Talk Doesn't Come Cheap

Gardiner Harris has an article in today's New York Times called "Talk Doesn't Pay So Psychiatrists Turn to Drug Therapy." The article is a twist on an old Shrink Rap topic--Why your Shrink Doesn't Take Your Insurance. Only in this article, the shrink does take your insurance, he just doesn't talk to you.

With his life and second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Ah, Dr. Levin sees 40 patients a day. And the doc is 68 years old. This guy is amazing, there is no way I could see 40 patients a day for even one day. He's worried about his retirement, but I wouldn't make it to retirement at that pace. Should we take a bet on whether Dr. Levin has a blog?

So the article has a whimsical, oh-but-for-the-good-old-days tone. In-and-out psychiatry based on prescribing medications for psychiatric disorders is bad, but the article doesn't say why. In the vignettes, the patients get better and they like the psychiatrist. Maybe medications work and psychotherapy was over-emphasized in the days of old? The patients don't complain of being short-changed, and if Dr. Levin can get 40 patients a day better for ---your guess is as good as mine, but let's say-- $60 a pop and they only have to come every one to three months, and there's a shortage of psychiatrists, then what's the problem? Why in the world would anyone pay to have regular psychotherapy sessions with the likes of someone like me?

After my post last week about The Patient Who Didn't Like the Doc. On Line , I'm a bit skeptical about on-line reviews. Still, I Googled the psychiatrist in the story, and the on-line reviews are not as uniformly positive as those given by the patients who spoke to Mr. Harris. Some were scathing, and they complained about how little time he spends with them. In all fairness, others were glowing.

The article makes psychiatrists sound like money-hungry, unfeeling, uncaring, sociopaths. Either they're charging $600 a session (...oh, can I have that job?) or the financial aspect is so important that they're completely compromising their values for the sake of a buck. This doctor believes that patients get the best care when they receive psychotherapy, and the rendition Mr. Harris gives is that it's understandable that he's compromised his values to maintain a certain income. I don't buy it and I don't think it portrays psychiatrists accurately or favorably. If the doctor felt that it was the high ground to give treatment to 40 patients a day who otherwise couldn't get care, then this portrayal wouldn't be so bad. And that may be the case---I don't know him and I don't know Mr. Harris and I do know that an occasional reporter has been known to slant a story. I found it odd that there were no other options here aside from 4 patients/hour, 10 hours/day, not to mention the 20 emergency phone calls a day that he manages in the midst of all the chaos. Why hasn't this doctor left the insurance networks and gone to a fee-for-service model with a low volume practice if psychotherapy is what he enjoys and what he feels is best? Or why doesn't he devote an hour or two a day to psychotherapy? Okay, I shouldn't rag on the poor doc, I only know him through a newspaper portrayal, but I don't think this article showed psychiatry at its finest hour. And yes, I know there are psychiatrists out there who have very high volume practices.

Who Is A Criminal?

I'll admit this seems like an odd question with an obvious answer. Most people would say that a criminal is anyone convicted of a crime. However, there is a difference between someone who has merely been convicted of a single crime and someone with a pattern of criminal behavior. Repetitive criminals may be psychopaths or sociopaths. Fictional characters like Hannibal Lechter or Tony Soprano are good examples of sociopathic or psychopathic personalities.

It might be a bit disconcerting to know that people like this actually exist and that they've been around for a long time. In 1837 an English psychiatrist named James Pritchard wrote a book entitled Treatise on Insanity in which he described people who lacked the ability to form attachments to others and who were unable to experience normal human affection or emotions. These individuals had little regard for the feelings or rights of others, however they didn't have the hallucinations or impaired cognitive functioning that was seen in other psychiatric disorders. Dr. Pritchard coined the term 'moral insanity' to describe this disorder, which he felt was a defect in area of the brain responsible for moral reasoning. Around this time the American Journal of Insanity (which later became the American Journal of Psychiatry) published several individual case studies of homicide offenders, all of which were entitled "A Case of Homicidal Insanity". They were all essentially just case descriptions of murderers. The letters to the editor of the journal following these case studies debated the validity of 'moral insanity' as a mental illness. The difficulty was that the term 'insanity' implied that from a legal standpoint the criminal should not be held responsible or punished for his behavior. Eventually the term 'moral insanity' was dropped in favor of the term 'psychopath', a term proposed by a Nineteenth Century German psychiatrist.

More recently, the term 'sociopath' has been used instead of 'psychopath'. This latest change happened because people were getting confused by the 'psycho' part of the psychopathy label---psychopathy doesn't mean that the criminal is psychotic. Actually, neither sociopathy nor psychopathy are actual 'official' psychiatric diagnoses in that they can't be found in the Diagnostic and Statistical Manual (DSM). The DSM uses the term antisocial personality disorder (ASPD). Patients with antisocial personality disorder have difficulty with lying, impulsivity, repeated criminal acts, and impulsivity or irresponsibility. The majority of people with ASPD are not psychopaths. Psychopaths represent a minority of severely disordered people who lack emotional attachments or responsiveness. They are narcissistic and are unable to learn from experience. They lack empathy or remorse and are cold, cruel, callous people. This callousness is what distinguishes psychopathy from antisocial personality disorder.

There are a lot of people with antisocial personality disorder---about 3% of the United States population or nine million people. The exact prevalence of psychopathy may never be known because psychopaths usually only come to the attention of clinicians when they are caught committing crimes or when those around them coerce them into treatment. The most skillful psychopaths may not come to the attention of the law and may function successfully as politicians, religious leaders or heads of large corporations.

A screening tool for psychopathy was developed in the 1980's and has been widely used in research and forensic practice. Scores on the Hare Psychopathy Check List-Revised (PCLR-R) have been found to be useful for predicting violence and criminal recidivism. Psychopaths identified by the PCLR-R are being studied through functional neuroimaging in order to identify the physical basis for the disorder. These studies have shown that in psychopaths the part of the brain responsible for processing emotions works differently than in normal people. They also have different physiologic responses to emotion.

There is a genetic component to both ASPD and psychopathy as shown by adoption and twin studies. One large twin study has shown that for severe psychopaths as much as two-thirds of psychopathy can be attributed to genetics rather than environmental influences. For ASPD, the condition originates in childhood. A study done in the 1960's followed children from a mental health center who were referred for evaluation of their behavior problems. The study found that over fifteen years, one-third of the children with conduct disorder grew up to have antisocial personality disorder.

Can psychopaths be treated?

This is a tough question to answer. Psychopaths don't generally seek treatment voluntarily because they aren't bothered by their condition. They must be coerced into treatment or persuaded to participate by engaging their self-interest. For example, by emphasizing that treatment is a condition of parole and is necessary to stay out of jail or prison. Since psychopaths have difficulty learning from consequences, several treatment attempts may be necessary. The treatment must be designed to have open lines of communication between others involved in the psychopath's life in order to ensure truthfulness. There must be clear, consistent and firm boundaries between the patient and the therapist. Psychopaths with a high risk of violent behavior should only be treated in a secure and structured setting like a correctional facility. Psychopaths and people with ASPD are at increased risk of developing other psychiatric conditions such as mood disorders and substance abuse. Medication may be indicated for treatment of these co-existing conditions.

There is no evidence that psychopathy or ASPD can be cured. The goal of treatment is to minimize the impact of the conditions on others and on the patient. For example, one goal of treatment might be to minimize the risk of accidental injury by teaching the patient to recognize situations that trigger dangerous risk-taking behavior. Violence is another focus of treatment with psychopaths; violent behavior can be managed with administrative disciplinary procedures within the correctional facility or through the use of medication.

Specific treatment goals should be set up collaboratively with the patient so that expectations and treatment parameters are clear. The patient's self-identified treatment goal may also reveal his level of insight. When I asked one of my prisoners what he was working on in therapy, his answer was telling. "The truth," he said. "Telling the truth, it's something I've been working on for a while."

It's a beginning.

What's A Sociopath?

As my fourth and final post for Clink Week here at Shrink Rap, I have been inspired by Roy (again). I was curious about our different reactions to the character Tippi Hedron played in the Alfred Hitchcock movie Marnie. Roy pointed to different aspects of her personality to say that she wasn't a sociopath, so it got me thinking about why I reacted so differently. We've already speculated about whether or not Darth Vader had borderline personality disorder, so lets progress to another Cluster B disorder by talking about Marnie.

First of all, sociopathy per se does not exist in the Diagnostic and Statistical Manual. It was originally conceived in the mid-nineteenth century as "moral insanity", in other words a defect in moral reasoning. Even then there was argument about whether or not this constituted a "real" mental disorder.

Later in the Twentieth Century sociopathy was further refined by Hervey Cleckley's book The Mask of Sanity. His series of case reports of psychopaths formed the basis for Robert Hare's later Hare Psychopathy Checklist, a tool that is in common use in forensic settings. Both of these sources describe several core features of psychopathy:

• a parasitic lifestyle, the ability to control or manipulate others
• superficial charm, glibness, pathological lying
• criminal versatility
• lack of remorse, inability to empathize or lack of regard for impact on others
• shallow or feigned emotions
• early behavior problems, impulsive or unstable adult behavior
  

The descriptions go on and on, but those are some of the main aspects. So, that being said, how does Marnie stack up?

Well, what struck me at first was her level of ease and comfort while committing her crimes. She took her time, observed her workplace surroundings, kept her cool and escaped without breaking a sweat. She readily used aliases and multiple false identities, and her facile lying ability allowed her to quickly gain the confidence of the employers who later became her victims. Many people commented on her confidence, poise, intelligence and charm. She showed no apparent remorse nor did she ever even comment upon the damage her crimes inflicted on others. It's true that she was committing crimes to buy the love of her mother, as Roy suggests, but she showed a startling level of callousness to a young girl in her mother's care who also needed attention. She loved her horse, an attachment that seemed to be her only genuine emotion. Although she agreed to marry Connery, her love for him is closely tied to his willingness to help her as he made restitution for her crimes and took steps to help her avoid prosecution. As far as the impulsive or unstable lifestyle goes, one of the most intense scenes in the movie took place after she shot her horse (her only strong consistent relationship) when it seemed she might shoot Connery as well.

And for the last criteria---the early childhood behavior problems---well, you'll have to watch the movie to find out what that was. Let's just say it's not the behavior of a typical child. (I'm amazed she was so strong for such a little kid!)

So that's why I thought Marnie was a sociopath, for those who are interested in them.

I'm going to let Dinah out from under the floorboards now.

Marnie: A Movie Review

Alfred Hitchock's film "Marnie" is both a romance and a pop psychology study of sociopathy. Sean Connery, playing an amatuer jaguarundi-taming zoologist, traps and marries Tippi Hedron, a compulsive liar and thief who represents the ultimate challenge for him, taming the predatory American female. Hedron is also suffering from erythrophobia (fear of the color red), which drives her sociopathic behavior. Connery feels compelled to cure his wife of the early childhood trauma which lead her in adulthood to commit a series of robberies.

Apart from the questionable wisdom of trying to analyze your wife, his "treatment" tactics are also dubious from my prospective. He attempts to cure his wife through bibliotherapy---titles such as "The Sexual Deviations Of The Female Criminal" and Jung's "The Undiscovered Self", word association and abreaction. Unfortunately, none of this prevents her from shooting her horse, attempting to rob Connery's father, attempting suicide by drowning on her honeymoon and banning her husband from their honeymoon suite.

In true pop psychology form, he ultimately learns that she committed the robberies and used the loot in an attempt to buy the love of her mother. Wow! What a film. Hitchcock takes us from the horseracing track to the brothels of 1960's Baltimore to the estate of Connery's blueblood father. Along the way Hedron reveals clues to her early trauma---she freaks out at any sight of the color red and at the sound of thunder.

Since all criminal behavior is caused by an early childhood trauma, Hedron's secret is of course eventually revealed in a massive regression scene involving Connery and her creepy mother. In the final scene we find her turning gratefully to Connery to say:

"Mark...I won't go to jail for this, will I?"

He answers: "Not after what I have to tell them."

I silently answered: "You may or may not go to prison, Marnie, but you do need a good forensic psychiatrist."

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This is the movie I went to in order to escape my lack of air conditioning this past weekend. Dinah wanted a review, so here it is. It was fun.

Disturbing Things

I received the following e-mail from a friend. Copied without permission:

I get some of the craziest emails but this one is short and pretty good. I mean, we're all a bit nutty…but really.

Psychopath Test

Read this question, come up with an answer and then scroll down to the bottom for the result. This is not a trick question. It is as it reads. No one I know has got it right.

A woman, while at the funeral of her own mother, met a guy whom she did not know. She thought this guy was amazing. She believed him to be her dream guy so much, that she fell in love with him right there, but never asked for his number and could not find him. A few days later she killed her sister.

Question: What is her motive for killing her sister?

[Give this some thought before you answer]




Answer:

She was hoping the guy would appear at the funeral again. If you
answered this correctly, you think like a psychopath. This was a test by
a famous American Psychologist used to test if one has the same
mentality as a killer. Many arrested serial killers took part in the test and
answered the question correctly.


If you didn't answer the question correctly, good for you. If you got the answer correct, please let me know so I can take you off my email list. (ha)

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So I got it right....I promise I haven't killed anyone, but apparently I'm off Harry's e-mail list. The picture, by the way, was stolen off Fat Doctor's blog. Psychopathic cows for sure. Clink, any thoughts here?

A New Use For Gangs

(A BGF tattoo)

I found a new use for prison gangs today. It was completely unexpected.

The patient was a very large, somewhat scarey-looking guy with a history of bipolar disorder. When manic (and psychotic) he got violent. He was transferred back to my facility for refusing to take his meds in a lower security setting. I forget what happened there, but he just wasn't doing well. Back in my facility he was among his associates from the Black Guerilla Family, a well-known prison gang. They respected his size and definitely didn't want him getting sick. They made sure he went down from the tier to the pill line to get his medication.

You'd never guess he had a mental illness when he was well. He was still big and scarey-looking, but he was also articulate. He talked about being able to haul someone into a shower and "mess him up" without guilt or remorse. He talked about staying vigilant, knowing that being part of the BGF made him a target for other gangs. He talked about being bothered by the fact that his violence and lack of conscience didn't bother him. He talked about "wearing a mask" and passing as normal. I could have listened to him forever, and it would have made a good documentary about sociopathy.

But anyway, back to the gang. In psychiatry you hear a lot about the importance of social networks and family support and how this can prevent relapse for people with psychotic disorders. What you don't always think about is how a prison gang can serve this same function. The BGF helped keep my patient well.

He finished the appointment by asking how I was doing and if I was OK, which I thought was rather interesting. It was a bit like Tony Soprano, someone who could execute a guy without batting an eye, being concerned about the ducks in his pool. And I was the duck.

My Three Shrinks Podcast 43: How Doctors Think

[42] . . . [43] . . . [44] . . . [All]

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The Benzo Wars are over now, and podcast #43 is much more dispassionate and level-headed. Later this week, we'll also put out podcast #44, with the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo.

The three of us have been busy with other things, so we apologize for not getting these podcasts our more regularly, but please keep coming back for more.

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March 18, 2008: #43

Topics include:

• My Three Shrinks: The Book. We've been talking about writing a book which explains how psychiatrists go about thinking about approaching problems, such as selecting medications or diagnosing illness. We are debating about how to format the chapters in the book. One option is for each of us to write individual chapters about various topics. Another is to maintain the conversational tone so that we each would have some back-and-forth commentary within each chapter. What do you think? Let us know in the comments below, or email us.
  
  
• NYT: Time Off From Electronics. Mark Bittman had an article in last week's New York Times called "I Need a Virtual Break. No, Really." The article talks about forgoing today's electronic trappings for one day each week, similar to some business' "email-free Fridays." No cell phone. No voicemail. No Blackberry. No internet. This provoked anxiety for Dinah (and "what's the point" from Clink and me), who speculates further about "internet addiction" and the risk of death by videogame. Addiction vs compulsion.
  
  
• PT: Why Psychiatrists Should Read the Humanities. Clinkshrink discusses a Psychiatric Times article from the Feb 2008 issue by Cynthia M.A. Geppert, suggesting that more humanities should be taught to medical students and residents. Dinah remembers my first blog post about Tom Cruise.
  
  
• Female Sociopaths in Literature. Clink lists a number of female sociopaths portrayed in operas, books, and other literary works.
  
  
• Brain Maturation Delayed in ADHD. Also in the Feb 2008 issue of Psychiatric Times is this article by Arline Kaplan, describing research suggesting that the brains of kids with ADHD mature a little later than others, bringing into question the medication treatment of this disorder, rather than more behavioral and "tincture of time" methods.
  
  
• How Doctors Think, book by Jerome Groopman MD. Dinah is reading this now and notes that Dr Groopman chose not to discuss how psychiatrists think, because this is "beyond [his] abilities." (We really need to get our book written.)
  
  
• How Psychiatrists Think. Once again, we are starting a book and would like some feedback from our listeners and readers. The question is about the style of writing. Option 1 would be for each of us to take on topics and write a short (1-5 pages) chapter on a given topic. Option 2 would be for each of us to chime in within each topic/chapter, thus more resembling a discussion. Option 1 is more traditional. Option 2 would sound more like our podcast, at the risk of confusing the reader about who is "talking" at any given point.
  
  Email us with your thoughts about these options at mythreeshrinksATgmailDOTcom.
  

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.