money and get on TV. They used their child, who blew their scheme open with his remark about getting ready for a show.

This is reminiscent of cases in which parents exploit the children's good looks or talents. We were all appalled at clips of JonBenet Ramsey getting dressed up, and dancing and prancing to please her parents. A child exploited in this way might, in fact, learn to enjoy the attention and might learn to adapt his or her attitudes and responses to gain adulation.

Much the same can be said of Michael Jackson, whose father pushed him to become a professional performer as a young child. His talent apparently pleased his father, who Michael complained over the years deprived him of a normal boyhood. Generally, we have not thought of what happened in the Jackson family as abuse. However, I don't see the dynamics as that different. Why, for example, was it so important to immerse Michael and his brothers in show business and make Michael a star? We would all agree that Michael Jackson's father was probably motivated by money. We are back to greed.

If I see in my practice a family in which a child has been exploited for financial gain or some other utility, I try first to assess the degree of trauma in the child.

The most important part of this story is the possible failure of the child to develop a normal superego, a conscience, and a sense of right and wrong consistent with societal norms. The superego is not innate. It is a learned or acquired part of the mental structure, and it is learned from the parents who set the moral tone in the house.

If a mother earns her living by selling illegal drugs, her child might be led to believe that this activity is normal and acceptable. Physical punishment does not help the superego to develop, and parents must know this in order to help their children understand the moral code of the nation, the city, the neighborhood, and the house. If those moral codes are all different, the child becomes confused, because each adult has a different message. Psychiatrists can help parents learn how to parent better and convey consistent moral values so that their children develop a normal superego.

The child has to know when his/her parent is displeased. Knowing when the parent is displeased helps young children to be toilet trained. A gentle, patient tone in the parent's voice during toilet training might teach the child that there is no urgency in getting trained. The message sent to the Heene boys is this: It is fine to create chaos in the community in order to achieve personal goals. The superego will incorporate this lesson most effectively unless there is an early midcourse correction.

Children absorb almost everything they hear in the home. Children sitting at the dinner table walk away with a lot of information, even if they don't truly understand what the information means. Unkind gossip and other talk that violates the supposed moral values of the family are heard and absorbed by children. Saying grace before a meal and then listening to adult conversation that contradicts the moral tone of grace creates a paradox for children. The Heene child was clearly confused by conflicting messages from his parents and he repeated his father's talk about “the show.” His articulation of his confusion to the news media blew the cover off the entire hoax.

Getting children to aid and abet criminal behavior is criminal. For the Heene family, capturing the attention of the entire nation was a wish granted. We talked and blogged about the story. Cable television news crews were all over it. Millions offered prayers for the boy we had been led to believe was in the balloon.

The Heene boys, meanwhile, were in on the ruse. They knew what mom and dad were up to, but only the youngest let it slip out because he was not yet a hardened liar.

As we psychiatrists evaluate patients and treat them, we must determine the nature and strength of the superegos.

All of us treat people with depression, which is a disease of the superego characterized by guilt. We saw no guilt in Mr. Heene. Now that he has confessed, we can see his distorted pathological purpose, which was to get an offer to participate in a reality show. We don't know how the father will deal with the child for blowing the hoax with his honesty or naivete. I'm not sure what to call it.

If I were treating this child, I would first get a history of how the children are disciplined and whether they are afraid of their father. That would make a big difference. Children in treatment often identify with their therapist and repeat things that the therapist says to their parents. That could endanger the child and could even end the treatment.

Retraining a child to form a strong and socially acceptable superego is difficult when he or she is living with parents who offer the child conflicting or inappropriate messages about moral values. Their messages are vitally poignant and more powerful than the ideas of the therapist.

Family therapy is a much more acceptable concept if everyone understands that the child's superego is the important subject of the therapy. The Heene family will need a great deal of help to heal the wounds perpetrated by the father. If they are not corrected, family members may grow up as damaged goods. Just as can happen in a family in which the father routinely beats the children, the damage to the children is long-lasting. The father might be deeply hated by those children.

Families like the one I'm describing rarely have family therapy and get a chance to correct the damage. I know of a case in which an 80-year-old man apologized to his 50-year-old son on his deathbed. That is much too late. The balloon boy might tell the story 20 years from now as if it were an adventure and talk about his father with pride. He might never get a mid-course correction to allow his life and his own children to live in a different world where morality is important.

A friend of mine, Wendy Murphy, who is a lawyer and teaches law, also writes op-eds for the Daily Beast and other papers. In a recent op-ed about the Heene family, she closed the piece this way:

“Advertisers know that audiences tune in to reality shows when they can identify with the stars. The Heenes will never attract viewers because among all the moms and dads who sat glued to their television last week, not a single one can relate to people who see value in the criminal exploitation of their own 6-year-old child.”

We in psychiatry have to help heal our nation and its moral wounds. This story is a disgrace–and a prime example of the extent to which we get excited by duplicity and criminality.

Fortunately, Richard Heene was among the few who got caught. But that doesn't solve the problem of this child, whom he engaged as a coconspirator.

[email protected]

The incident involving the boy in the balloon is sure to have triggered a lot of concern among psychiatrists who watched the drama unfold.

In my view, the Heene family's misuse of their child is not so different from the drug pusher who recruits a 10- or 11-year-old runner. In the latter case, the child also is put into serious danger–and the adult disregards the needs and interests of the child.

Reportedly, the father, Richard Heene, is a trained actor, and he wanted a job. So, in order to achieve his goal he knowingly endangered helicopter pilots, police, and many others involved in the the search and rescue effort.

One of the most disturbing lessons for the Heene children is that they were made aware that their parents are capable of being less than truthful. Such a lesson might make the boys think that lying is acceptable. After all, many children learn to lie from their parents. “Don't tell your mother” is a common household phrase. Too often, if a child comes home from school and tells mom or dad that they lied, cheated, or hurt another child, the behavior is condoned. This kind of reaction helps the child avoid any pangs of conscience and feel comfortable with psychopathy and sociopathy. At least in the Heene family, the children did not learn that dishonesty pays off.

The Heene family saga also is a reminder of the devastating impact of greed. We have become a nation of cynics, because we expect everyone to cheat. This is expected to such an extent that illegal gains often are worked into the budget, because everyone assumes that someone is bending the rules.

Thirty years ago, I was on my way to New York City to see a show with my wife and 16-year-old son. We got a flat tire, and my son changed the tire while I held an umbrella over his head. The spare was a donut that said on it, “Do not go more than 50 miles on this tire.”

So we drove into a Sunoco station to get the flat fixed. I ran into the station, fell, and broke a leg. Instead of going to New York City to see Amadeus, I went to the hospital to be operated on. Two weeks after the incident, I was at home and received a call from a lawyer for the Sun Oil Co. He asked me numerous questions about grease on the ground or my clothes, and I finally said in an exasperated tone: “I ran, I slipped, and I broke my leg. I am not suing you.” There was a long silence, and he finally said, “Dr. Fink, this is the most unusual conversation I've had in 15 years of practicing law!” He had expected me to sue. But I saw no reason to sue the company, even though I, like everyone else, could have used the money. It just never occurred to me, and I hope that this lesson in honesty was not lost on my son.

The issue of greed is clearly a big part of the balloon boy case. The parents wanted to find an easy way to make money and get on TV. They used their child, who blew their scheme open with his remark about getting ready for a show.

This is reminiscent of cases in which parents exploit the children's good looks or talents. We were all appalled at clips of JonBenet Ramsey getting dressed up, and dancing and prancing to please her parents. A child exploited in this way might, in fact, learn to enjoy the attention and might learn to adapt his or her attitudes and responses to gain adulation.

Much the same can be said of Michael Jackson, whose father pushed him to become a professional performer as a young child. His talent apparently pleased his father, who Michael complained over the years deprived him of a normal boyhood. Generally, we have not thought of what happened in the Jackson family as abuse. However, I don't see the dynamics as that different. Why, for example, was it so important to immerse Michael and his brothers in show business and make Michael a star? We would all agree that Michael Jackson's father was probably motivated by money. We are back to greed.

If I see in my practice a family in which a child has been exploited for financial gain or some other utility, I try first to assess the degree of trauma in the child.

The most important part of this story is the possible failure of the child to develop a normal superego, a conscience, and a sense of right and wrong consistent with societal norms. The superego is not innate. It is a learned or acquired part of the mental structure, and it is learned from the parents who set the moral tone in the house.

If a mother earns her living by selling illegal drugs, her child might be led to believe that this activity is normal and acceptable. Physical punishment does not help the superego to develop, and parents must know this in order to help their children understand the moral code of the nation, the city, the neighborhood, and the house. If those moral codes are all different, the child becomes confused, because each adult has a different message. Psychiatrists can help parents learn how to parent better and convey consistent moral values so that their children develop a normal superego.

The child has to know when his/her parent is displeased. Knowing when the parent is displeased helps young children to be toilet trained. A gentle, patient tone in the parent's voice during toilet training might teach the child that there is no urgency in getting trained. The message sent to the Heene boys is this: It is fine to create chaos in the community in order to achieve personal goals. The superego will incorporate this lesson most effectively unless there is an early midcourse correction.

Children absorb almost everything they hear in the home. Children sitting at the dinner table walk away with a lot of information, even if they don't truly understand what the information means. Unkind gossip and other talk that violates the supposed moral values of the family are heard and absorbed by children. Saying grace before a meal and then listening to adult conversation that contradicts the moral tone of grace creates a paradox for children. The Heene child was clearly confused by conflicting messages from his parents and he repeated his father's talk about “the show.” His articulation of his confusion to the news media blew the cover off the entire hoax.

Getting children to aid and abet criminal behavior is criminal. For the Heene family, capturing the attention of the entire nation was a wish granted. We talked and blogged about the story. Cable television news crews were all over it. Millions offered prayers for the boy we had been led to believe was in the balloon.

The Heene boys, meanwhile, were in on the ruse. They knew what mom and dad were up to, but only the youngest let it slip out because he was not yet a hardened liar.

As we psychiatrists evaluate patients and treat them, we must determine the nature and strength of the superegos.

All of us treat people with depression, which is a disease of the superego characterized by guilt. We saw no guilt in Mr. Heene. Now that he has confessed, we can see his distorted pathological purpose, which was to get an offer to participate in a reality show. We don't know how the father will deal with the child for blowing the hoax with his honesty or naivete. I'm not sure what to call it.

If I were treating this child, I would first get a history of how the children are disciplined and whether they are afraid of their father. That would make a big difference. Children in treatment often identify with their therapist and repeat things that the therapist says to their parents. That could endanger the child and could even end the treatment.

Retraining a child to form a strong and socially acceptable superego is difficult when he or she is living with parents who offer the child conflicting or inappropriate messages about moral values. Their messages are vitally poignant and more powerful than the ideas of the therapist.

Family therapy is a much more acceptable concept if everyone understands that the child's superego is the important subject of the therapy. The Heene family will need a great deal of help to heal the wounds perpetrated by the father. If they are not corrected, family members may grow up as damaged goods. Just as can happen in a family in which the father routinely beats the children, the damage to the children is long-lasting. The father might be deeply hated by those children.

Families like the one I'm describing rarely have family therapy and get a chance to correct the damage. I know of a case in which an 80-year-old man apologized to his 50-year-old son on his deathbed. That is much too late. The balloon boy might tell the story 20 years from now as if it were an adventure and talk about his father with pride. He might never get a mid-course correction to allow his life and his own children to live in a different world where morality is important.

A friend of mine, Wendy Murphy, who is a lawyer and teaches law, also writes op-eds for the Daily Beast and other papers. In a recent op-ed about the Heene family, she closed the piece this way:

“Advertisers know that audiences tune in to reality shows when they can identify with the stars. The Heenes will never attract viewers because among all the moms and dads who sat glued to their television last week, not a single one can relate to people who see value in the criminal exploitation of their own 6-year-old child.”

We in psychiatry have to help heal our nation and its moral wounds. This story is a disgrace–and a prime example of the extent to which we get excited by duplicity and criminality.

Fortunately, Richard Heene was among the few who got caught. But that doesn't solve the problem of this child, whom he engaged as a coconspirator.

[email protected]

The incident involving the boy in the balloon is sure to have triggered a lot of concern among psychiatrists who watched the drama unfold.

In my view, the Heene family's misuse of their child is not so different from the drug pusher who recruits a 10- or 11-year-old runner. In the latter case, the child also is put into serious danger–and the adult disregards the needs and interests of the child.

Reportedly, the father, Richard Heene, is a trained actor, and he wanted a job. So, in order to achieve his goal he knowingly endangered helicopter pilots, police, and many others involved in the the search and rescue effort.

One of the most disturbing lessons for the Heene children is that they were made aware that their parents are capable of being less than truthful. Such a lesson might make the boys think that lying is acceptable. After all, many children learn to lie from their parents. “Don't tell your mother” is a common household phrase. Too often, if a child comes home from school and tells mom or dad that they lied, cheated, or hurt another child, the behavior is condoned. This kind of reaction helps the child avoid any pangs of conscience and feel comfortable with psychopathy and sociopathy. At least in the Heene family, the children did not learn that dishonesty pays off.

The Heene family saga also is a reminder of the devastating impact of greed. We have become a nation of cynics, because we expect everyone to cheat. This is expected to such an extent that illegal gains often are worked into the budget, because everyone assumes that someone is bending the rules.

Thirty years ago, I was on my way to New York City to see a show with my wife and 16-year-old son. We got a flat tire, and my son changed the tire while I held an umbrella over his head. The spare was a donut that said on it, “Do not go more than 50 miles on this tire.”

So we drove into a Sunoco station to get the flat fixed. I ran into the station, fell, and broke a leg. Instead of going to New York City to see Amadeus, I went to the hospital to be operated on. Two weeks after the incident, I was at home and received a call from a lawyer for the Sun Oil Co. He asked me numerous questions about grease on the ground or my clothes, and I finally said in an exasperated tone: “I ran, I slipped, and I broke my leg. I am not suing you.” There was a long silence, and he finally said, “Dr. Fink, this is the most unusual conversation I've had in 15 years of practicing law!” He had expected me to sue. But I saw no reason to sue the company, even though I, like everyone else, could have used the money. It just never occurred to me, and I hope that this lesson in honesty was not lost on my son.

The issue of greed is clearly a big part of the balloon boy case. The parents wanted to find an easy way to make money and get on TV. They used their child, who blew their scheme open with his remark about getting ready for a show.

This is reminiscent of cases in which parents exploit the children's good looks or talents. We were all appalled at clips of JonBenet Ramsey getting dressed up, and dancing and prancing to please her parents. A child exploited in this way might, in fact, learn to enjoy the attention and might learn to adapt his or her attitudes and responses to gain adulation.

Much the same can be said of Michael Jackson, whose father pushed him to become a professional performer as a young child. His talent apparently pleased his father, who Michael complained over the years deprived him of a normal boyhood. Generally, we have not thought of what happened in the Jackson family as abuse. However, I don't see the dynamics as that different. Why, for example, was it so important to immerse Michael and his brothers in show business and make Michael a star? We would all agree that Michael Jackson's father was probably motivated by money. We are back to greed.

If I see in my practice a family in which a child has been exploited for financial gain or some other utility, I try first to assess the degree of trauma in the child.

The most important part of this story is the possible failure of the child to develop a normal superego, a conscience, and a sense of right and wrong consistent with societal norms. The superego is not innate. It is a learned or acquired part of the mental structure, and it is learned from the parents who set the moral tone in the house.

If a mother earns her living by selling illegal drugs, her child might be led to believe that this activity is normal and acceptable. Physical punishment does not help the superego to develop, and parents must know this in order to help their children understand the moral code of the nation, the city, the neighborhood, and the house. If those moral codes are all different, the child becomes confused, because each adult has a different message. Psychiatrists can help parents learn how to parent better and convey consistent moral values so that their children develop a normal superego.

The child has to know when his/her parent is displeased. Knowing when the parent is displeased helps young children to be toilet trained. A gentle, patient tone in the parent's voice during toilet training might teach the child that there is no urgency in getting trained. The message sent to the Heene boys is this: It is fine to create chaos in the community in order to achieve personal goals. The superego will incorporate this lesson most effectively unless there is an early midcourse correction.

Children absorb almost everything they hear in the home. Children sitting at the dinner table walk away with a lot of information, even if they don't truly understand what the information means. Unkind gossip and other talk that violates the supposed moral values of the family are heard and absorbed by children. Saying grace before a meal and then listening to adult conversation that contradicts the moral tone of grace creates a paradox for children. The Heene child was clearly confused by conflicting messages from his parents and he repeated his father's talk about “the show.” His articulation of his confusion to the news media blew the cover off the entire hoax.

Getting children to aid and abet criminal behavior is criminal. For the Heene family, capturing the attention of the entire nation was a wish granted. We talked and blogged about the story. Cable television news crews were all over it. Millions offered prayers for the boy we had been led to believe was in the balloon.

The Heene boys, meanwhile, were in on the ruse. They knew what mom and dad were up to, but only the youngest let it slip out because he was not yet a hardened liar.

As we psychiatrists evaluate patients and treat them, we must determine the nature and strength of the superegos.

All of us treat people with depression, which is a disease of the superego characterized by guilt. We saw no guilt in Mr. Heene. Now that he has confessed, we can see his distorted pathological purpose, which was to get an offer to participate in a reality show. We don't know how the father will deal with the child for blowing the hoax with his honesty or naivete. I'm not sure what to call it.

If I were treating this child, I would first get a history of how the children are disciplined and whether they are afraid of their father. That would make a big difference. Children in treatment often identify with their therapist and repeat things that the therapist says to their parents. That could endanger the child and could even end the treatment.

Retraining a child to form a strong and socially acceptable superego is difficult when he or she is living with parents who offer the child conflicting or inappropriate messages about moral values. Their messages are vitally poignant and more powerful than the ideas of the therapist.

Family therapy is a much more acceptable concept if everyone understands that the child's superego is the important subject of the therapy. The Heene family will need a great deal of help to heal the wounds perpetrated by the father. If they are not corrected, family members may grow up as damaged goods. Just as can happen in a family in which the father routinely beats the children, the damage to the children is long-lasting. The father might be deeply hated by those children.

Families like the one I'm describing rarely have family therapy and get a chance to correct the damage. I know of a case in which an 80-year-old man apologized to his 50-year-old son on his deathbed. That is much too late. The balloon boy might tell the story 20 years from now as if it were an adventure and talk about his father with pride. He might never get a mid-course correction to allow his life and his own children to live in a different world where morality is important.

A friend of mine, Wendy Murphy, who is a lawyer and teaches law, also writes op-eds for the Daily Beast and other papers. In a recent op-ed about the Heene family, she closed the piece this way:

“Advertisers know that audiences tune in to reality shows when they can identify with the stars. The Heenes will never attract viewers because among all the moms and dads who sat glued to their television last week, not a single one can relate to people who see value in the criminal exploitation of their own 6-year-old child.”

We in psychiatry have to help heal our nation and its moral wounds. This story is a disgrace–and a prime example of the extent to which we get excited by duplicity and criminality.

Fortunately, Richard Heene was among the few who got caught. But that doesn't solve the problem of this child, whom he engaged as a coconspirator.

[email protected]

Psychiatry is such a screwed-up field that we cannot retain a language that is scientific and meaningful.

Several months ago I railed against the bastardization of the word “depression.” Now we have a new one, “distress,” which a recent study on causes of stroke equates with emotional distress (see details about the study in article below).

I'm also disturbed–rather than depressed or anxious–by the constant annual effort to rediscover Freud. Rename it, and call it a new finding. Freud said: “Analysis exchanges the pain of neurons for the misery of everyday life.” Was he stealing the idea from Henry David Thoreau, who said, “The mass of men lead lives of quiet desperation”?

I don't use the terms stress and distress to have significant measurable diagnosable meaning. But now, researchers in the United Kingdom have determined that psychological distress is linked to increased risk of stroke (Neurology 2008;70:788–94). I take that to mean that all normal people are at risk for stroke.

Someone has to make very clear to me and the general public what psychological distress means. Is that more than the psychological pain related to the death of a loved one or the loss of a job? For me, stress and distress are lay terms and not psychiatric terms. We need to guard our areas of interest and concern very closely.

Perhaps when the study's authors refer to distress, they are alluding to anxiety. If anxiety, not depression, were linked to increased stroke risk, I would be very interested. Now I think I know why we separated neurology from psychiatry. Emotional disease is nothing about which we should be casual. It is our bread and butter.

About 2 years ago, I became excited about new scientific information suggesting that if a person feels any symptoms that could presage a stroke, he or she should get to a hospital for a CT scan and the medicine that can abort a stroke (if it is not being caused by hemorrhage). The individual should get to a hospital in 15 minutes. Knowing the life-altering and life-endangering nature of stroke, I thought this was a terrific piece of information, but no layperson I know seems to have heard of it. Furthermore, it is highly unlikely that anyone would bypass denial and get to the hospital. Whenever I have a friend or patient tell me about an episode of illness, the story is always exasperating, because the individual first self-diagnoses and delays calling a doctor or rushing off to an emergency department.

My mother became blind as she got older, but I will never forget how it started. I went to Florida for her 75th birthday party, and she complained that her eyesight was getting bad. I asked if she had called the doctor, to which she gave her usual reply, “I didn't want to bother him.” I insisted on going with her to the doctor the next morning, before I was scheduled to fly out. She had hemorrhagic macular degeneration, and I believe she might have had many more years of sight had she seen the value of going to a doctor and getting proper care immediately.

In this context, the U.K. researchers are eager to show that depression, while it often follows a stroke, is not a causative factor. That is important, but one form of human distress is depression. Are we sure that some of those designated as “distressed” were not depressed?

I continue to have great difficulty with researchers and neurologists making psychiatric diagnoses, particularly when the big category is psychological distress, a term of no use or meaning to psychiatrists. No one is free of distress. We are all in conflict about some aspect of our lives. There are lots of categories where we feel confused, fearful of hurting someone, or where we want something we cannot afford or desire sex with someone who is uninterested.

I'm allowing for these conflicts as examples of psychological distress. Or are the authors really talking about some kind of personality disorder in which the patient is always complaining, chronically discontented, or backfilling for things either said or done? Several personality disorders are characterized by psychological distress. The most common is obsessive compulsive disorder, but I'm sure each reader can recall a patient who was always bitching about someone else. It's a very common defense for people to complain about others rather than look at their own role in their unhappiness. My patients with OCD are in terrible pain. Their obsessive thoughts torment them. Is that the distress? The U.K. researchers are talking about every diagnosis in DSM-IV to get the meaning of distress. I think we should try to help them become better diagnosticians of psychiatric disorders. What they have done is demonstrated their stigma and disdain for psychiatry by trivializing distress as a nondescript concept against which to compare depression.

The question posed by the study–Are there psychiatric disorders that help precipitate a stroke?–is an important one. Psychiatrists and neurologists should be working together to either retrospectively or prospectively discover who has strokes.

It seems to me that we should be singling out those who develop arterial sclerosis or other vessel-blocking disorders, testing carotid arteries for blockages, or looking at those who have other evidence of vessel blockage for signs of imminent stroke, weakness, difficulty speaking, etc. Since I obviously am not impressed with the discovery that psychological distress may increase strokes, it means nothing to me. I wouldn't know whom to warn.

In the biopsychosocial world in which we live, a need for greater precision is needed. We analytic types often have been accused of imprecision, guesswork, and flawed theories, and we have, in fact, often lacked the necessary precision that is considered in the biomedical world to be scientific. But as I experience more and more of how the rest of medicine operates, I am amazed by how sloppy others can be in their science! Add to that the institutionalized rudeness of office staff, the lack of concern about the patient's time, and the habitual lack of feedback to the patient and/or the family, and you can begin to understand why I find the misuse of terms and the failure of accurate diagnosis so exasperating.

The use of the anomalous and meaningless word “distress” is obviously one of the nodal points that gets to me. It's worse if you are a physician, because the doctor will often answer my questions with “you know what to do.” If I knew, I wouldn't ask! I assume that he doesn't act the same way with nonphysician patients.

What I'm begging for in this column is a better recognition of the body of knowledge called psychiatry with all of its theories, diagnoses, and treatments. I have resented for decades the stigma against psychiatry practiced by nonpsychiatric physicians, which is passed on by residents to medical students. No matter how hard we fight to erase the stigma, we are stuck with chronic joking and gentle harassment by our colleagues. I believe that much of our thinking is incomprehensible to these men and women who appear to be offended that we seem to know something about how the human mind works and what makes people tick.

I have avoided using the word “castration” in my teaching and scientific talks for years, but today I saw a patient with the residents and students where it was absolutely appropriate. A 56-year-old man with depression and anxiety had severe chronic obstructive pulmonary disease, the result of smoking three packs of cigarettes a day for more than 40 years and drinking two cases of beer a day for decades. Now totally incapacitated, unhappily living with his daughter and son-in-law whom he despises, unable to get out of the house, work or “do” anything, he is depressed, largely because of his unfitness and the death of his wife. Also, he is reliving the death of his mother when he was 7 years old. Today, he is a shadow of his former self: a vibrant husband, father, and construction worker.

This patient is jumping out of his skin to rejoin the living but “doesn't have the energy” and can hardly breathe. Does the pulmonologist, who is recommending a lung transplant, care about any of this, or does he know that his treatment can actually help this man get his life back?

We in psychiatry have to resist glib and often unnecessary research in areas that do not further our work and might start whole new areas of thought that are of no practical use.

Both stroke and depression are important areas for our concern. Knowing the relationship between the two can be helpful to scores of patients. Let's make sure that we don't go along with “scientific” nonsense.

[email protected]

Psychiatry is such a screwed-up field that we cannot retain a language that is scientific and meaningful.

Several months ago I railed against the bastardization of the word “depression.” Now we have a new one, “distress,” which a recent study on causes of stroke equates with emotional distress (see details about the study in article below).

I'm also disturbed–rather than depressed or anxious–by the constant annual effort to rediscover Freud. Rename it, and call it a new finding. Freud said: “Analysis exchanges the pain of neurons for the misery of everyday life.” Was he stealing the idea from Henry David Thoreau, who said, “The mass of men lead lives of quiet desperation”?

I don't use the terms stress and distress to have significant measurable diagnosable meaning. But now, researchers in the United Kingdom have determined that psychological distress is linked to increased risk of stroke (Neurology 2008;70:788–94). I take that to mean that all normal people are at risk for stroke.

Someone has to make very clear to me and the general public what psychological distress means. Is that more than the psychological pain related to the death of a loved one or the loss of a job? For me, stress and distress are lay terms and not psychiatric terms. We need to guard our areas of interest and concern very closely.

Perhaps when the study's authors refer to distress, they are alluding to anxiety. If anxiety, not depression, were linked to increased stroke risk, I would be very interested. Now I think I know why we separated neurology from psychiatry. Emotional disease is nothing about which we should be casual. It is our bread and butter.

About 2 years ago, I became excited about new scientific information suggesting that if a person feels any symptoms that could presage a stroke, he or she should get to a hospital for a CT scan and the medicine that can abort a stroke (if it is not being caused by hemorrhage). The individual should get to a hospital in 15 minutes. Knowing the life-altering and life-endangering nature of stroke, I thought this was a terrific piece of information, but no layperson I know seems to have heard of it. Furthermore, it is highly unlikely that anyone would bypass denial and get to the hospital. Whenever I have a friend or patient tell me about an episode of illness, the story is always exasperating, because the individual first self-diagnoses and delays calling a doctor or rushing off to an emergency department.

My mother became blind as she got older, but I will never forget how it started. I went to Florida for her 75th birthday party, and she complained that her eyesight was getting bad. I asked if she had called the doctor, to which she gave her usual reply, “I didn't want to bother him.” I insisted on going with her to the doctor the next morning, before I was scheduled to fly out. She had hemorrhagic macular degeneration, and I believe she might have had many more years of sight had she seen the value of going to a doctor and getting proper care immediately.

In this context, the U.K. researchers are eager to show that depression, while it often follows a stroke, is not a causative factor. That is important, but one form of human distress is depression. Are we sure that some of those designated as “distressed” were not depressed?

I continue to have great difficulty with researchers and neurologists making psychiatric diagnoses, particularly when the big category is psychological distress, a term of no use or meaning to psychiatrists. No one is free of distress. We are all in conflict about some aspect of our lives. There are lots of categories where we feel confused, fearful of hurting someone, or where we want something we cannot afford or desire sex with someone who is uninterested.

I'm allowing for these conflicts as examples of psychological distress. Or are the authors really talking about some kind of personality disorder in which the patient is always complaining, chronically discontented, or backfilling for things either said or done? Several personality disorders are characterized by psychological distress. The most common is obsessive compulsive disorder, but I'm sure each reader can recall a patient who was always bitching about someone else. It's a very common defense for people to complain about others rather than look at their own role in their unhappiness. My patients with OCD are in terrible pain. Their obsessive thoughts torment them. Is that the distress? The U.K. researchers are talking about every diagnosis in DSM-IV to get the meaning of distress. I think we should try to help them become better diagnosticians of psychiatric disorders. What they have done is demonstrated their stigma and disdain for psychiatry by trivializing distress as a nondescript concept against which to compare depression.

The question posed by the study–Are there psychiatric disorders that help precipitate a stroke?–is an important one. Psychiatrists and neurologists should be working together to either retrospectively or prospectively discover who has strokes.

It seems to me that we should be singling out those who develop arterial sclerosis or other vessel-blocking disorders, testing carotid arteries for blockages, or looking at those who have other evidence of vessel blockage for signs of imminent stroke, weakness, difficulty speaking, etc. Since I obviously am not impressed with the discovery that psychological distress may increase strokes, it means nothing to me. I wouldn't know whom to warn.

In the biopsychosocial world in which we live, a need for greater precision is needed. We analytic types often have been accused of imprecision, guesswork, and flawed theories, and we have, in fact, often lacked the necessary precision that is considered in the biomedical world to be scientific. But as I experience more and more of how the rest of medicine operates, I am amazed by how sloppy others can be in their science! Add to that the institutionalized rudeness of office staff, the lack of concern about the patient's time, and the habitual lack of feedback to the patient and/or the family, and you can begin to understand why I find the misuse of terms and the failure of accurate diagnosis so exasperating.

The use of the anomalous and meaningless word “distress” is obviously one of the nodal points that gets to me. It's worse if you are a physician, because the doctor will often answer my questions with “you know what to do.” If I knew, I wouldn't ask! I assume that he doesn't act the same way with nonphysician patients.

What I'm begging for in this column is a better recognition of the body of knowledge called psychiatry with all of its theories, diagnoses, and treatments. I have resented for decades the stigma against psychiatry practiced by nonpsychiatric physicians, which is passed on by residents to medical students. No matter how hard we fight to erase the stigma, we are stuck with chronic joking and gentle harassment by our colleagues. I believe that much of our thinking is incomprehensible to these men and women who appear to be offended that we seem to know something about how the human mind works and what makes people tick.

I have avoided using the word “castration” in my teaching and scientific talks for years, but today I saw a patient with the residents and students where it was absolutely appropriate. A 56-year-old man with depression and anxiety had severe chronic obstructive pulmonary disease, the result of smoking three packs of cigarettes a day for more than 40 years and drinking two cases of beer a day for decades. Now totally incapacitated, unhappily living with his daughter and son-in-law whom he despises, unable to get out of the house, work or “do” anything, he is depressed, largely because of his unfitness and the death of his wife. Also, he is reliving the death of his mother when he was 7 years old. Today, he is a shadow of his former self: a vibrant husband, father, and construction worker.

This patient is jumping out of his skin to rejoin the living but “doesn't have the energy” and can hardly breathe. Does the pulmonologist, who is recommending a lung transplant, care about any of this, or does he know that his treatment can actually help this man get his life back?

We in psychiatry have to resist glib and often unnecessary research in areas that do not further our work and might start whole new areas of thought that are of no practical use.

Both stroke and depression are important areas for our concern. Knowing the relationship between the two can be helpful to scores of patients. Let's make sure that we don't go along with “scientific” nonsense.

[email protected]

Psychiatry is such a screwed-up field that we cannot retain a language that is scientific and meaningful.

Several months ago I railed against the bastardization of the word “depression.” Now we have a new one, “distress,” which a recent study on causes of stroke equates with emotional distress (see details about the study in article below).

I'm also disturbed–rather than depressed or anxious–by the constant annual effort to rediscover Freud. Rename it, and call it a new finding. Freud said: “Analysis exchanges the pain of neurons for the misery of everyday life.” Was he stealing the idea from Henry David Thoreau, who said, “The mass of men lead lives of quiet desperation”?

I don't use the terms stress and distress to have significant measurable diagnosable meaning. But now, researchers in the United Kingdom have determined that psychological distress is linked to increased risk of stroke (Neurology 2008;70:788–94). I take that to mean that all normal people are at risk for stroke.

Someone has to make very clear to me and the general public what psychological distress means. Is that more than the psychological pain related to the death of a loved one or the loss of a job? For me, stress and distress are lay terms and not psychiatric terms. We need to guard our areas of interest and concern very closely.

Perhaps when the study's authors refer to distress, they are alluding to anxiety. If anxiety, not depression, were linked to increased stroke risk, I would be very interested. Now I think I know why we separated neurology from psychiatry. Emotional disease is nothing about which we should be casual. It is our bread and butter.

About 2 years ago, I became excited about new scientific information suggesting that if a person feels any symptoms that could presage a stroke, he or she should get to a hospital for a CT scan and the medicine that can abort a stroke (if it is not being caused by hemorrhage). The individual should get to a hospital in 15 minutes. Knowing the life-altering and life-endangering nature of stroke, I thought this was a terrific piece of information, but no layperson I know seems to have heard of it. Furthermore, it is highly unlikely that anyone would bypass denial and get to the hospital. Whenever I have a friend or patient tell me about an episode of illness, the story is always exasperating, because the individual first self-diagnoses and delays calling a doctor or rushing off to an emergency department.

My mother became blind as she got older, but I will never forget how it started. I went to Florida for her 75th birthday party, and she complained that her eyesight was getting bad. I asked if she had called the doctor, to which she gave her usual reply, “I didn't want to bother him.” I insisted on going with her to the doctor the next morning, before I was scheduled to fly out. She had hemorrhagic macular degeneration, and I believe she might have had many more years of sight had she seen the value of going to a doctor and getting proper care immediately.

In this context, the U.K. researchers are eager to show that depression, while it often follows a stroke, is not a causative factor. That is important, but one form of human distress is depression. Are we sure that some of those designated as “distressed” were not depressed?

I continue to have great difficulty with researchers and neurologists making psychiatric diagnoses, particularly when the big category is psychological distress, a term of no use or meaning to psychiatrists. No one is free of distress. We are all in conflict about some aspect of our lives. There are lots of categories where we feel confused, fearful of hurting someone, or where we want something we cannot afford or desire sex with someone who is uninterested.

I'm allowing for these conflicts as examples of psychological distress. Or are the authors really talking about some kind of personality disorder in which the patient is always complaining, chronically discontented, or backfilling for things either said or done? Several personality disorders are characterized by psychological distress. The most common is obsessive compulsive disorder, but I'm sure each reader can recall a patient who was always bitching about someone else. It's a very common defense for people to complain about others rather than look at their own role in their unhappiness. My patients with OCD are in terrible pain. Their obsessive thoughts torment them. Is that the distress? The U.K. researchers are talking about every diagnosis in DSM-IV to get the meaning of distress. I think we should try to help them become better diagnosticians of psychiatric disorders. What they have done is demonstrated their stigma and disdain for psychiatry by trivializing distress as a nondescript concept against which to compare depression.

The question posed by the study–Are there psychiatric disorders that help precipitate a stroke?–is an important one. Psychiatrists and neurologists should be working together to either retrospectively or prospectively discover who has strokes.

It seems to me that we should be singling out those who develop arterial sclerosis or other vessel-blocking disorders, testing carotid arteries for blockages, or looking at those who have other evidence of vessel blockage for signs of imminent stroke, weakness, difficulty speaking, etc. Since I obviously am not impressed with the discovery that psychological distress may increase strokes, it means nothing to me. I wouldn't know whom to warn.

In the biopsychosocial world in which we live, a need for greater precision is needed. We analytic types often have been accused of imprecision, guesswork, and flawed theories, and we have, in fact, often lacked the necessary precision that is considered in the biomedical world to be scientific. But as I experience more and more of how the rest of medicine operates, I am amazed by how sloppy others can be in their science! Add to that the institutionalized rudeness of office staff, the lack of concern about the patient's time, and the habitual lack of feedback to the patient and/or the family, and you can begin to understand why I find the misuse of terms and the failure of accurate diagnosis so exasperating.

The use of the anomalous and meaningless word “distress” is obviously one of the nodal points that gets to me. It's worse if you are a physician, because the doctor will often answer my questions with “you know what to do.” If I knew, I wouldn't ask! I assume that he doesn't act the same way with nonphysician patients.

What I'm begging for in this column is a better recognition of the body of knowledge called psychiatry with all of its theories, diagnoses, and treatments. I have resented for decades the stigma against psychiatry practiced by nonpsychiatric physicians, which is passed on by residents to medical students. No matter how hard we fight to erase the stigma, we are stuck with chronic joking and gentle harassment by our colleagues. I believe that much of our thinking is incomprehensible to these men and women who appear to be offended that we seem to know something about how the human mind works and what makes people tick.

I have avoided using the word “castration” in my teaching and scientific talks for years, but today I saw a patient with the residents and students where it was absolutely appropriate. A 56-year-old man with depression and anxiety had severe chronic obstructive pulmonary disease, the result of smoking three packs of cigarettes a day for more than 40 years and drinking two cases of beer a day for decades. Now totally incapacitated, unhappily living with his daughter and son-in-law whom he despises, unable to get out of the house, work or “do” anything, he is depressed, largely because of his unfitness and the death of his wife. Also, he is reliving the death of his mother when he was 7 years old. Today, he is a shadow of his former self: a vibrant husband, father, and construction worker.

This patient is jumping out of his skin to rejoin the living but “doesn't have the energy” and can hardly breathe. Does the pulmonologist, who is recommending a lung transplant, care about any of this, or does he know that his treatment can actually help this man get his life back?

We in psychiatry have to resist glib and often unnecessary research in areas that do not further our work and might start whole new areas of thought that are of no practical use.

Both stroke and depression are important areas for our concern. Knowing the relationship between the two can be helpful to scores of patients. Let's make sure that we don't go along with “scientific” nonsense.

[email protected]

Treatment of drug and/or alcohol addicts is extremely difficult for those psychiatrists not specifically trained to handle such patients. Let me start by describing two patients with whom I failed miserably because, in my commitment to addressing the symptomatic side of the disability, I did not address the addiction.

The first case involved a 41-year-old single man, who was a son of very rich parents. The patient seemed to have had a lifetime of debilitating depression. He appeared attached to his elderly mother and had no friends, work, or real source of pleasure. All of that should have been enough for me to delve into the possibility of addiction, but he did not offer the information and I did not ask.

He described a terribly abusive childhood, mostly at the hands of his alcoholic mother, who beat and humiliated him constantly and essentially blamed him for everything–since his brother could do no wrong. The most pathetic sentence I can remember from his treatment was: “Every day when I got home from school, I tried to get from the front door to my bedroom in the hope that I would not rouse or encounter my drunken mother.”

He ended treatment by going into an alcohol rehab center.

The second case was even worse, because I knew when I started treating this patient that he was an alcoholic. He was a 42-year-old lawyer with a history of many rehab admissions and attempts to stop his use of drugs and alcohol. I was persuaded to take him into treatment by his father, whom I had known casually more than 40 years earlier.

His father, who was extremely intrusive, domineering, and controlling, took his son into his law practice. The father was such a hovering and demanding presence in his son's life that the treatment started by my attempting to help the patient separate from him. This turned out to be extremely difficult, and I was not paying enough attention to the drinking.

From time to time, his father would call to scold me and tell me about a drunken episode that had occurred over the weekend. I was so resentful of the father and committed to the patient that I did not take a strong, objective view of the regression as a good treater of an alcoholic would have done. Instead, I took a softer psychotherapeutic approach that was not absorbed in a positive way by the patient. I was going to be a better, kinder, gentler father figure for this patient.

Clearly, this is antithetical to the best treatment for an addict. He, too, left therapy for another tour through a rehab center, and I never heard from him again. I would like to believe that his silence stemmed from his father's rage at me rather than his own disappointment with my care.

Both of those cases illustrate the need for a general psychiatrist to have specific training in caring for the addicted patient.

I hope that today's residents fulfill the requirement to learn about addiction psychiatry. It should be something every practicing psychiatrist should learn and know how to do. The most important question to be asked is whether the use of drugs and alcohol is primary with anxiety and/or depression superimposed on the addiction because of the failure, dissipation, and uncontrollable craving. Or are the anxiety and/or depression primary, and is the patient using drugs and/or alcohol as self-medication?

Many patients whom I have evaluated start drinking early in adolescence because of the posttraumatic stress disorder (PTSD) suffered as a result of serious physical or emotional abuse as a child. I believe the first patient's problems were at least partly a result of his serious abuse as a child. But there is also the genetic element that cannot be discounted.

It is important that the clinician try to make the distinction as part of the patient's evaluation so that he knows what direction to take in the treatment. Regardless of the answer, the initial care must be directed to the cessation of substance use.

For the nonaddict, the most difficult thing to understand is the depth and extent of the craving. Because brain changes clearly take place in the addict that make this craving a biologically driven reality, it is very difficult for the patient to “just say no.” Willpower is an insignificant force, compared with the attraction of the patient's substance. We all know former smokers who, even though they have not smoked for 20 years, still desire a cigarette–especially when they are in the company of someone who is smoking. Similarly, the drug and alcohol addict cannot really control this desire. That's why Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) are so important and should be part of every treatment regime. The key to AA/NA, in my opinion, is the sponsor. The sponsor is someone who is a mentor, guide, and coach who is available 24/7 so that the user can call upon that person to help them suffer through the attack (of desire) and not succumb to it.

There are many elements to AA/NA, but the secret is in the meetings–for beginners, daily–which brings the addict out of seclusion and into the presence of many others who are suffering from the same disorder and share their experiences with the group. At least the naïve addict knows that he is not alone, and while shame and humiliation might initially stop him from “sharing,” he listens to the others and recognizes his own pain as he hears about the pain suffered by others.

Finding a sponsor is critical, and for some, the sooner the better. The psychiatrist or psychologist cannot do what the sponsor can do. Some psychiatrists try to be constantly available to the addicted patient but always fail, because such availability is not really part of their general modus operandi. Such expectations only serve to put a hostile distance between the doctor and the patient, and will clearly lead to failure, for which the doctor generally blames the patient.

There are several forms of iatrogenic precipitation of addiction. The first deals with actions that I feel are appropriate: the proper prescription of opiates to patients with severe and unremitting pain, most often in patients with advanced cancer. Unfortunately, some physicians still underprescribe opiates for their patients, because they do not want to cause them to be addicted (even though in many cases, the condition is incurable and the patient is going to die relatively soon). This absurd idea is sadistic on the part of any doctor who would deprive such a patient of adequate relief of pain for sanctimonious and righteous reasons.

The prescription of opiates for undefined and poorly described pain, e.g., back pain or headache, is an opposite situation. Often, psychiatrists are cajoled into prescribing such drugs for patients who may see a general practitioner or internist very rarely, and without a clear diagnosis of the problem and a determination of whether the problem is physical or mental.

Such determinations often require imaging procedures and/or blood tests that are not part of the psychiatrist's usual practice, and it is easier to prescribe the drug than to worry about the threat of addiction. These psychiatrists often find themselves with an iatrogenically produced addict on their hands and in a real dilemma about how to resolve the problem. We psychiatrists generally are not schooled in how to detox a patient, and it becomes apparent in both of these situations–the patients whose complaint sounds very severe and the patient with less severe pain.

Writing a prescription that says “go to a methadone clinic” is not only inadequate but cowardly, because the psychiatrist would rather not expose himself to criticism over his poor behavior. Once again, narcissism gets in the way of the best interests of the patient.

In the prescription of nonopiates, we are also often too cavalier. Xanax and Valium are highly addictive psychotropic drugs. While I believe that prescriptions for Valium are fewer these days, there is still a lot of Xanax being prescribed, because it is an extremely efficacious drug for people with panic disorder or severe anxiety. Psychiatrists have to be more careful in prescribing psychotropic drugs and try to avoid creating an avoidable problem.

The concept of the addictive personality is important. There are people whose propensity for developing an addiction, whether one that is socially acceptable or one that isn't, is very important because we generally have not considered the factors that contribute to this kind of diagnostic formulation.

The study mentioned in the question above demonstrated that patients with a psychiatric history are at risk for aberrant drug-related behavior if they have chronic pain (Clin. J. Pain 2007;23:307-15). The investigators found that patients who were classified in the high psychiatric group used more drugs and higher doses. The bottom line? A consistent association was seen between psychiatric morbidity and prescription opioid misuse in chronic pain patients.

We as psychiatrists must be acutely aware that factors such as a history of mood disorders, other psychiatric problems, and psychosocial stressors might place patients at risk for misuse of prescription opioids. We often contribute to patients 'addiction by continuously prescribing opiates at patients' request without carefully scrutinizing the problem or even thinking twice about the deleterious effects of what we are doing.

“Use caution” and “Have a high index of suspicion” are two expressions we heard often as medical students. This column raises many issues that call those expressions to mind. The addict is often wary and suspicious, certainly distrustful. Much of his energy is exerted in persuading us to write the prescription. As I indicated in the case examples, such patients are often not committed to therapy–which is why I tell residents and students to make sure that a dual-diagnosis patient gets rehab first and then psychotherapy.

In psychiatry, we have two subspecialties that should be fully accepted not only by medicine as a whole and the public but by psychiatrists as well. These are addiction psychiatry and pain medicine. The former is older and better defined. As this column makes clear, this specialty needs to be better understood and incorporated into the full practice of psychiatry with appropriate knowledge of the field as well as the use of trained colleagues to help us navigate what is a significant part of our specialty. This is especially the case in light of the serious problems of dual diagnosis patients and the ever growing problem of prescription drug abuse among teenagers and young adults in our country.

Pain medicine, which is shared with anesthesiology, oncology, neurology, and a raft of specialties outside of medicine (in particular hypnotism), is a growing field. We need to understand this field better so that we can do a better job of treating patients who are in pain and are addicted, and also have a psychiatric disorder. Addiction psychiatry and pain medicine truly demonstrate the complexity of our work as psychiatrists.

[email protected]

Treatment of drug and/or alcohol addicts is extremely difficult for those psychiatrists not specifically trained to handle such patients. Let me start by describing two patients with whom I failed miserably because, in my commitment to addressing the symptomatic side of the disability, I did not address the addiction.

The first case involved a 41-year-old single man, who was a son of very rich parents. The patient seemed to have had a lifetime of debilitating depression. He appeared attached to his elderly mother and had no friends, work, or real source of pleasure. All of that should have been enough for me to delve into the possibility of addiction, but he did not offer the information and I did not ask.

He described a terribly abusive childhood, mostly at the hands of his alcoholic mother, who beat and humiliated him constantly and essentially blamed him for everything–since his brother could do no wrong. The most pathetic sentence I can remember from his treatment was: “Every day when I got home from school, I tried to get from the front door to my bedroom in the hope that I would not rouse or encounter my drunken mother.”

He ended treatment by going into an alcohol rehab center.

The second case was even worse, because I knew when I started treating this patient that he was an alcoholic. He was a 42-year-old lawyer with a history of many rehab admissions and attempts to stop his use of drugs and alcohol. I was persuaded to take him into treatment by his father, whom I had known casually more than 40 years earlier.

His father, who was extremely intrusive, domineering, and controlling, took his son into his law practice. The father was such a hovering and demanding presence in his son's life that the treatment started by my attempting to help the patient separate from him. This turned out to be extremely difficult, and I was not paying enough attention to the drinking.

From time to time, his father would call to scold me and tell me about a drunken episode that had occurred over the weekend. I was so resentful of the father and committed to the patient that I did not take a strong, objective view of the regression as a good treater of an alcoholic would have done. Instead, I took a softer psychotherapeutic approach that was not absorbed in a positive way by the patient. I was going to be a better, kinder, gentler father figure for this patient.

Clearly, this is antithetical to the best treatment for an addict. He, too, left therapy for another tour through a rehab center, and I never heard from him again. I would like to believe that his silence stemmed from his father's rage at me rather than his own disappointment with my care.

Both of those cases illustrate the need for a general psychiatrist to have specific training in caring for the addicted patient.

I hope that today's residents fulfill the requirement to learn about addiction psychiatry. It should be something every practicing psychiatrist should learn and know how to do. The most important question to be asked is whether the use of drugs and alcohol is primary with anxiety and/or depression superimposed on the addiction because of the failure, dissipation, and uncontrollable craving. Or are the anxiety and/or depression primary, and is the patient using drugs and/or alcohol as self-medication?

Many patients whom I have evaluated start drinking early in adolescence because of the posttraumatic stress disorder (PTSD) suffered as a result of serious physical or emotional abuse as a child. I believe the first patient's problems were at least partly a result of his serious abuse as a child. But there is also the genetic element that cannot be discounted.

It is important that the clinician try to make the distinction as part of the patient's evaluation so that he knows what direction to take in the treatment. Regardless of the answer, the initial care must be directed to the cessation of substance use.

For the nonaddict, the most difficult thing to understand is the depth and extent of the craving. Because brain changes clearly take place in the addict that make this craving a biologically driven reality, it is very difficult for the patient to “just say no.” Willpower is an insignificant force, compared with the attraction of the patient's substance. We all know former smokers who, even though they have not smoked for 20 years, still desire a cigarette–especially when they are in the company of someone who is smoking. Similarly, the drug and alcohol addict cannot really control this desire. That's why Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) are so important and should be part of every treatment regime. The key to AA/NA, in my opinion, is the sponsor. The sponsor is someone who is a mentor, guide, and coach who is available 24/7 so that the user can call upon that person to help them suffer through the attack (of desire) and not succumb to it.

There are many elements to AA/NA, but the secret is in the meetings–for beginners, daily–which brings the addict out of seclusion and into the presence of many others who are suffering from the same disorder and share their experiences with the group. At least the naïve addict knows that he is not alone, and while shame and humiliation might initially stop him from “sharing,” he listens to the others and recognizes his own pain as he hears about the pain suffered by others.

Finding a sponsor is critical, and for some, the sooner the better. The psychiatrist or psychologist cannot do what the sponsor can do. Some psychiatrists try to be constantly available to the addicted patient but always fail, because such availability is not really part of their general modus operandi. Such expectations only serve to put a hostile distance between the doctor and the patient, and will clearly lead to failure, for which the doctor generally blames the patient.

There are several forms of iatrogenic precipitation of addiction. The first deals with actions that I feel are appropriate: the proper prescription of opiates to patients with severe and unremitting pain, most often in patients with advanced cancer. Unfortunately, some physicians still underprescribe opiates for their patients, because they do not want to cause them to be addicted (even though in many cases, the condition is incurable and the patient is going to die relatively soon). This absurd idea is sadistic on the part of any doctor who would deprive such a patient of adequate relief of pain for sanctimonious and righteous reasons.

The prescription of opiates for undefined and poorly described pain, e.g., back pain or headache, is an opposite situation. Often, psychiatrists are cajoled into prescribing such drugs for patients who may see a general practitioner or internist very rarely, and without a clear diagnosis of the problem and a determination of whether the problem is physical or mental.

Such determinations often require imaging procedures and/or blood tests that are not part of the psychiatrist's usual practice, and it is easier to prescribe the drug than to worry about the threat of addiction. These psychiatrists often find themselves with an iatrogenically produced addict on their hands and in a real dilemma about how to resolve the problem. We psychiatrists generally are not schooled in how to detox a patient, and it becomes apparent in both of these situations–the patients whose complaint sounds very severe and the patient with less severe pain.

Writing a prescription that says “go to a methadone clinic” is not only inadequate but cowardly, because the psychiatrist would rather not expose himself to criticism over his poor behavior. Once again, narcissism gets in the way of the best interests of the patient.

In the prescription of nonopiates, we are also often too cavalier. Xanax and Valium are highly addictive psychotropic drugs. While I believe that prescriptions for Valium are fewer these days, there is still a lot of Xanax being prescribed, because it is an extremely efficacious drug for people with panic disorder or severe anxiety. Psychiatrists have to be more careful in prescribing psychotropic drugs and try to avoid creating an avoidable problem.

The concept of the addictive personality is important. There are people whose propensity for developing an addiction, whether one that is socially acceptable or one that isn't, is very important because we generally have not considered the factors that contribute to this kind of diagnostic formulation.

The study mentioned in the question above demonstrated that patients with a psychiatric history are at risk for aberrant drug-related behavior if they have chronic pain (Clin. J. Pain 2007;23:307-15). The investigators found that patients who were classified in the high psychiatric group used more drugs and higher doses. The bottom line? A consistent association was seen between psychiatric morbidity and prescription opioid misuse in chronic pain patients.

We as psychiatrists must be acutely aware that factors such as a history of mood disorders, other psychiatric problems, and psychosocial stressors might place patients at risk for misuse of prescription opioids. We often contribute to patients 'addiction by continuously prescribing opiates at patients' request without carefully scrutinizing the problem or even thinking twice about the deleterious effects of what we are doing.

“Use caution” and “Have a high index of suspicion” are two expressions we heard often as medical students. This column raises many issues that call those expressions to mind. The addict is often wary and suspicious, certainly distrustful. Much of his energy is exerted in persuading us to write the prescription. As I indicated in the case examples, such patients are often not committed to therapy–which is why I tell residents and students to make sure that a dual-diagnosis patient gets rehab first and then psychotherapy.

In psychiatry, we have two subspecialties that should be fully accepted not only by medicine as a whole and the public but by psychiatrists as well. These are addiction psychiatry and pain medicine. The former is older and better defined. As this column makes clear, this specialty needs to be better understood and incorporated into the full practice of psychiatry with appropriate knowledge of the field as well as the use of trained colleagues to help us navigate what is a significant part of our specialty. This is especially the case in light of the serious problems of dual diagnosis patients and the ever growing problem of prescription drug abuse among teenagers and young adults in our country.

Pain medicine, which is shared with anesthesiology, oncology, neurology, and a raft of specialties outside of medicine (in particular hypnotism), is a growing field. We need to understand this field better so that we can do a better job of treating patients who are in pain and are addicted, and also have a psychiatric disorder. Addiction psychiatry and pain medicine truly demonstrate the complexity of our work as psychiatrists.

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Treatment of drug and/or alcohol addicts is extremely difficult for those psychiatrists not specifically trained to handle such patients. Let me start by describing two patients with whom I failed miserably because, in my commitment to addressing the symptomatic side of the disability, I did not address the addiction.

The first case involved a 41-year-old single man, who was a son of very rich parents. The patient seemed to have had a lifetime of debilitating depression. He appeared attached to his elderly mother and had no friends, work, or real source of pleasure. All of that should have been enough for me to delve into the possibility of addiction, but he did not offer the information and I did not ask.

He described a terribly abusive childhood, mostly at the hands of his alcoholic mother, who beat and humiliated him constantly and essentially blamed him for everything–since his brother could do no wrong. The most pathetic sentence I can remember from his treatment was: “Every day when I got home from school, I tried to get from the front door to my bedroom in the hope that I would not rouse or encounter my drunken mother.”

He ended treatment by going into an alcohol rehab center.

The second case was even worse, because I knew when I started treating this patient that he was an alcoholic. He was a 42-year-old lawyer with a history of many rehab admissions and attempts to stop his use of drugs and alcohol. I was persuaded to take him into treatment by his father, whom I had known casually more than 40 years earlier.

His father, who was extremely intrusive, domineering, and controlling, took his son into his law practice. The father was such a hovering and demanding presence in his son's life that the treatment started by my attempting to help the patient separate from him. This turned out to be extremely difficult, and I was not paying enough attention to the drinking.

From time to time, his father would call to scold me and tell me about a drunken episode that had occurred over the weekend. I was so resentful of the father and committed to the patient that I did not take a strong, objective view of the regression as a good treater of an alcoholic would have done. Instead, I took a softer psychotherapeutic approach that was not absorbed in a positive way by the patient. I was going to be a better, kinder, gentler father figure for this patient.

Clearly, this is antithetical to the best treatment for an addict. He, too, left therapy for another tour through a rehab center, and I never heard from him again. I would like to believe that his silence stemmed from his father's rage at me rather than his own disappointment with my care.

Both of those cases illustrate the need for a general psychiatrist to have specific training in caring for the addicted patient.

I hope that today's residents fulfill the requirement to learn about addiction psychiatry. It should be something every practicing psychiatrist should learn and know how to do. The most important question to be asked is whether the use of drugs and alcohol is primary with anxiety and/or depression superimposed on the addiction because of the failure, dissipation, and uncontrollable craving. Or are the anxiety and/or depression primary, and is the patient using drugs and/or alcohol as self-medication?

Many patients whom I have evaluated start drinking early in adolescence because of the posttraumatic stress disorder (PTSD) suffered as a result of serious physical or emotional abuse as a child. I believe the first patient's problems were at least partly a result of his serious abuse as a child. But there is also the genetic element that cannot be discounted.

It is important that the clinician try to make the distinction as part of the patient's evaluation so that he knows what direction to take in the treatment. Regardless of the answer, the initial care must be directed to the cessation of substance use.

For the nonaddict, the most difficult thing to understand is the depth and extent of the craving. Because brain changes clearly take place in the addict that make this craving a biologically driven reality, it is very difficult for the patient to “just say no.” Willpower is an insignificant force, compared with the attraction of the patient's substance. We all know former smokers who, even though they have not smoked for 20 years, still desire a cigarette–especially when they are in the company of someone who is smoking. Similarly, the drug and alcohol addict cannot really control this desire. That's why Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) are so important and should be part of every treatment regime. The key to AA/NA, in my opinion, is the sponsor. The sponsor is someone who is a mentor, guide, and coach who is available 24/7 so that the user can call upon that person to help them suffer through the attack (of desire) and not succumb to it.

There are many elements to AA/NA, but the secret is in the meetings–for beginners, daily–which brings the addict out of seclusion and into the presence of many others who are suffering from the same disorder and share their experiences with the group. At least the naïve addict knows that he is not alone, and while shame and humiliation might initially stop him from “sharing,” he listens to the others and recognizes his own pain as he hears about the pain suffered by others.

Finding a sponsor is critical, and for some, the sooner the better. The psychiatrist or psychologist cannot do what the sponsor can do. Some psychiatrists try to be constantly available to the addicted patient but always fail, because such availability is not really part of their general modus operandi. Such expectations only serve to put a hostile distance between the doctor and the patient, and will clearly lead to failure, for which the doctor generally blames the patient.

There are several forms of iatrogenic precipitation of addiction. The first deals with actions that I feel are appropriate: the proper prescription of opiates to patients with severe and unremitting pain, most often in patients with advanced cancer. Unfortunately, some physicians still underprescribe opiates for their patients, because they do not want to cause them to be addicted (even though in many cases, the condition is incurable and the patient is going to die relatively soon). This absurd idea is sadistic on the part of any doctor who would deprive such a patient of adequate relief of pain for sanctimonious and righteous reasons.

The prescription of opiates for undefined and poorly described pain, e.g., back pain or headache, is an opposite situation. Often, psychiatrists are cajoled into prescribing such drugs for patients who may see a general practitioner or internist very rarely, and without a clear diagnosis of the problem and a determination of whether the problem is physical or mental.

Such determinations often require imaging procedures and/or blood tests that are not part of the psychiatrist's usual practice, and it is easier to prescribe the drug than to worry about the threat of addiction. These psychiatrists often find themselves with an iatrogenically produced addict on their hands and in a real dilemma about how to resolve the problem. We psychiatrists generally are not schooled in how to detox a patient, and it becomes apparent in both of these situations–the patients whose complaint sounds very severe and the patient with less severe pain.

Writing a prescription that says “go to a methadone clinic” is not only inadequate but cowardly, because the psychiatrist would rather not expose himself to criticism over his poor behavior. Once again, narcissism gets in the way of the best interests of the patient.

In the prescription of nonopiates, we are also often too cavalier. Xanax and Valium are highly addictive psychotropic drugs. While I believe that prescriptions for Valium are fewer these days, there is still a lot of Xanax being prescribed, because it is an extremely efficacious drug for people with panic disorder or severe anxiety. Psychiatrists have to be more careful in prescribing psychotropic drugs and try to avoid creating an avoidable problem.

The concept of the addictive personality is important. There are people whose propensity for developing an addiction, whether one that is socially acceptable or one that isn't, is very important because we generally have not considered the factors that contribute to this kind of diagnostic formulation.

The study mentioned in the question above demonstrated that patients with a psychiatric history are at risk for aberrant drug-related behavior if they have chronic pain (Clin. J. Pain 2007;23:307-15). The investigators found that patients who were classified in the high psychiatric group used more drugs and higher doses. The bottom line? A consistent association was seen between psychiatric morbidity and prescription opioid misuse in chronic pain patients.

We as psychiatrists must be acutely aware that factors such as a history of mood disorders, other psychiatric problems, and psychosocial stressors might place patients at risk for misuse of prescription opioids. We often contribute to patients 'addiction by continuously prescribing opiates at patients' request without carefully scrutinizing the problem or even thinking twice about the deleterious effects of what we are doing.

“Use caution” and “Have a high index of suspicion” are two expressions we heard often as medical students. This column raises many issues that call those expressions to mind. The addict is often wary and suspicious, certainly distrustful. Much of his energy is exerted in persuading us to write the prescription. As I indicated in the case examples, such patients are often not committed to therapy–which is why I tell residents and students to make sure that a dual-diagnosis patient gets rehab first and then psychotherapy.

In psychiatry, we have two subspecialties that should be fully accepted not only by medicine as a whole and the public but by psychiatrists as well. These are addiction psychiatry and pain medicine. The former is older and better defined. As this column makes clear, this specialty needs to be better understood and incorporated into the full practice of psychiatry with appropriate knowledge of the field as well as the use of trained colleagues to help us navigate what is a significant part of our specialty. This is especially the case in light of the serious problems of dual diagnosis patients and the ever growing problem of prescription drug abuse among teenagers and young adults in our country.

Pain medicine, which is shared with anesthesiology, oncology, neurology, and a raft of specialties outside of medicine (in particular hypnotism), is a growing field. We need to understand this field better so that we can do a better job of treating patients who are in pain and are addicted, and also have a psychiatric disorder. Addiction psychiatry and pain medicine truly demonstrate the complexity of our work as psychiatrists.