Pursuing Treatments That Are Not Evidence Based:How DSM IV clarifies, how it

blinds psychiatrists to issues in need of investigation

by Simon Sobo, M.D.

Summary of the argument

Evidence based medicine claims to be the paradigm for modern psychiatry. It

represents proven treatments for defined diagnoses. But there are major problems
with this position, starting with the fact that while they are superior to
placebo, evidence based treatments too often are ineffective.

It cannot be assumed that classifying psychopathology diagnostically is the best

way to move forward. Established diagnostic entities, are as much wish as reality.
DSM IV diagnoses are arrived at by committee decisions, by the convening of
“experts”, with all that implies. Complicating the process is the fact that expert
committee members can be influenced by pressures from those with an agenda,
especially experts who receive a significant part of their income from
pharmaceutical companies.

The authors of DSM III and IIIr had it right. They also had to make committee
decisions but they emphasized that their conclusions were tentative, so tentative
that they weren't willing to use the term diagnosis to characterize DSM designated
illnesses. They were presenting operational definitions, with all the strengths
and weaknesses this implies. In keeping with their scientific orientation, they
insisted that the term “disorder” rather than “diagnosis” be used in the
diagnostic manual. This starkly contrasts with the spirit behind the soon to be
DSM V. “Evidence based medicine”, is being touted for its scientific prestige
precisely as the process has forsaken the true spirit of science, openness about
what is known and not known.

Robert Spitzer MD, former chair of the work group for DSM III, has rightfully
condemned the confidentiality agreements required of DSM V committee participants.
25 He wants detailed minutes of the task force’s deliberations, a no-brainer for
those who understand the necessary tentativeness of scientific information, but
problematic for those who want to provide an illusion of consensual certainty
about diagnostic categories.

There is also a more fundamental issue, not answerable to the vote of even the
most “expert” committee. What do diagnoses represent? Does every diagnosis in DSM
IV represent an actual real illness, in the sense that polio, cancer, or a strept
throat actually exist? Or can they represent the reification of an idea, taking
diagnoses beyond useful limits? Evidence based medicine, it is implied, should
monopolize clinical approaches. But at this stage the proper question isn’t should
we exclusively use treatments that have proven superior to placebo? It is what is
the best way to formulate treatment strategies when now, and in the foreseeable
future, science can’t offer answers that we need? Conjecture, out of necessity,
must play a significant role. Given mediocre treatment results, we need all the
help we can get, the art of psychiatry as well as the science.

Pharmacological agents can be viewed as inducing particular psychological states

which, though not specifically related to diagnosis, are nonetheless the basis for
their usefulness. SSRIs are efficacious in a broad range of conditions because
increasing serotonin has a psychological impact that is nonspecific to the
disorders. It can be used in treatment contexts when diagnosis is irrelevant (e.g.
helping a picked on, thin skinned adolescent, develop thicker skin)
The core issue is our approach to patients. Evidence based medicine eschews the
anecdotal in the name of generalized conclusions, based on the odds that the
patient’s ailments are typical for their group. This is not a ridiculous
consideration, but it can miss important particulars brought by the patient.
Knowing a patient well can be the difference between effective and ineffective
treatment. Premorbid defenses, character style, the nature of the patients’
stressors, their story can guide clinicians to a particular medication, and
influence dosage . While evidence based medicine has a place, especially when low
cost is a consideration, it cannot lay claim to being optimal treatment. It is
especially detrimental if this perspective acts like blinders, obscuring more than
it clarifies

Evidence based treatments are the gold standard. Each has demonstrated superiority
to placebo that could not have been due to chance. Unfortunately, this doesn’t
guarantee effectiveness. Even with treatment compliance, many patients do not
return to their premorbid selves. Their ailment may last for years. A given
percentage is not helped at all. Typically, 30-50% of depressed patients 1,2,3
will not respond, and among non-responders only 23.5-28% are helped by a second
medication.4 The relatively common failure of evidence based treatments to achieve
remission is not unique to depression. Frustrating both doctor and patient,
similar results are found throughout the full spectrum of DSM IV disorders.

This is not surprising. The science of psychiatry is still young, its conclusions
necessarily preliminary. Psychiatry has not found its penicillin, a drug that will
succeed 99 per cent of the time in eliminating strep throat, because it kills the
germ causing the illness. DSM IV diagnoses are operational definitions, the best
attempt by committees of experts to group manifestations of psychopathology into
“disorders”. This cataloguing is not the same thing as understanding cause and
effect. We haven’t yet discovered the etiology of any DSM IV diagnosis. The true
fruits of science usually await this knowledge.

Sometimes, psychiatric medications work as miraculously as penicillin. The patient

returns a few weeks after beginning a medication and is amazingly restored.
However, this doesn’t happen as often as we’d like, and when it does, we cannot
always explain what has occurred. Neuropharmacology is a sophisticated science.
Medication can be designed having specific effects on specific neurotransmitters.
Extraordinary technological advances enable us to see what parts of the brain are
effected by the drugs that scientists have designed. But, in contrast to
penicillin, we are reduced to guessing how the various medications work with a
given disorder. Our success rate reflects this.

What is the clinician to do when the promised results of treatment are limited? He
has no choice. Decisions about therapy must be made with or without needed hard
knowledge. In a similar vein, there is a more general problem over and beyond
inadequate efficacy for a given diagnosis. While researchers have the luxury of
choosing patients who comply exactly with DSM IV criteria, in the real world of
clinical practice, patients’ presenting symptoms are not always as cooperative.
Whether a patient’s symptoms exactly correspond, or not, to DSM IV criteria,
clinicians must treat patients as they exist. Otherwise they will be treating only
a fraction of those needing care.

Trying to remain within a scientific paradigm, once the first treatment (and
perhaps a second or third) has failed, well-trained clinicians can become very
“creative” when assigning a diagnosis. Presumably, once that decision is made,
further treatment can be guided by evidence based protocols. However, reaching the
documented 60-70% success rate for the disorder in question is unlikely since the
liberties taken with diagnostic criteria leaves the clinician very far from
scientific ideals. And this is not taking into account a different strategy, being
guided by expert consensus protocols, treatment recommendations for a given
diagnosis based on a polling of “experts” rather than empirical evidence.

In the journals these problems may be tackled in a similar way. Fuzzy diagnoses
are encouraged by imaginatively broadening diagnostic criteria (for example
spectrum disorders). Or new criteria are created, as has been done, for example,
with bipolar disorder in children. This diagnosis has apparently captured the
imagination of a good many practitioners. There has been a forty fold increase in
this diagnosis over the course of a decade,6 despite its speculative nature. There
is scant evidence that adult bipolar meds work for children. Nor is it known
whether what is being called childhood bipolar disorder is the real thing (i.e.
longitudinal studies documenting that these children are indeed at the beginning
of a life long cycle of mania and depression)

Those advocating newer broader criteria for what constitutes a disorder may
reasonably argue for broadened diagnostic criteria in a future DSM V. The expanded
diagnosis may indeed represent progress, forwarding our understanding of a given
disorder. But, all too often, new scientific knowledge is not the basis for the
expansion. It is the need to find a diagnosis so as to adhere to a science based
protocol, even though scientific reliability has been necessarily violated by a
loose application of diagnostic requirements.

Besides controversies about specific diagnoses it is useful to step back and

reconsider what, at first glance, seems like a simple issue. What do DSM IV
diagnoses represent? As already noted, when DSM III, and later, DSM IV were
released, the authors acknowledged the distinction between diagnoses based on
etiology or pathophysiology, and the operational definitions APA committees of
experts voted on. Operational definitions have a specific purpose in research.
Amidst uncertainty, they allow researchers to move forward, confident that they
are talking about the same thing. On the other hand, not paying heed to this
issue, assuming that DSM IV diagnoses are more than they are, reifying them, can
lead to conclusions that make no sense whatsoever, when viewed in the light of
later understanding of what is actually occurring.

To illustrate, let us consider congestive heart failure (CHF) as a model. An

important aspect of CHF treatment is to focus on a manifest symptom such as edema,
especially pulmonary edema and pleural effusions. The strain on the heart from
excessive fluid demands the use of diuretics (which, of course, do not act on the
heart but on the kidneys). Unencumbered by fluid in the lungs, shortness of breath
and orthopnea will improve. Treatment addresses pathophysiology without taking
etiology into account.

The actual diseases that brought about the heart failure are once removed from the
focus of treatment. Heart failure might be due to muscle damage from an MI or a
viral cardiomyopathy. There might be valvular damage from rheumatic fever, or
subacute bacterial endocarditis, and so forth through a long list of diseases that
can damage the heart. A clinician focusing on the presenting symptoms of CHF is
proceeding rationally because regardless of etiology, when the heart doesn’t do
its job--when it is not pumping blood powerfully enough--the final common pathway
manifested by the accumulated fluid may be of more immediate concern than the
underlying cause of the illness. One hundred years ago CHF could be described
without an understanding of its many causes, and that description remains
therapeutically relevant today, even after we can now better understand underlying
causality.
But there is a problem illustrated by CHF as a diagnosis, which is relevant to the
way we use DSM IV today. For argument’s sake, let us say our knowledge base
remained at the turn of the 20th century and hypothyroidism was causing the heart
failure of a given patient. Thyroid extract would fail miserably when tested in a
larger population of patients whose “disorder” had been defined as “congestive
heart failure.” It might worsen in particular, the illness of those patients whose
CHF was, for instance, caused, or exacerbated, by atrial fibrillation due to
hyperthyroidism.

Viewed from the perspective of the heart failure diagnosis, the few patients it
helped might be described in individual case studies, but would be rightly
dismissed as anecdotal, if proponents argued that it should be used as a general
treatment for congestive heart failure. Yet, the fact remains that it is exactly
the correct treatment for CHF due to hypothyroidism.

My point is obvious. As reasonable as evidence-based treatment protocols for

symptom-defined “disorders” might seem to be in psychiatry, they can be
nonsensical compared to what is possible when a true understanding of etiology can
be used to provide rational care.

Analogous to CHF, schizophrenia might be 5 or 7 or 12 different diseases all with

the same common final pathway. The heart is basically a pump. Thus, many different
illnesses can manifest themselves as the same “disorder” when its pumping action
is defective. Similarly, there may be limited numbers of ways that the brain can
malfunction when its higher integrative functions are not working properly, or are
overpowered by extremely forceful primitive emotional currents. There might be a
genetic-caused schizophrenia-like illness with 100% (or 25%) penetrance, a virally
based illness, nutritional etiologies (besides known vitamin deficiency induced
psychosis.). Some have suggested fetal damage. There might even be (dare I say it)
an illness primarily caused by detrimental child rearing. At one time, a
syphilitic psychosis resembling schizophrenia used to fill up mental hospitals, so
let us not ignore bacterial causality. And what will we learn about prions?

The point is that any number of diseases sharing common symptoms could mistakenly
be lumped together. It is an inherent shortcoming of any system based on symptoms
alone. Each of the DSM IV disorders could be several illnesses that appear similar
to each other but are, nevertheless, not the same illness. Indeed, a person with
no symptoms at all might be a closer match to a person with symptoms, than someone
with very similar symptoms. For example, we now know that someone with early
latent syphilis (two years in to the disease) showing no signs of illness (once
again, for arguments sake, before VDRLs were available) should be treated for the
disease regardless of symptoms. Someone with optic neuritis (a common
manifestation of neurosyphilis) who is not infected by treponema pallidum, would
not be helped by penicillin. There is nothing perplexing here. Our understanding
of cause and effect allows clear thinking.

Families with schizophrenia running through them have an abundance of schizotypal

disorder.5 Once again, not a surprise; some day in the future we might find
certain patients now diagnosed with panic disorder, or obsessive compulsive
disorder, appropriately grouped, from the standpoint of etiology, with some
schizophrenics. On the other hand, someone with a biological predisposition, say,
towards excessive fearfulness (anxiety), or passivity, might have manifest
symptoms that veer towards phobias, avoidant personality, obsessive compulsive
disorder, panic disorder, or any one of a number of DSM IV disorders, the
differences between them attributable to family or culturally learned defenses,
parental models of coping, individual trauma, or individual psychodynamics. For
example a person using counter phobic defenses (say sky diving) to “choose” and
attempt to master their risks for themselves, will present very differently than a
frightened individual passively yielding to that fear, or trying to gain a sense
of control through repetitive OCD rituals, or dependent on the protection of
others, or on idealized love, or through submersion in cults. And medications that
treat “anxiety” might be helpful in a large number of disorders that vary greatly
from each other in manifest symptoms, but might have in common the fact that the
particular symptoms (shaped by other factors) were fundamentally a response to
genetically based greater quantities of “fear.”

Are they all the same disease, or as some would have it, are they part of a
spectrum? Using the common effectiveness of a given treatment might give hints
about etiology, but, not necessarily. Syphilis, pneumococcal pneumonia, and strep
throat, are very different diseases, with symptoms that do not resemble each
other, but they are all bacterial and are all handled very nicely by penicillin,
just as SSRIs are effective for all kinds of different illnesses. To play with the
analogy a bit more, strep throat is not really the same disease as rheumatic
fever, although the same germ is involved in both diseases. The key point is that
current DSM IV disorders are not likely to be equivalent to each other as
separate, equal diagnostic entities once we understand the complexity of their
underpinnings.

That there are gray areas in making a diagnosis is perfectly legitimate. The
concept of spectrum disorders is also legitimate. The problem is in the
application of the idea. Implicit in the decision to stretch the diagnosis, to
include a patient that doesn’t meet criteria for that disorder, is the belief that
the disorder exists in the same sense as an infection or tumor or diabetes. It is
not just an operational definition. It is real in the same way as say, a child
presenting with fever, achiness, vomiting and diarrhea, without complaining of a
scratchy throat, may nevertheless be suffering from strep throat. A clinician who
claims a child or adult “really” has bipolar disorder, or ADHD despite not meeting
defined criteria, assumes something is going on related to their actually having a
specific disease process. Something is wrong with their brain circuitry, or
neurotransmitters, or genetics that justifies the diagnosis even if it isn’t
presenting itself in the usual way, or cannot be demonstrated. And a medicine is
going to be effective because it somehow attacks the fundamental pathological
process. While clinicians sometimes succeed when they try one medication after
another on a trial basis, justifying this by a series of guesses about the “real”
diagnosis, attributing a diagnosis doesn’t necessarily add to treatment success.
Since, for the most part, we do not understand how the medications work for a
given diagnosis, we haven’t added very much to our approach.

The problem of reifying diagnoses extends beyond trying to classify patients who
don’t meet full DSM IV criteria. Some disorders are problematic not only because
they are spectrum extensions of a diagnosis. From a common sense perspective the
cluster of symptoms defining the “disorder” is unlikely to be a disease, as that
term is commonly understood. For example, it is possible to operationally define
the cluster of symptoms that constitutes oppositional defiant disorder. While
certainly something is troubling about the behavior, and in theory it may be
studied objectively, is classifying this a “disorder” necessarily the best way to
conceptualize it?

Merely labeling a syndrome of behavior a disease creates problems. Here is a quote

from Educational Horizons Spring 1996: "Once upon a time parents who lacked the
courage and/or interest necessary to set limits and impose responsibilities were
thought to produce lamed and defiled children. "Spoiled brats" was the common
lexicon. Happily, this benighted notion no longer enjoys currency. We now know
that a child's upbringing may really have little to do with "brattiness." Children
behaving like "spoiled brats" are often really suffering from an illness known as
oppositional disorder.”

Is this what we meant to do? Are we really going to solve the problem of
oppositional and defiant children by calling it an illness? Are doctors “experts”
in this area? Any parent who has raised a child with minor or major problems,
knows that understanding their family’s and children’s issues in its specifics is
more likely to bring results than the crude portrayal that emerges from the use of
the broad brush strokes of diagnostic perspectives.

There are other issues. A perfect illustration of how using the evidence based
model is inadequate can be found in the use of Herceptin for those breast cancer
patients who have too much HER2 protein. Herceptin does nothing for the others.
Statistical studies of its efficacy for all breast cancer patients would be
meaningless if everyone with the diagnosis were studied. Similarly, the evidence
based treatment model (based on diagnosis) can lead to cruder than necessary
formulations as illustrated by the finding that Risperidone is effective for major
depression when added to standard antidepressants treatments.7 Is this due to
decreased anxiety in an agitated depression ( since anxious depressed patients
don’t respond as well to treatment8 )? Or is there an inherent antidepressant
quality possessed by Risperidone? Would Risperidone be as helpful for a depressed
patient with anergia or hypersomnia or psychomotor retardation? Or, would it make
things worse? This question is not addressed by the research because the study
design is locked into the evidence-based model of diagnosis rather than the
alleviation of specific symptoms. (It is noteworthy that the FDA seemingly
considered this diagnosis perspective necessary for a formal listing of treatment
indications)

There are many other problematic issues to raise about evidence based medicine’s
reliance on diagnostic psychiatry. However, we will leave this topic in order to
return to the main point of this paper, that as laudable as a scientific stance
is, we should unapologetically acknowledge the obvious. The inadequacy of our hard
knowledge means clinical psychiatry is, and for the foreseeable future will remain
an art as well as a science. There is value in formulating treatment rationales
that are not statistically validated protocols based on diagnosis, but are,
nonetheless, sensible.

The use of medications within a psychological/ clinical context paradigm as

opposed to a strictly diagnostic (evidence based) perspective

Herman Van Praag’s classic “Nosological Tunnel Vision In Biological Psychiatry. A

Plea For A Functional Psychopathology” (1990)9 warned that exclusively focusing on
diagnosis can blind clinicians to other useful ways of approaching patients’
difficulties. Many clinicians limit their focus almost exclusively to the
treatment of DSM IV defined symptoms. The rest of the patient’s complaints may be
considered chaff, and therefore, shouldn’t be a treatment concern. With this
perspective, fifteen minute, once a month med visits, may be all that is needed.
However, as will be seen, this may not be optimal care, even if it is the
treatment recommended by “experts.” It isn’t only frills we are addressing. A
broader view of patients’ problems may yield more informed use of medication.
Clinical context can be just as, or more important, than diagnosis. To illustrate
this it will be necessary to repeatedly resort to what is commonly dismissed as
the anecdotal.

Mr. T., a thirty-year-old man, unhappy in his marriage, had always pictured a
family life with two or three children. His wife, a beautiful woman, whom he had
originally been smitten by, had never wanted kids. Mr. T assumed she would change
her mind. But now, six years into the marriage, he understood that there would be
no change of heart. She was to be the project of the marriage, her
vulnerabilities, her needs, the vicissitudes of her emotions. It had gotten old.
Over the years, he had noticed his impatience with her grow into indifference and
then sarcasm. He came for help when he had become depressed. He couldn't sleep. He
couldn't eat. He couldn't concentrate at work. Constantly running through his mind
was how trapped he felt in his unhappy marriage.

I'll put the issue in a nutshell. What if an antidepressant worked like a charm
and completely rid him of his depression? What if it returned bounce to his life
and now he found he could, after all, live happily with the status quo? This is,
in fact, what happened. As long as he remained on an SSRI he was fine. But here is
the key question. What if 25 years from now, Mr. T. were to wake up and realize he
had wasted his life? He really had wanted children and a family all along. What if
he wouldn't allow a doubling of his SSRI dose at that point? A drug had deceived
him, cheating him of what had been meant to be.

Would Mr. T. have had major depression if he weren't biologically predisposed? We

don't know. (Nor do we know with others.) But even if he would not have gotten as
depressed without having a biological predisposition, it is wrong to dismiss his
marital situation as merely a precipitant. In this case, his misery was an alarm
signal. Depression represented his true feelings that the life he was living was
making him very unhappy

A further question: would a different antidepressant have led to a different

conclusion about his marriage? SSRIs are excellent at turning off the alarm
system. Respite from overwhelming emotions may have something to do with healing
and recovery. The depressed person is no longer being overloaded with the
experience of helplessness, a demoralizing sense that nothing the patient can do
will matter. The question for us is would a dopaminergic, or adrenergic drug have
led to a different idea about the marriage? In rats, when confronted with the
hopelessness created in the FST (forced swimming test) those on SSRIs will do
better than rats being fed placebo. They won’t give up as easily when faced with
the impossible. Those on desipramine, interestingly, will more often try to climb
out of the threatening environment.10

Ms. B. was having an affair with a married man who was on fluoxetine. When he came
off his medications he couldn't stand his marriage for a moment longer and he
intended to marry Ms. B. As soon as he was back on meds his concern switched to
his teen-age daughter who needed him to stay.

Which was the true judgment? Among my patients on SSRIs some have found the
courage to ignore their fear of loneliness and leave an unsuitable marriage.
Others found the courage to have what proved to be an unwise affair that
devastated their family. The ramifications can get complicated.

On an SSRI Mr. Q, a 27 year old car mechanic with an Ivy League degree, decided to
quit his 9-5 job as well as his part time band (which all along he had considered
not up to his talent level). He planned to use his inheritance and "go for it" as
a singer. Was this realistic? I suppose it depends on his talent, connections, and
luck. He had previously been cautious about his inheritance (one million dollars
from his grandfather) recognizing that it was a one-time thing and was his only
hope for financial security. He felt guilty about receiving the money. “ It was
unfair to others.”

On medication this no longer applied. One of his original complaints, his social
phobia, which was particularly paralyzing when he was attracted to a woman, had
not been cured. However, he was no longer depressed and suicidal during weekends
when he felt most isolated. He said he had come to realize that he could be
content without people. Perhaps his contentment was helped by a significant drop
in his libido, a great relief for this well brought up young man, whose trips to
pornographic sites on the internet left him feeling even more ashamed than when he
tried to overcome his shyness, and was rejected after he tried to initiate sexual
contact on a date.

Only after Mr. Q decided he was going to use his inheritance to develop a solar
car did I feel forced to act. He was not manic or hypomanic. He was calm and
sleeping well. But he was about to gamble with his future financial security,
possibly on the basis of a drugged state. When advised he would have to stop the
SSRI, so that he could review without medication his solar power car investment,
he stopped therapy and went to a different doctor.

Van Praag argued that pharmacological agents can be viewed as inducing particular
psychological states which, though not specifically related to diagnosis, are
nonetheless the basis for the usefulness of the medication. As an alternative to a
chemical imbalance paradigm, which hypothesizes that inadequate serotonin is a key
factor in an assortment of psychiatric illnesses, a case can be made that SSRIs
are efficacious in conditions as disparate as borderline character, depression,
obsessive-compulsive disorder, anorexia nervosa, panic disorder, social phobias,
and so forth because increasing serotonin has a psychological impact that is
nonspecific to the disorders in question. Alcohol will produce inebriation in a
person with schizophrenia, obsessive-compulsive disorder, depression, or someone
with no psychiatric diagnosis. Analogously, SSRIs typically impact individuals in
ways that are not specific to diagnosis. What is that effect?

Normal guinea pig and rat pups in the laboratory loudly squeal (emitting stress
induced vocalizations) when separated from their mothers. If given SSRIs these
vocalizations are reduced.11 The most frequent description of the effects of SSRIs
that I have heard from patients are "It doesn't matter." or "Don't sweat the small
stuff." or "What's the big deal?" It is this "Don't sweat the small stuff"
perspective that I believe is SSRIs unique blessing and curse. It means relief
from worry, relief from the feeling that something is missing, something needs to
be done, something needs to be fixed, "my makeup isn't right, the sky is falling,
I won't be able to pay my bills, I'm not smart enough, I won't be able to tolerate
the loneliness if I leave my lover" (even if he/she is abusive). SSRIs supply, if
not always happiness, then a nice contented feeling that all is well and will be
well. They can allow parents to be able to play with their children more, fret
less over the details, appreciate what is, actually want to do the proverbial
modern mantra, stop and smell the roses.

On the other side of the equation consider this:

Ms. D became pregnant while successfully being treated with an SSRI . Despite
misgivings, she decided to marry the father of her unborn child. Several years
later, the patient now divorced, and again depressed, returned for treatment. I
suggested an SSRI. She would not consider it. She blamed the SSRI for her original
poor decision to go ahead with marriage.
A psychiatrist colleague took fluoxetine to relax on her vacation. It worked so
well she tried it at home when she returned. She quickly stopped it when she found
herself thinking, "Who cares?" when her patients described their problems.
Pomerantz 12 describes a patient that was getting speeding tickets while on an
SSRI and similarly didn’t seem to be bothered.

According to this theory it is the "well whatever" feeling, emotional blunting,

that is so useful in the great variety of different syndromes. Thus, for a person
with anorexia nervosa to react with "well whatever" after they have gained a pound
or two gets at the heart of the problem. The same can be said for body dysmorphic
disorder, when imagined, or slight, body defects no longer seem important. In
obsessive-compulsive disorder, the ability to treat compulsions and obsessional
thoughts in this manner is a godsend (which interestingly is similarly helped by
morphine13 a non-serotonergic med but which creates an even stronger but
comparable mindset) Similarly, a depressed person's preoccupation with the
hopelessness of their situation, the gravity of their errors and defects, and so
forth will be enormously relieved to regain a less "negative" perspective. In
panic disorder, a condition characterized by exquisite sensitivity to body
sensations, and a catastrophizing of consequences (a patient described an attack
of terror after she feared she was losing her vision and only later, when she
removed her glasses, did she realize that her dirty eyeglasses had set her off),
SSRIs have been found to be effective because the sense of imminent catastrophe
leaves. For similar reasons social phobias and bridge phobias and flying phobias
often become manageable on SSRIs, as do intermittent explosive disorder which may
improve because it is harder to press the patient's button. Alcoholism,
pathological gambling, overeating and the like may respond if a sense of
frustration has significantly contributed to the pathological behavior. (these
conditions can worsen if a disciplined battle is being waged against temptation,
which is then weakened by a "well whatever" letting down of the guard). SSRIs can
help perfectionists ("obsessive compulsive personalities") give themselves a
little (or a lot of) slack. They can allow borderline personality disorder
patients to cool off, to not be tortured, like a wounded lover, when the person,
upon whom they have passionately centered their survival, is not reciprocally
involved with them. And so we can apply this perspective about SSRIs down a long
list of DSM-IV defined disorders that have been empirically found to be treatable
by a change in brain chemistry.

This perspective also suggests itself as useful in psychological circumstances

where a specific DSM-IV diagnosis is not at issue. Thus, for instance, a not
uncommon treatment scenario is teenagers who are having a very rough go of it with
their classmates, kids who are picked on precisely because of their vulnerability.
The popular students are the ones who are cool; that is, they don't blush easily,
are bold with the opposite sex, and so forth. Adolescents often turn to illicit
drugs (analogous to adults at cocktail parties), to get rid of their social
anxiety. What they are up against can be far more traumatic than what adults’
face, who more often gossip without the criticized person present. By contrast,
teenagers may be extremely up front in social situations, meaning they delight in
publicly torturing the nerds.

It is not unusual for adolescents to come to therapy because they feel like
misfits and to put it bluntly, the use of SSRIs may help by providing a thicker
skin, which is exactly the quality they needed all along to not get picked on and
possibly even have the "cool" to be "popular." How does that differ from drugging
oneself out of problems rather than "learning critical skills during the formative
years? Isn't discomfort often a stimulant of growth, (the stutterer who becomes
the grand public speaker, the short guy who becomes Napoleonic)? I'm not sure it
is different, but that discussion will have to await a different article. The fact
is however, that SSRIs are used exactly in this way and a myriad of other
analogous ways by clinicians to the tune, according to one estimate, of 65 million
people in the United States since their introduction. Right now, when they are
found effective, a diagnostic perspective leads to the conclusion that the patient
must have "really" been depressed, or has a subclinical version of an illness, or
has a spectrum disorder. I am suggesting we can spare ourselves this pseudo logic
and address the real question. Should we or should we not drug people into
subjectively improved states when an officially designated "illness" is not at
issue?14

As implied above, there are other perspectives that may lead to treatment success,
characterological qualities that may guide our treatment, conflicts causing
depression or anxiety, or mood instability, situations that may be highly relevant
not only to psychotherapy, but more to the point, to the choice and timing of
medications.

Mrs. L. had originally required hospitalization and 40 mg of paroxetine to recover

from a postpartum depression. It worked well, but after seven 15 months on the
meds, an incident happened which disturbed her. During her lunchtime she was
visiting her infant at his daycare center when one of the workers began screaming
at another infant without picking her up. The next day Mrs. L went shopping during
her lunch break. Later that week a coworker became tearful during the course of a
conversation with Mrs. L. regarding her own child's daycare center. Only then did
Mrs. L. wonder about her decision to go shopping the day after she had witnessed
the daycare worker's inappropriate reaction. She wondered if her paroxetine had
made her indifferent, when ordinarily she would have reacted and worried about
such a thing.

Paroxetine was reduced to 20 mg. On less medicine there was a dramatic change in
her perspective about many things. For the first time she spoke about the
pressures she had been under at the time of her original hospitalization. Mrs. L.
had tried to find time to be the powerhouse worker at her job that had brought her
so many promotions in the past, an ideal mother for her newborn infant, and
responsive to her husband's very exacting standards about her housekeeping.
Suddenly, without the higher doses of paroxetine, her fury poured out. She
described, in detail, episode after episode in which her husband stood to the side
and supplied her with a never-ending critique of her adequacy as a mother. The
higher doses of medication had muted her responsiveness, allowed his criticism to
go in one ear and out the other, but now there would have to be change "or else".
Mrs. L. also acknowledged that she had not been doing her job as carefully as in
the past and eventually the company would discover her drug induced "what the
hell" attitude. At home, she had bounced several checks, something that had never
happened before she was on medication.

Therapy now turned to how her life would have to change. She seriously considered
stopping her job. She loved being a mother and didn't want to miss out on her
son's crucial early years. She demanded changes in her husband (with the threat of
divorce). Her new assertiveness had rapidly put him on good behavior even before
marriage counseling started. A few times, during her sessions, she became tearful
about her dilemmas. Although we discussed the possibility of returning to higher
doses of medication should the need arise, she was not eager to do this. She felt
her tears were about real things and did not consider herself depressed. She did
not feel hopeless or helpless. Her sleep was not as restful. She sometimes tossed
and turned. But she was okay. We joked that we might go up on the paroxetine
temporarily if, and when, she needed a vacation from her stresses. In fact,
throughout I was concerned that her greater emotionality might be a prelude to the
return of her original symptoms. But this perspective was quite different than an
automatic increase of medicine at the first sign of tears. As it happens she did
not need to return to a higher dose. She did quite well, eventually deciding to
work part time. Three months after making that decision she was the happiest she
had been in years.

It is noteworthy that when, at her urging, she was reduced to 10mg there was
another improvement (depending on perspective). She again noticed dust on her
furniture. She noticed that the pictures on her table had been placed haphazardly.
She arranged them more aesthetically, which is what she had done before SSRI
treatment. She did not feel driven to take better care by the internalized monster
described in obsessive personalities by Shapiro in "Neurotic Styles",16 by an
unending "I should, I should I should." She took pride in her newly regained
"attention to detail." She also regained a degree of empathy for her husband.
There certainly was the danger that she was returning to a dynamic of taking care
of everyone and everything, of offending no one, a role that she had assigned
herself from early on in childhood. This pattern may have played a part in her
original postpartum depression as she tried to juggle her responsibilities and
became overwhelmed, consequently generating forbidden anger at her newborn.
Certainly, her regained empathy for her husband might be the beginning of
permission for him to begin carping again but she thought she "would be able to
handle that."

The other issue that can be gleaned from these clinical vignettes is evaluation of
proper dosage. If we stick to a strictly DSM IV symptom checklist, fewer and
milder symptoms, are an absolute good in terms of the risk/ benefit ratio. While
this perspective is often proper, with Mrs. L there was a downside to SSRIs as
well as an upside. The dulling of emotions such as panic, anxiety, helplessness,
uncertainty, feeling uncomfortable in social situations and so forth are
indisputably good. It allows patients to get off the emotional roller coaster that
psychiatric symptoms often represent, and puts them back in charge. This dulling
issue would not necessarily qualify as a side effect, unless it became an
inappropriate degree of indifference to consequences developed (as seen in mania,
hypomania or as illustrated by Pomerantz’ case of the patient who was indifferent
to speeding tickets). Yet, less dramatic effects on a patient’s fear of
consequence, can still have importance in the patient’s life.

What about a bookkeeper, or the architect of a bridge, or an engineer who has been
driven by anxiety to produce perfectly executed calculations? What about a mother-
in-law who is barely sensitive to her son-in-law’s feelings, but now medicated,
and more relaxed about consequences, has her say. (Of course it is also possible
that on meds she might be less sensitive to her son-in-law’s shortcomings.) If the
above observations are correct, the qualities we are describing are inherent in
this class of drugs. In other words what is good about them is what is bad about
them. The evaluation of clinical appropriateness is not invariably related to
diagnosis or symptoms, or the usual side effects. We are entering layers and
layers of evaluation that psychiatrists may not consider their role. Certainly
they cannot accomplish this in 15 minute once a month visits. Yet, if choosing
proper dosage is an important function of psychiatrists, shouldn’t these more
subtle considerations be part of delivering optimal care? Shouldn’t experts
address these issues?

When our patients are making critical decisions about their life, while on SSRIs,
is it good or bad to be under the influence? Increasing self esteem, or lowering
fears of consequences (such as loneliness or rejection) may be a good thing for
someone stuck in a bad marriage or job and afraid to make changes. Indecision can
reach total paralysis in severe depression when self-esteem is fractured and fears
of consequences are gravely multiplied, so here symptoms are clearly distorting
the ability to act. The same can be said when mania leads to the opposite,
reckless impulsivity. But, in the real world, these issues are often a question of
degree and medication can be a complicating variable.

Ms. D a computer consultant, with a terrible foster home childhood, was

successfully treated for depression with an SSRI. She had never felt she was as
good a techie as her 4 male partners. She had a never-ending need for reassurance,
which was embarrassing to her. It was part of the reason she had gotten involved
in a number of foolish affairs. Every night on her drive home she tortured herself
with the things she felt she had mishandled. On an SSRI all of this changed. She
acknowledged that she wasn't as good a techie as her partners, “but she wasn't
bad.” More importantly, she realized she was indispensable to her team. She was
the only one with sufficient social skills to handle their clients. For the first
time in her life she was able to ask questions at conferences without feeling like
an idiot. No longer hungry for confirmation she was also able to stop her cycle of
love affairs. On the other hand, her comment coming off meds was noteworthy. "I
feel like I've been drugged for two years. Now I want to take a look at my
checkbook." She also reported behavior that now, off the meds, seemed bizarre. She
had bought a puppy that she kept in an unfinished basement. While medicated she
had not cleaned up the poop, reacting with "well whatever." Off the medicine she
was shocked by her behavior.

Mr. K., a patent attorney for a large corporation, was overwhelmingly depressed at
home and work. He had been depressed once before. The apparent cause was a
difficult supervisor at his job. Almost daily, his supervisor would criticize some
aspect of his work and Mr. K. would be immobilized for the rest of the day.
Sometimes he would stare at the wall in a daze... "my father always called me a
complainer...you don't have to love your job; you just have to get it done... I'm
a loser ... those years in law school-- all for nothing..." Placed on an SSRI Mr.
K. was quickly fixed. His supervisor would enter his office, make his usual
derogatory remarks and nothing would happen. Mr. K. returned to working
productively. There were other benefits. His overweight wife lost 35 pounds. For
the first time in years, Mr. K. put down the TV remote control. They began having
good conversations, the kind of talks they used to have when their relationship
was fresh and engaging. Everything became new. Mr. K. realized that for years he
had been going out on Sundays because he was irritated by the tumult of his
children. On his SSRI, he found himself playing with his children and having a
great time. After ten months on the medication we decided to see how he would do
without it. Within a few weeks we were back to square one. His supervisor's
remarks were again devastating him and he was a grouch at home. He made a quick
recovery once he was placed back on the medication. After 16 months on the SSRI
Mr. K. found a new job. He loved it. He came off the meds. He did fine.

There were only a few peculiarities that he commented on when he got off the
medication. Although overall he had worked far more effectively on meds, for the
first time in his life he found himself ignoring deadlines. Once or twice, that
had caused difficulties. He bought a Mercedes on the medication. He had always
wanted a Mercedes, but off of the medication he considered it a budget buster and
foolish.

Mr. K’s case is noteworthy not only because his judgment was altered by the SSRI,
but because, at ten months, when we first tried stopping the meds, he would have
seemingly illustrated the statistics often replicated in studies, of patients who
have a recurrence without their meds, thus providing one more piece of evidence,
seeming to confirm the life long implied biological basis of his illness. But, at
16 months, with the apparent cause of his depression eliminated (his critical
supervisor), he did just fine without an SSRI. This doesn't diminish the almost
miraculous effectiveness of his original meds, or that they may have helped him
gain the initiative to find a new job, or that he might get depressed again some
time in the future. However, it does highlight the kind of questions that
clinicians should ask themselves about the particulars involved in a specific
patient's illness, as opposed to exclusively focusing on the operative factors in
a specific diagnosed illness. This perspective is in contrast to the clinical
practice guideline issues by the U.S. Department of Health and Human Services
which flatly states that where there has been a prior episode(s) of major
depression "maintenance of antidepressant medication treatment should be for at
least one year" 17 Statistically this assertion may have a basis for a population
of patients but surely there are circumstances when this “rule” should not guide
us.

The fact that on follow up recurrences are found so frequently in unmedicated, as

opposed to medicated, patients does not automatically demand continued treatment
with meds. Generally speaking, the issues involved in a depression are deeply
woven into a patient's character or the fabric of his life. Miraculous
transformations are the stuff of melodrama not reality. One would not expect a
change in the original factors that led to depression eight months or nine months
into treatment, or even years later unless the patient or his circumstances
changed. Hence, depression is going to recur off of meds and it is a good idea to
continue them. But , this does not have to be the case. There can be a dramatic
change in circumstances. If a patient has gone into a deep depression because of
financial hardship after he/she has been fired from a job, chances are that
finding a new terrific job will very effectively keep depression from recurring.
Winning the lottery works even better. The same can be said for a person who does
not have a neurotic pattern of relationships, who has gone into a depression after
being rejected by a spouse or lover. Finding a new mate works wonders whether it
is three months or two years after medication was begun.

The perspective being presented here also applies when medication is not involved,
for example evidence based treatment using cognitive behavioral therapy.18

A sixteen years old teenager was evaluated for medication for depression. As a
young child he was abandoned by his biological mother and raised by his
grandparents. His grandmother/mother had died two years before at the age of 74
after her third stroke. His 79 year-old grandfather had severe emphysema, and
judging by his labored breathing in the waiting room, didn’t look like he was too
long for this world either. At his prep school the patient kept talking about
death. Like others when they are depressed, his dark moods didn’t make him very
popular with the other students at school, which made him even more depressed. On
the basis of his depression diagnosis, his therapist was utilizing cognitive
behavioral therapy. Attempts were being made to replace his negative thoughts with
positive thoughts through homework exercises.

Although I am a non-believer I would have had no problem if he was being comforted

by religion, if he was given a positive way to think about death, for example,
that his mother was in heaven, and he would one day see her there. But being told
to repetitively practice not thinking about death, replacing it with more positive
thoughts by doing homework assignments again and again to accomplish this, places
psychiatric cure on the level of its behavioristic antecedents, training rats to
perform a task through repetitive exercise.

Is planning the treatment of a 16 year old boy, upset by the death of his mother,
and the impending death of his father, best conceptualized with blinders worn by
the doctor, that eliminates every non scientific consideration? If a boy, about to
become an orphan, had asthma, a pulmonologist could properly focus on the asthma
alone and leave ministrations of his soul to a priest. Must this be the position
of psychiatrists? The cognitive behavioral therapy offered him, while
scientifically sound, was alienating him from the reality of his experience. Fine,
given his situation and personality he wasn’t going to be very cheerful. But he
might be able to learn to love the blues, or read authors who have come to terms
with the death of a loved one, or find friends who like to visit sad territory, or
be helped by a therapist who wants to visit him in his own experience, who might
legitimize his “negative” feelings and bring dignity to his suffering. Is a doctor
who conceptualized the issues this way no longer practicing medicine because he
has left the realm of diagnostic psychiatry and clearly defined symptoms?

It isn’t that evidence based treatment based on medication trials, or cognitive

behavioral shouldn’t be considered, it is that these other clinical issues cannot
be addressed unless they are conceptualized. Van Praag’s description of tunnel
vision resulting from an exclusive focus on nosology is exactly the point here.
Indeed, once a month 15 minute med checks (which may be all that is necessary when
practicing evidence based, symptom vs side effect psychiatry) can lead to
practitioners being blind to clinically crucial observations. Indeed, laymen
described the “well-whatever effect” long before it was addressed in the
literature. Consider this ad for a t-shirt.

How is this possible other than the "experts" have had their eyes closed to the
obvious. They do not know their patients well enough to observe what is apparent
to others. Diagnoses, described symptoms for that diagnosis, and the alleviation
of this is all that matters

Brainstorming: Further perspectives and unusual uses of drugs resulting from a

psychological rather than diagnostic point of view

SSRIs, and bupropion are believed to be roughly equal in their antidepressant

efficacy. But while each stimulates neurotransmitters to give a positive ring to
the day, they do not induce the same psychological profile, since rather than
effecting serotonin, bupropion acts primarily by enhancing dopamine, and to some
extent, norepinephrine. It tends to be activating rather than calming.

Most clinicians use bupropion in depression when anergia or anhedonia is

prominent, and tend to avoid it if anxiety or agitation characterize a depression.
Not surprisingly, it is one of the few antidepressants that hasn’t proven to be
effective with panic disorder. It can give an edgy feeling, which, in an already
nervous person, can set off panic attacks. But here is the important point for
clinicians. There are no hard and fast rules. There are as many exceptions as
rules. Guidelines based on the general can serve as starting points, but
eventually the particulars are more important, especially when all is not going as
planned.

When Mr. K., a 50 year old businessman, transferred to my care, he was already on
bupropion for panic disorder. Since this was not indicated for that diagnosis I
took him off it. His condition worsened so he was put back on it and he did well.
It look the better of 8 or 9 months in weekly psychotherapy sessions before I came
up with a plausible explanation. It wasn’t that his brain chemistry was different
than others so that bupoprion effected his brain chemicals differently ( a
speculation that a chemotherapy oriented psychiatrist might assume). I thought it
more likely, after I got to know him better, that bupropion helped his panic
attacks for reasons particular to his story.

His mother, during a bohemian interlude in her 20s, had left Connecticut and gone
to live in Greenwich Village. New York suited her well. She was attractive,
charming, energetic and intelligent. There she met, fell in love with, and married
Mr. Ks father, a good looker but a ne’r do well charmer and, it turned out,
alcoholic. It didn’t take long for the honeymoon to evaporate. After six or seven
years, his mother’s trust fund proved inadequate to support the two of them and
their two sons, ( Mr. K and his brother). After many discussions, promises to
change, and falling off the wagon Mrs. K’s mother left Mr. K’s father, and
returned to her family in Connecticut a broken prodigal daughter.

She soon was resuscitated. Having learned her lesson, she met and married the
opposite kind of man. Unlike, Mr. K’s true father, a bohemian a moral relativist,
taking great satisfaction poking holes in the hypocrisy and inconsistencies of
conventional rules of behavior, his new father stayed on the righteous path of
responsibility to the community, and to Christian ideals. He paid unwavering
attention to good intentions. Straying from the path, was forever tempting and
adventurous compared to the boredom of sticking to what is expected. But the
interesting is not always relevant. Christ suffered to relieve the faithful of
sin. Mr. K did not cash in on this gift. He preferred to follow Christ’s example.
It took supreme effort. Sufffering was proof enough that you were going about
things as Christ might have.

His new father lived by the book. He loved books. He taught at a very respectable
prep school where he took his place alongside other respectable teachers those
charged with setting an example for the sons of wealthy families.

The lure of no monthly child support checks, allowed Mr. Ks biological father to
give up all parental rights so, along with his brother, Mr. K was adopted by his
mother’s new husband. And so his only contact with his father, was hearing about
his father irresponsible behavior from his new father who could cluck insistently
when his father’s name was mentioned,

After the blush of their early romance, his parents settled into real life. The
atmosphere was tense. There were some nice things. He could cut a nice figure when
he was in a good mood. His mother had chosen her new husband, because of her
attraction to him, but it turned out., as in most marriages, physical magnetism
hindered clarity of vision. She found his tight ass rule irresistible. And as she
had done through earlier incarnations of her unleashed demons, she was a mighty
opponent.

She asserted her independence in many nice ways, but in the end it was driven by a
nasty side of her, that led to symptoms. Secretly she took laxatives, to keep
herself stylishly thin. She did well. This time around, she was perfectly
presentable to the community, to her husband’s world of headmasters, and fellow
teachers. But in the privacy of her castle, she almost constantly had gas, which
for comfort often had to be released wherever she was in the house. Several times
she had to be hospitalized for her mysterious colonic illness. It took 25 years
for her laxative abuse to be discovered, long after my patient had left home.

Mr. K’s adopted father was a perfectionist of the worst variety, stern and
unforgiving, and when pushed by my patient’s childish half effort, he was capable
of furious outbursts. Not all of this was earned by his misbehavior. In
reconstructing the probable scenario in therapy, we thought it very possible that
both he and his brother were easier targets than their mother. She, after all, was
sickly.

Mr K’s adopted father could be friendly to the young. He coached the prep school’s
soccer team with passion. He was extremely stern here too. He would scream at his
players’ screw-ups, give them the cold eye, or devise some other form of torture.
However, he enjoyed soccer and this enjoyment was infectious. Most of those he
coached considered him tough, but over all, a good experience. His father’s
relationship however to non sport related work was completely different.

As with most people it wasn’t a lot of fun, but here his neurotic patterns let
loose the full fury of his frustration. As Marlon Brando in On the Waterfront put
it, and tens of millions working stiffs since and forever after, have put it, when
youth and its possibilities has passed them by: He could have been someone, been a
champ. He had been off to a good start, before the army and World War II took him
away from his career. It never got going again, not like his brother who had had a
fantastic career. He told himself that he chose teaching because of his desire to
do some good, to make a difference for other people. He made sure this wasn’t a
cop out, wasn’t simply a flight from the battle field, by dedicating his life to
hard labor. It wasn’t just his admiration for Christ and wish to be like him. He
brought the battlefield with him. He heaped on the challenges, took second and
third helpings of things he hated to do. He took pride in this stoicism.

His father’s greatest contempt was reserved for slackers. When they didn’t do
their job it meant twice as much for him. He felt sorry for himself because of all
of the unrewarded work life dumped on him. The work was never done well enough and
never done which made all of his life gruelingly hard. Mr. K and his brother, as
children, were kids, champion slackers. The choice between play and work was not
difficult. Both knew to get out of the room when their father was in a foul mood,
especially if he had been drinking.

When he was given an assignment at home Mr. K quickly learned that no matter how
well he did it, his father would be dissatisfied, sometimes very dissatisfied, on
more than one occasion furious exploding over a mistake, or half effort. God
cursed Adam and the human race with have to work with the sweat of their brow. The
chain of command (the curse of work) has since been extended from father to son
generation after generation, none more so then from stepfather to stepson Even if
briefly he pleased his father, it never lasted. We speculated that his father’s
bitterness and disappointment with his stymied career fanned the flames of any
hatred his father felt toward his adopted sons (my patient and his brother). There
is a good chance that his father’s drinking grew out of proportion to all of it,
to financial stresses not adequately covered by his salary and Mr. K’s mother’s
trust fund.

Schoolwork was the worst, whenever Mr. K’s intelligence was challenged. His father
seemed to take particular pleasure demonstrating how smart he was and how stupid
my patient was, perhaps because he still wanted to prove to Mr. Ks mother that she
had made a smart move choosing him and not Mr. Ks biological father. Or perhaps,
as noted, it was a way of getting even with his disappointing wife These theories
about his parents’ motivations cannot be proven with scientific certainty. (They
are a mix of speculation and likelihood. They are offered as an illustration of
the kind of thinking that might go on during insight therapy.)

In high school, having been compared to him repeatedly, Mr. K soon resembled his
biological father. He goofed off, got high on pot, alcohol, and acid. He faked it
whenever he ran into a bump in the road, homework that demanded intellectual
effort. If it didn’t come effortlessly, it meant he wasn’t smart enough to
understand it. This reinforced his adopted father’s characterization of him as a
loser/slacker. . Back then ADHD and doctors were not the solution to Mr K’s soon
to be disintegration of effort. By not making the effort, he didn’t have to face
the possibility that his father was right. He was dumb. It was a self defeating
strategy. By giving up early when challenged by difficulty, he wasn’t able to
prove to himself that he had the intellectual capacity, to overcome the problem.
Most children aren’t sure they have much in the brain department . Not trying and
not getting good grades , reinforces the original fear. He was as his father saw
him, dumb, a loser. By the time he was in high school he feared, he might fail out
of school even if he tried. So try he didn’t. Because of his rule breaking, drug
abuse, and failure to do assignments, he was asked to leave the prep school his
father taught at. It left an indelible mark on his identity.

In later years, through AA, regular church attendance and conformity to a persona
that would have made his now dead adopted father proud, he achieved
respectability. There was only one problem. His panic attacks.

The first one occurred after a rare visit, when he was 18, to his biological
father. His father had actually prospered. After a week together he was driving
home in the new car his father gave him, feeling great about himself, great about
his car, probably great about the revenge this might exact on his adopted father.
It was then that his first panic attack occurred. He was to have several of these
throughout his life, whenever he was feeling terrific over his purchase of a new
car. Apparently he was terrified of what victory against his father might bring.
He was no match for his father’s rage. That much had been branded starting from
three and four years old. You didn’t want to get him too angry.

There were other dynamics that evolved out of the above framework. If he could put
off the pain, offend no one, make promises that he would come through, he’d be
safe for a while. This meant regularly promising more than he could deliver. He
did it (in the heat of the moment) to be nice, or because he was too afraid to ask
for assistance when he didn’t know how to do something. When there were
expectations at work beyond what he believed were his capacities, he was in real
trouble. As a deadline date approached, the pressure mounted and mounted.

It turned out that his panic was related to a fear that the sh—t was going to hit
the fan, a panic that his laziness, incompetence, and dishonesty would be
discovered. As it had time and again with his father. He had been terrified then
and was terrified now.

As a dopamineric agent, the bupropion helped him to get things done, thus
alleviating the source of his anxiety and panic. It gave him the confidence to
forge ahead, an expectation that he was going to accomplish what he had set out to
do and take pleasure doing it. His results weren’t guaranteed to be good when he
was influenced in this way by the medication, but it didn’t matter. It was his
positive expectations. If we recall, his father was equally perfectionistic when
he coached soccer, but because he was having a good time, my patient (and his team
mates had a good time.) It put my patient in a different psychological mode. Like
many fathers and sons, whatever tensions might build up during their lifetimes,
sports was the one area they could enjoy each other. Interestingly, Mr. K, well
into his 40’s, continued to play and coach soccer, capable of great effort and
failures, but with a pleasure that forgave all shortcomings. It worked far better
at getting work done than a grinding adherence to the work ethos.

Bupropion seemed to put him in a mode where work he customarily slacked off on
became easy, half challenging, sometimes stimulating. This should not be a total
surprise. Bupropion is often used in the treatment of depression to augment SSRIs
when anhedonia remains. This seems to be a general characteristic of dopaminergic
medicines.

In the 19th century another dopaminergic agent, cocaine was the most popular
miracle drug in the world, regularly used and extolled by the likes of President
McKinley, Queen Victoria, Pope Leo Xlll, Thomas Edison, Robert Lewis Stevenson,
Ibsen , Anatole France and a host of other renowned members of society. 19 Sigmund
Freud wrote the following about it, “You perceive an increase of self-control and
possess more vitality and capacity for work. 20 According to the Sears, Roebuck
and Co. Consumers’ Guide (1900), their extraordinary Peruvian Wine of Coca
“...sustains and refreshes both the body and brain....It may be taken at any time
with perfect safety...it has been effectually proven that in the same space of
time more than double the amount of work could be undergone when Peruvian Wine of
Coca was used, and positively no fatigue experienced.”

Nothing has changed. Here is a headline and blurb from the New York Times 21
regarding the effect of stimulants and amphetamines:

“Latest Campus High: Illicit use of Prescription Medication, Experts and Students
Say”

“Ritalin makes repetitive, boring tasks like cleaning your room seem fun” said
Josh Koenig a 20 year old drama major from NYU

“Katherinen Plyshevsky, 21, a junior from New Milford NJ majoring in marketing at

NYU said she used Ritalin obtained from a friend with ADD to get through her
midterms “It was actually fun to do the work,” she said.

What is the difference between tasks that are experienced as drudgery and those
that are satisfying? It is a key question because students diagnosed with ADHD,
presumably unable to attend to tasks because of a biological deficit, have no
problem paying attention when they are having fun. Many can sit for hours with
video games that require extraordinary focused attention. Why does their presumed
biological attention deficit not operate here? I evaluated a student who told me
that his mind completely fogged over when he had to read something for school.
Without his medicine he could go over a page a hundred times and absorb nothing.
“Really?” I asked, “You aren’t able to read anything?” “Well,” he told me, “there
is one exception.” He was totally into mountain biking. Each month his mountain
biking magazine arrived and he devoured that without medicine. Also supportive of
this argument-unique charismatic teachers, who make educational material fun, can
sometimes succeed with these students. Hence the effectiveness of amphetamines and
Ritaline.

Besides ADHD diagnosed adolescents, and their friends, who sometimes borrow their
meds when they have to do chores that they dread, stimulants (“greenies”),
according to David Wells22, and more recently Mike Schmidt 24have long been part
of the professional athletes’ equipment, helping them to step up to the plate with
confidence. It changes their state of mind from a passive, reactive, position to a
take charge proactive stance. Or as one basketball player put it, “Give me the
ball. I can make the shot.” This taking charge, ‘I can do it’ feeling, when
approaching tasks, is a key element in most people’s perception of whether they
are up to a challenge, and whether it is ‘work’ or pleasurable.

A patient reported to me that one of her employees decided, on her own, that their
showroom needed a new paint job. My patient wasn’t sure if this were true, or if
she liked the color of paint chosen, but she didn’t object. She came in one day
and it was done. Her employee had done a terrific job. If my patient, who was her
boss, had asked her to paint the showroom, the reaction would have been, “You have
to be kidding. I am not a painter.” It has something to do with the idea, the
inspiration coming from her employee. Hence her consequent enthusiasm to make her
point.

Observe the new owner of the local diner. He will work ten, twelve, fifteen hours
at a clip. He will polish the windows, try to improve the menu, rearrange the
napkin holders, move from project to project always with energy to spare. Unless
he has a gift for management his teen age employees will be moving along at a
snail’s pace, keeping one eye on the clock. They will go home more tired than the
boss. Dopaminergic drugs help you feel like the boss. They make you feel in
charge. They make you feel like reward will be assured. They make arduous tasks
easy.

It was not just Mr. K. I soon learned bupropion seems to often be effective for
anxiety whenever it was connected to not getting things done, when, in a person’s
psychology, chores hang over them, as both dreaded tasks, and dastardly
consequences will ensue if the work isn’t done. When they get the work done the
anxiety diminishes. So a drug that at first glance might be expected to make a
patient edgy works against anxiety in those with this particular dynamic.

My off the cuff guess is that this dynamic is not particularly common in panic
disorder. Mr Ks case was unique. Bupropion could never become an “evidence based”
treatment for panic disorder, but like our example of thyroid hormone in CHF it
made perfect sense in Mr. Ks case and others with that kind of conflict. It is
probably not uncommon in Generalized Anxiety Disorder, but most likely, patients
with this relationship to getting work done make up a minority of cases. As noted,
dopaminergic drugs makes sense in a large number of children and adolescents with
ADHD because there has been a failure to bond and identify with parents’ and
teachers’ expectations. Children without ADHD, to a much greater extent, have
incorporated into their bond with their parents (and later authority figures) the
satisfaction and sense of self initiative when they are asked to do something to
please (or not disappoint) them. It is far from perfect but compared to children
(or adults) with ADHD, for whom almost any expectations are experienced as
drudgery, boredom in the classroom is assured. In that case their behavior is
exactly what could be expected from any bored trapped child, daydreams and
restless fidgetiness, trying to liven thing up to suit their need to not feel at
the mercy of the situation. Doing what they want, including making noise, gives
them the feeling that they are in charge of their experience. It may get them in
trouble, but they are not vanquished. How much simpler to supply this feeling
through stimulants. Thus, instead of stimulating hyperactive qualities, the
stimulant becomes calming by making the work pleasurable instead of oppressive. It
does not addresses the core problem, the child’s failure to bond with authority
figures, or group norms, or transform expected behavior to comply with another’s
will, so that they feel like an active participant when obeying. But it is not a
bad approximation

The key issue is searching for a connection between symptoms and psychological
issues rather than assuming biological causality of a DSM IV diagnosis explains
the problem. I have applied this thinking to certain causes of anxiety, and the
behavior of children when they are not responding well to tasks, but the same kind
of approach offers opportunities in many areas of psychopathology. For example,
like patients with obsessive compulsive personality (as well as many with OCD)
like Mr. K’s father, often experience their life as continually oppressive,
essentially filled with exhausting never ending chores. With every bit of his
strength, Sysyphus, had to push his boulder to the top of the hill, then it would
roll back to the bottom and he had to begin again. His punishment went on forever.
For patients with this curse there is no end to it unless they die and “rest in
peace,” or become disabled and receive government checks for their bad backs.
Unlike those with ADHD they perform tasks (begrudgingly), or attempt it, or intend
to attempt. Their to-do list never gets done.

They cannot deal with the shame associated with goofing up. One way or another,
whatever they actually do, the conflict preoccupies and exhausts them. Resentment
of those who don’t work as hard as they do is inevitable. Like Mr. K’s father
there may be fury at their adolescent children who don’t pitch in, or spouses, or
partners in business.

Joffe24 found that amphetamines can help OCD. SSRIs allow obsessive patients to
soften their sense of imprisonment from their injunctions. They can let some of
them go. In those obsessive patients where I have tried bupropion (I have not yet
tried to use stimulants for obsessive symptoms) as expected, it seemed to make
work less oppressive, sometimes make it seem, as noted above, easy and “fun.” In
two cases, when I used it in this context, some of their anger seemed to diminish
(as well as their guilt and feelings of worthlessness for their mysterious
unacceptable (often consciously denied) hatred/ anger. Once again I did not make
the decision on the basis of diagnosis, but when their resentment over duties,
bubbled furiously into the sessions, we went with the bupropion.

Case after case can be cited, where this kind of thinking can be productive,
serving as a rich source of hypothesis and hunches that might provide a
therapeutic dividend, but we will end with a very unusual use of medication. Once
again, it is understandable when the psychological issues are considered.

A patient with PTSD for over ten years presented on high doses of Adderall that
had been given to him for what his family physician diagnosed as adult ADHD. (He
had reported difficulty concentrating.) His physician then became uncomfortable
administering stimulants and sent him to me. His history revealed that he did not
have ADHD. But he reported that on the Adderall his post traumatic stress disorder
was the best it had been in over a decade. It took a while to make sense of this
but once again the explanation appeared to be found in his history. He and his
fiancé had been trainees at a state police academy. His fiancé committed suicide
with her gun, blowing her brains out. My patient found her body. He couldn’t clear
his mind of the scene. During the day, during his dreams, her brain and skull
fragments on the wall remained vivid. To make matters worse, he became a paramedic
working on an ambulance which brought him to car crash scenes where horribly
damaged bodies were not infrequent. Eventually in therapy 5 years before he came
to me, he realized this was not good for him, and for years he had worked on a
hospital ward. Even with SSRIs and benzodiazepines, his PTSD not infrequently took
control of his mind. This no longer happened with the addition of Adderall.

My guess was the Adderall brought back his pre-morbid, state policeman defensive
structure. Instead of experiencing his trauma again and again as a helpless
passive victim, the essence of the psychological position occupied by those
suffering from PTSD, on the Adderall he had returned to being a take charge kind
of guy. Coincidentally I was also seeing another patient with PTSD. She was a drug
salesman who had been a work out nut. She spoke in short staccato sentences. Boom
boom, bam bam, not a trace of sentimentality in her, not a soft syllable in her
repertoire. She had been in a car accident and broken her collarbone, right arm
and one of her legs. She couldn’t work out. She kept re-experiencing her
helplessness in the accident. She was on SSRIs which were helpful but not
curative. The addition of Adderall worked like a charm.
Like the other examples, this is not an endorsement of Adderall for PTSD. It is an
endorsement for this kind of thinking in formulating cases where this might be
helpful. We are not talking about psychoanalytic understanding being necessary,
but it does require training to think psychologically in a productive way.

The treatments described will not prove efficacy to a scientist’s satisfaction.

Moreover, some, or all of these formulations may turn out to have been wrong. But
it throws down a challenge. These ideas are only a fraction of what might be
possible if others were thinking this way. This should be encouraged. Psychiatric
journals should be publishing ideas on subjects like these, so that we can discuss
and brainstorm, and end the monopoly that DSM IV and scientific psychiatry has
imposed on legitimate practice and discussion. Our experts should weigh in on
these issues. Hopefully, one day our patients will be effectively treated by a
psychiatry entirely based on science. However, we are far away from being there.
Until we have the knowledge to practice in that way, we are doing a disservice by
making believe we scientifically know what we do not, and ignore faculties we
possess, or that lively discussion and training can improve. It might be helpful
to our patients.

References and notes

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14. Are we acting as doctors if we treat a condition that is not an “illness?”

Should medical insurance cover treatment of a condition that is not an “illness?”
Or should DSM describe adolescent turmoil as a condition with full understanding
that narrowly defined efficacy studies aren’t particularly helpful? The key issue
is that psychopathology is being addressed regardless of diagnosis. We might even
get better diagnostic thinking if clinicians didn’t have to fabricate DSM
conditions to suit insurance forms, and parity regulations.

15. Previously, I have cited other lengths of time in describing this but after
reviewing my notes this is the accurate time period

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http://www2.truman.edu/~marc/webpages/andean2k/cocaine/history.html

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25 Kaplan, Arlene DSM-V Controversies Psychiatric Times v26 p1 January 2009

A good portion, though not all, of this article will be published in the journal
Medical Hypthesis in early 2009.