The Cape Cod Summer Symposia have been happening for three decades; this year the PL editor conducted the first week long course on basic concepts that are central to PL: How should we diagnose? How should we use medications? How do we understand the role of psychotherapies? Special emphasis was given to the existential approach in psychotherapy.
Highlights of some of the material presented, and the discussion that ensued, are presented here.
It was taught that family history and course of illness can inform diagnosis. For instance, if an adult has a family history of bipolar illness in a first degree relative, age of onset of depression before 25 years, and psychotic features during a depressive episode, a study found that 2/3 of such depressed persons would be found to have a manic episode at some point; in other words, they had bipolar illness. The teaching point was that you can increase your likelihood of correctly identifying bipolar illness, or any diagnosis, by assessing family psychiatric genetics and course features consistent with that illness.
A colleague then asked the following question: I treat children. They all have depression before age 25; many have psychotic features, but it’s questionable, because it could have been caused by amphetamines. Many have family history of bipolar illness, but it’s questionable. I could diagnose them all bipolar, but it would be on questionable evidence based on the course and family history.
The PL view is that if one’s evidence is truly questionable, then one should not put much weight on it. But our evidence often is much less questionable than we think. For instance, in the case of a child, the parents are usually present for a clinician to interview herself. If the clinician wants to remove doubt, assess the parent with a psychiatric interview to identify whether they’ve ever had manic symptoms or not.
To focus on family history, it often appears to be the case that clinicians downplay or write off some evidence of psychiatric illness in families. For instance, they’ll note that an uncle was reported to have bipolar disorder, and then proceed to diagnose major depressive disorder (MDD). They don't realize that the whole concept of MDD was based on the notion that it is genetically separate from bipolar illness, and thus it should not happen, or rarely so, in persons with relatives with bipolar illness. Thus, it is important to find out if that uncle truly had bipolar illness or not. How can you do it? The simplest way is to ask the patient to describe what the uncle was like. Suppose the patient says: “He would spend months in bed, not doing anything at all, and then for weeks on end he was all over the place, spending tons of money and visiting prostitutes.” That is not a very questionable history for mania. If the patient doesn't know the relative well, often a family member is present in the waiting room, who can provide that evidence. This is one reason why PL recommends that family members never sit in the waiting room if feasible; they should be invited into the office and be part of the diagnostic interview.
There are many studies which have assessed the accuracy of psychiatric family history. They compare "family history" with "family study." In other words, first they asked patients about psychiatric illness in their family members; then they went and interviewed many family members about their own psychiatric symptoms. The conclusion? You won't be surprised: If anything, patients underreport, rather than overreport, psychiatric illness in their families.
Keep in mind that the only two highly genetic psychiatric conditions are bipolar illness and schizophrenia. “Anxiety” and “depression” are not
“If anything, patients underreport, rather than overreport, psychiatric illness in their families. ” highly genetic, besides being vague symptom definitions (like “fever") rather than diagnoses. Manic-depressive illness is the kind of genetic illness that causes depression. And schizophrenia is the genetic illness that causes chronic delusions. Those are the two main psychiatric conditions to assess in a family history.
When discussing how to treat high neuroticism, generalized anxiety in DSM lingo, we discussed the risks and benefits of long-term use of serotonin reuptake inhibitors (SRIs) versus benzodiazepines. In relation to the latter, some clinicians expressed concern about their abuse liability. Research was cited stating that their abuse liability is low, if someone has no history of substance abuse. The overall percentages will vary, but in one study, less than 5% of such persons developed an addiction to benzodiazepines. Even if past substance abuse was present, only about 15% of such persons developed a new addiction to benzodiazepines. This is not to say that these agents are not addictive; they are. But they are not addictive in 85% or more of the persons who take them. Thus this potential risk is not a reason to avoid them nor to be stingy about them, especially in persons with no past substance abuse.
Yet the question was raised whether it was not abuse when someone took benzodiazepines regularly for years, as prescribed, but would not, or could not, come off them. This is a legitimate question. The same could be said regarding amphetamines when taken for ADHD. There certainly is tolerance for benzodiazepines, which will make it difficult to come off after years of regular treatment. The same is the case, perhaps even worse, with SRIs. This doesn't mean that the individuals are “addicted” to those agents; but they are stuck with them. This is all the more reason to avoid long-term treatment beyond one year with any of these drugs, whether benzodiazepines or SRIs. There will be a substantial minority of persons in whom such long-term use might be needed in some cases. Perhaps high neuroticism is the most legitimate situation for such use. But even then, attempts should be made to have drug holidays for months at least, or maybe longer, as frequently as possible.
Still this long-term concern about withdrawal syndromes is no reason to avoid giving benzodiazepines short-term, meaning for months, especially in those without past substance abuse.
A final point: Many persons in whom benzodiazepines or SRIs are used for anxiety do not have anxiety “disorders.” Anxiety is the most nonspecific symptom; it is the fever of psychiatry. It is often caused by something else, usually mood episodes, sometimes psychosis. Treat the underlying disease, the mood illness for instance, and the anxiety will eventually improve in many persons. In many cases, the benzodiazepines can be used in such settings short-term for symptom relief while the underlying mood disease is getting controlled. Then when the mood symptoms improve, the benzodiazepines can be tapered off and anxiety often does not recur. In those cases where anxiety persists despite improvement in mood or psychotic illness, then one might have a true comorbidity, and then, in that minority of patients, long-term use of benzodiazepines might be warranted, despite the reality of withdrawal.
Some evidence was discussed, as summarized here, about the lack of studies of validators of diagnosis (course, genetics, biological markers) supporting the legitimacy of adult ADHD as a scientifically valid diagnosis. The question was raised whether the same held for childhood ADHD.
The details about the relevant studies are cited in the PL website article. Further discussion of adult ADHD will happen in future PL issues in more detail. For now, the summary PL view is that adult ADHD is a scientifically invalid diagnosis, and that childhood ADHD mainly represents a developmental phase. These perspectives are explained here.
One factor that was raised was the experience that apparent adult ADHD often reflects mood temperaments, especially hyperthymia and cyclothymia. In mood temperaments of those kinds, manic symptoms are always present. Since manic symptoms include distractibility, those persons often are misdiagnosed as having adult ADHD. In fact, they improve frequently with low-dose mood stabilizers, like lithium 300-600 mg/d or divalproex 250-500 mg/d.
Some concern was generated when there was a brief review of some of the animal data indicating neurobiological harm with amphetamines, including methylphenidate. This harm involves killing neurons, or cortical atrophy. A brief discussion is present here.
What should we do with amphetamines, if this kind of neurobiological harm is true? First, it should be noted that these animal effects have neither been proven nor disproven sufficiently in the limited human MRI studies so far. (See here for links to the few studies). Thus these animal data are neither a reason to avoid amphetamines automatically, nor a reason to simply give them out routinely. Rather, the PL view is that patients should be given informed consent. They should be told that these animal data exist, that their relevance to humans is unknown, and that information should be taken into consideration by patients in their decision about whether to take or not take amphetamines for purported ADHD or other purposes (e.g., to increase energy or improve cognition).
Further, patients should be warned that in middle-aged and older adults, amphetamines carry some risk of sudden cardiac death (about 1 in 1000 risk according to a recent study). Again, this is not an absolute contraindication to giving amphetamines to adults, but it is a piece of informed consent that should be given to patients to help them make their own personal risk/benefit calculations.
A major focus on the course was the use of existential psychotherapies, perhaps the least understood and least used style of psychotherapy in most parts of the world, especially the USA.
The basic principle of existential therapy - if one tries to identify it - is the concept of putting the world “in brackets”, that is, not making any judgments of any kind about anything. The therapist doesn't theorize, she doesn't think, she just experiences. The point of the therapy is not to convince the patient about anything, nor to identify any insights. It is simply to be with the patient. The patient isn't sick; the therapist isn't healthy; both are sick and healthy at the same time, and both will change.
This approach of just being with someone else can itself be therapeutic; it can be all that is needed to help the other person, in cases of pure existential psychotherapy. Or, it can be used to engage with the patient or client as part of a larger process, whether it be identification of a psychiatric disease to be treated with medications, or a later shift to a different kind of psychotherapy for a specific purpose, such as couples therapy or psychoanalytic therapy or cognitive behavioral therapy.
In short, existential therapy helps us to connect with the person inside the patient, as Leston Havens said, and that connection is the beginning of any treatment.
The concept of putting the world “in brackets” was introduced in the late 19th century in philosophy by Edmund Husserl. He saw it as a means of getting at the truth. He called his approach “phenomenology”. His ideas soon influenced the founders of existential philosophy, like Karl Jaspers, and thus this way of thinking often is called the “existential/phenomenological” approach. Jaspers trained and worked in Heidelberg, which was the most prominent academic center in psychiatry in the early 20th century. Thus, this approach has also been called the “Heidelberg school of psychopathology.”
In the US, the main person who introduced these ideas was the psychologist Rollo May, who had been mentored by the existential theologian Paul Tillich, who himself came from Germany where he had been influenced by a founder of existentialist philosophy, Martin Heidegger.
The other major founder of existentialist philosophy was Karl Jaspers. Jaspers was a psychiatrist, as well as a philosopher, hence he would seem to be an ideal source of existential psychiatry. In fact, he laid the foundation for this approach to psychotherapy. Many ideas we now take for granted were introduced into psychiatry by Jaspers in his classic 1913 book, General Psychopathology.
Take empathy: The word didn't exist before 1908, and Jaspers was the first to make it central to his approach to psychiatry. Before him, it hadn't been thought as important. Jaspers was the first to place empathy prominently in the tasks of the psychiatrist and psychotherapist. And he didn't do this because he was a nice man (which he was). He did it because empathy is central to existential psychotherapy.
The purpose of the existential approach to psychotherapy is not to provide insights to the patient; it’s not to apply some kind of theory. The existential theory is that there is no theory: there is just existence. There are two people, two existences, two human beings who are trying to make sense of their existing worlds. Both change, both the clinician and the patient. If one changes, the other does too. The patient gets better, the clinician might get worse. In any case, therapy is not for one person, it’s for both. That’s the importance of empathy: you feel and experience what the other person feels; that’s both the method and the treatment. If you do so, you as the clinician will feel and change too, not just the patient.
Leston Havens has laid out different ways of achieving empathy, from a technical standpoint, in a few excellent books on psychotherapy. He distinguishes a few types of empathy:
Motor empathy is when you sit as the patient sits; you look where the patient looks; you move as the patient moves.
Sensory empathy is when you physically feel what the patient feels, like when you wince when another experiences pain.
Cognitive empathy is when you think what the patient thinks; you can test this by trying to finish the patient’s sentences in your head while he speaks. If you get it right, then you are connected with the patient’s thinking.
Affective empathy is when you feel the emotions that a patient feels.
Many people see empathy only from the affective perspective; but in fact, the other features usually are needed for affective empathy to finally occur.
In the symposium, the ideas of Havens’ teacher and mentor, the Harvard psychoanalyst Elvin Semrad, were discussed. Semrad provided an 8-word definition of existential psychotherapy that is an excellent ideal of the approach. Psychotherapy, Semrad said, means:
Future psychotherapy articles will expand on this idea. The basic principle is that empathizing with suffering reduces it.
Existentialist philosophy has the reputation for being somewhat dreary. Most people hear about it from the plays or novels of Jean-Paul Sartre or Albert Camus, both of whom were influenced by Heidegger. Sartre’s play No Exit and Camus’ novel The Stranger paint an existential picture of a world where nothing has any meaning. This nihilistic variety of existentialism is certainly depressing.
In the symposium, we discussed Karl Jaspers’ metaphor for life as a shipwreck. Jaspers emphasized all the limits of life, the limits of failures and defeats, and the ultimate “limit-situation” of death. To be an aware existing person, one has to accept these limits.
In doing so, one is faced with nihilism, the feeling of no meaning.
One symposium participant asked: So isn’t this existential psychiatry fatalistic?
It can be. Sartre and Camus were atheists; and their perspective can be seen as putting into doubt any real meaning to living. Their mentor Heidegger was famously inscrutable; he collaborated with the Nazi regime.
Jaspers, in contrast, was the most prominent intellectual who opposed Nazism and remained in Germany throughout that era; he was placed in house arrest and forbidden from writing or teaching.
Existential approaches can be fatalistic, but they also can lead to very moral and courageous stands.
Perhaps the best example here is the psychiatrist Viktor Frankl, who wrote one of the most widely read books ever written in psychiatry, Man’s Search for Meaning. This work grew out of Frankl’s experience as a prisoner in Nazi concentration camps. If ever there was a scenario where life could be seen as meaningless, it would have to be as a Nazi concentration camp prisoner.
Yet even there, Frankl argued that an existential approach would help us find a meaning in life. Read Frankl’s book, and see if you are convinced.
It is not us that have to give life a meaning, Frankl said; it is life which gives its meaning to us. It is there if we will but see it. But we won’t see it if we deny the realities of life, which include death, and evil. Limits are all around us: failure, evil, harm, death. And within those limits, we can find the meanings of life.
Suffering, for instance, has a good aspect, Frankl argued, because it shows we are alive. The worst scenario in the concentration camp, he observed, was not when a prisoner had extreme suffering and despair; it was when a prisoner had become apathetic, had given up, didn't care any more. Those were the persons who killed themselves or died. The suffering ones survived.
Nietzsche made the famous statement that what doesn't kill you makes you stronger. This is what Jaspers had in mind when he taught that it is through failure that you become who you are. This is what Frankl saw tested in the ultimate cruel experiment of the concentration camps: Those who suffered survived. Those who no longer felt anything, including pain, perished.
May’s view was that you reached joy only after experiencing despair. Jaspers’ view was that you had to travel through the “abyss of nihilism” to reach “existential liberation.” Both had spiritual leanings and religious backgrounds, though of very liberal bent. They opposed any specific doctrine of faith in a general sense, but Jaspers in particular held that everyone needed to find his own personal spiritual faith, stemming from his own existence, where he happened to be born and live and the cultural and historical background into which he was placed. For one person, the “philosophical faith” Jaspers described might occur in the formal context of Judaism, for another Islam, for a third Christianity, for a fourth Buddhism, for a fifth none of the above.
In other words, for Jaspers and May and Frankl, there is a spiritual aspect to the existential approach. Jaspers called it “philosophical faith”; Frankl called it “medical ministry." The contemporary psychologist Thomas Moore calls it “care of the soul.” In all cases, there is this awareness of limits of existence that leads one to a realization of a larger “transcendence” (to use Jaspers’ phrase, obviously also central to the thinking of Emerson), a “higher power” (to use William James’ phrase, made famous in Alcoholics Anonymous). This higher power can be seen non-theistically; it can be seen as nature. Or it can be seen theistically.
In any case, once one accepts the obvious fact that my existence is not all there is to the universe, that there is something bigger and larger than me, then one has taken a spiritual orientation to existence. This approach can help avoid fatalism and nihilism.
The mental health professions are secular, of course, and except for avowedly faith-based counseling, there is an attempt to avoid any talk of spirituality or religion in most approaches to psychotherapies. Tillich called psychiatry “the faith of the faithless.” Everyone needs a faith of some kind, these thinkers taught, even a faith in unfaith.
The first days of the symposium were spent in extensive discussion of the problems with the DSM approach to diagnosis. The main view presented was that DSM takes a nonscientific approach to diagnosis mainly. This is because it emphasizes social, cultural, professional, legal, and economic aspects to defining psychiatric diagnoses. This is not an opinion, but a fact. DSM codes are central to insurance reimbursement in the US; they are used by lawyers in malpractice lawsuits and in the penal system; they influence interest groups for and against certain psychiatric diagnoses. There is much debate in the public about how to change or not change DSM diagnoses. Scientific research is but one fact among many in the process; not infrequently, the scientific evidence is of less importance than all the other social and cultural professional factors in the process. Recent books by historians have documented this social process in DSM-III in 1980, the basic structure of the current DSM-5 system.
This process whereby many non-scientific factors influence diagnosis definitions is called “social construction.” Some use the phrase “pragmatism” to identify the same process: DSM decisions are made based on the practical outcomes of defining diagnoses this way versus that way. The practical outcomes might have relevance to insurance reimbursement, lawsuits, treatment decisions, and such. But whether or not the scientific evidence supports the validity of a diagnosis - separate from all the other social and cultural considerations - is not the primary factor used to define DSM diagnoses.
This is not meant to simply dismiss all DSM definitions. It is meant to be explicit about what is often unnoticed: DSM is not a purely, or even mainly, scientific document.
This is also not to say that one should not pay attention to social and cultural considerations. But it is important to note that the DSM system is primarily a social and cultural construct.
The main disadvantage to this approach is that since the DSM system is a social construction, and it is explicitly meant to be so, it is not primarily set up based on scientific data. It's not helpful for scientific research.
One notion to consider is that scientific research has failed in many important biological ways over the past few decades. New genes, biological markers or causes, and new pharmacological treatments have been scarce since the 1980s. One factor for this paucity of scientific progress may be that the DSM system, based on social construction, does not correlate well with nature. Genes don't care how we get reimbursed by insurance companies. Brain structure won’t follow phenotypes designed with courtro0ms in mind. The NIMH leadership has reached the same conclusions, and now will not accept DSM definitions for scientific research grants. Instead, the NIMH leaders will only fund studies that follow their own proposed approach to diagnosis, called Research Domain Criteria (RDoC), discussed further below.
There was some consternation in the symposium about some of these critiques. Many colleagues agreed, but some wondered:
What is a better option?
One participant noted that the NIMH leadership has provided an option, the RDoC. The RDoC are brain-based; they work from the brain outwards; there are five domains: negative valence, positive valence, cognitive, social systems, and arousal. These domains are based on brain structures that subsume those basic big-picture clinical domains.
What the NIMH approach doesn't understand is that scientific diagnoses can be based on scientific clinical research, and DSM never was a mainly scientific clinical research system. In other words, we can identify clinical diagnoses, and validate them based on the standard research validators (symptoms, genetics, course, biological markers). In the symposium, the PL editor described mixed depressive states (see PL issue 2) as a scientifically well-validated description of mood states (which would be part of the “negative valence” and “positive valence” states in the RDoC system). The depressive mixed state concept is more scientifically valid than “major depressive disorder” and it is more clinically useful than RDoC’s “negative” or “positive valence” states.
Clinical examples were provided about the harms of monoamine agonists (so-called antidepressants) and the benefits of dopamine blockers in mixed depressive states, as described in prior PL issues.
The symposium went into some detail on the Hippocratic approach to psychopharmacology, as described here. It was emphasized that the common view that this approach entails “First Do No Harm” is false, that Hippocrates never made this statement, and that in fact the Hippocratic school has nothing to do with a general conservatism about treatment, as that mistaken phrase implies. Instead the Hippocratic approach mainly entails treating diseases, often aggressively, rather than symptoms. Conservatism about treatment comes into play once diseases have been ruled out and when one is faced with symptoms, in the absence of disease.
There was some concern about whether diseases exist at all in psychiatric conditions. An ongoing discussion followed about the concept of “postmodernism”, and how psychiatry is strongly affected by postmodernist assumptions, including a denial of the disease concept. Briefly, postmodernist thinking, which has increased in influence in the last half century, involves a rejection of traditional views on truth. Both belief in God and belief in science are rejected; all truths are seen as relative to power. Truths aren't true in any real way; they are just the “discourses” of power. This critique was used by the French philosopher Michel Foucault to argue that there are no psychiatric diseases, and that all disease concepts, especially in psychiatry, are social constructions.
While many of the critics of psychiatry (anti-psychiatry) are fans of Foucault and are in fact postmodernists, it was noted that there is the paradox that the very mainstream of psychiatry itself, the DSM system, is also postmodernist. It is, and accepts being, a social construction, rather than begin a purely scientific search for truth.
Some participants were critical of this critique and remained skeptical about diseases in psychiatry. A discussion was given of neurosyphilis, which is clearly a medical disease, but which was indistinguishable in many of its symptoms from manic and depressive and psychotic episodes. It was claimed that schizophrenia and manic-depressive illness (recurrent severe unipolar depression and bipolar illness) were both diseases, as are obsessive-compulsive disease and autism. The view was that these are diseases as other medical conditions are diseases, in the standard concept of abnormalities of organs of the body that are internally produced (whether genetically or through environmental interactions with biological susceptibility) and which then produce stereotypic clinical syndromes. This discussion wasn't fully convincing to some participants, although it was convincing to others.
A discussion was also conducted of what we mean by “science” to clarify that the claims made here were not based on simplistic notions of scientific truth (often called “positivism”) but take into account the complexities of the scientific process, such as the production and rejection of hypotheses, the probabilistic nature of inductive confirmations of hypotheses, and social influences on science (such as the profit motive in the case of the pharmaceutical industry).
The goal of this approach to psychiatry, one that goes beyond simple DSM diagnoses and use of drugs, is a new psychiatry, one that puts the 20th century behind, and one that is ready to be scientific but not simplistic. The easy solutions of eclecticism are put aside for the hard decisions of scientific and humanistic thinking. The nihilism of pure social construction is rejected. This includes being willing to be biological when faced with a disease, but being willing to be existential when faced with the limits of living, in the absence of disease. And it means being willing to be humanistic under all conditions.
What does it mean to be a master clinician? The goal is not to be average. It's to be better than average. DSM is written for the lowest common denominator of practice. FDA indications and pharmaceutical marketing are aimed at herding clinicians to practice the same way.
There's nothing wrong with standards. There's plenty wrong with standardizing.
The old saying is true: A clinician who treats two patients identically harms both.
To modify a comment by Leston Havens: Be scholar enough to know the rules. Be clinician enough to break them.
So what is a master clinician? In the mental health professions, it means knowing DSM but not using it exclusively or even primarily in diagnostic judgments. The master clinician would use a diagnostic hierarchy, and not diagnose every symptom as a separate “disorder” , and then give a different drug for it. Rather, polysymptomatic conditions, like manic-depressive illness and schizophrenia, would be identified first and treated alone, with the view that most symptoms would resolve when the underlying cause was treated. It means knowing the drugs, but not using them routinely for symptoms. They should be used preferably for underlying diseases causing symptoms, of which only a few are proven so far to exist based on extensive biological research, namely: schizophrenia, manic-depressive illness (which means recurrent unipolar depression plus bipolar illness), obsessive-compulsive disease, and autism. Besides those conditions, medications should be seen as purely symptomatic, and only modestly beneficial, and thus with benefit/harm ratios that are borderline at best. Short-term use at the lowest doses possible would be the general approach. In the diseases, on the other hand, even “toxic” medications like lithium would be used very assertively, because the benefits are extensive and outweigh higher potential risks than is seen with some of the symptomatic agents (such as serotonin reuptake inhibitors).
In the majority of clinical situations, where symptoms are present but diseases are not, the master clinician can use existential approaches to psychotherapy to connect with the human being who has come to her as a patient. These approaches may be sufficient sometimes as the only “treatment” needed. Sometimes, they may allow enough connection to identify other problems that can be addressed non-biologically, such as other specific psychotherapies or even social and cultural interventions (moving one’s place of residence; addressing effects of crime and poverty to the extent feasible in a clinical setting).
The Hippocratic ideal was to cure sometimes, to heal often, and to console always. The disease-oriented drug treatment approach cures sometimes (though permanently); the symptom-oriented conservative drug approach heals often (though temporarily); the existential/humanistic approach to the person consoles always.
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