Increasing Anxiety in Recent Decades

Another question from a visitor:

Shifts towards higher anxiety and neuroticism: Twenge** has noted an increase in anxiety and neuroticism in recent decades. Is this the failure of psychiatry/psychology?

Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/11138751

This is a good and important article by Twenge, showing that anxiety and neuroticism (the tendency to experience negative emotion) have increased substantially in the past 5 decades, such that, for example, normal children in the 90's had similar scores on anxiety tests as child psychiatric patients from the 50's. The author finds that economic factors are not associated with this change, but that decreased social connectedness, and an increased sense of environmental danger or threat, are associated.

Here's a related comment:

Baumeister* suggests that purpose, values, sense of efficacy, and self-worth are needed for a meaningful life. Religions and spiritual belief-systems have long provided meaning and more. Nietzsche has supposedly said: "He who has a why to live for can bear almost any how". How do you think one can live a meaningful life? *Baumeister, R. F., & Vohs, K. D. (2002). The pursuit of meaningfulness in life. In C. R. Snyder& S. J. Lopez (Eds.), Handbook of positive psychology (pp. 608-618). Oxford: OxfordUniversity Press.

I have always felt that a strong sense of belonging, safety, meaningfulness, and community is necessary for mental health. Modern culture supports independence. Perhaps modernity also encourages the solitary pursuit of wealth, educational success, etc., in an increasingly competitive and busy culture. People are less likely to join community organizations or visit friends. People are more likely to remain single or live alone for longer periods of their lifetime (in their 20's and beyond). There are more activities that can absorb time and attention while alone (e.g. video games, recreational drugs). Even music--an aspect of life that was previously associated strongly with social connection--has become a medium in which a person can disappear alone, disconnected from the social milieu, thanks to portable music players. A cost of sexual or relationship freedom, particularly in the internet age, can be a tendency for people to have brief, less committed relationships, in the quest for variety, or in the quest for an "ideal mate." Intellectual freedom and advanced knowledge, while possibly allowing for heightened meaningfulness and enlightenment, may also shatter previous bastions of meaningfulness (such as religious dogmas), and may finally cause one to confront the absurdity and seeming empty arbitrariness of the universe. Owen Barfield, in his book Saving the Appearances, described modernity as a "shattering of idols", leaving a spiritual emptiness which science cannot fill.

I guess this is a failure of psychiatry/psychology. Not because the therapies don't work, but because the issue is one of public health and culture. I think this type of evidence emphasizes the importance of encouraging social connectedness and community involvement--to whatever degree is possible--as essentials in a therapeutic prescription for treating anxiety or depression.

In this regard, I encourage involvement in volunteering, community organizations, churches, sports teams, activity clubs, etc. It may be necessary to change one's personal culture in order to change anxiety or depression. You must be wary about being swept up in the prevailing culture, and must instead make active choices about what is healthy and meaningful for you.

*As an addendum here, I have to say that research data of this type may be biased by a variety of factors which differ between one time period and another, including use of language, cultural acceptance of symptoms, etc. Therefore, the children in the 50's may have had lower anxiety scores because they were less familiar with the language associated with anxiety symptoms, were less likely to admit such symptoms on a questionnaire, were more likely to deal with the underlying cause of such symptoms in a different way, etc. We now realize many terrible problems which were going on in the 50's (such as abuse), but which people did not talk about as openly back then. A questionnaire on these issues done at that time might have underestimated the degree of such problems.

**Here's another article, showing increasing life satisfaction over the past decades:
http://www.ncbi.nlm.nih.gov/pubmed/19227700

Intuition in Psychiatric Practice

Another question from a visitor:

Evidence-Based Medicine: Do you find that intuition has its place in practice of clinical psychiatry? Despite years of positive experience with a certain technique or medicine, would you decide against it if the only study done on it finds it harmful or useless? If not, how do you go about qualifying your sense of intuition and personal experience?

Good question. I think the crucial point here is "what constitutes evidence?"

Years of positive personal experience with something is itself a strong type of evidence. A negative study is another type of evidence. In all logical assessments of treatments, we must weigh the positive evidence against the negative.

If there was such a strong negative study, particularly if it was done with scientific and statistical rigour, it should lead to a critical re-appraisal of one's own practice, to examine reasons why one's own experience was so different from what another study shows. We should always be prepared to change our ways if strong evidence challenges the status quo.

I don't think "intuition" need be placed in opposition to "logic" or "evidence." I like to think that healthy intuition is a way to incorporate logic and evidence in a way which is flexible and open-minded, and which allows room for creativity.

In clinical practice, a manifestation of "intuition" may at times be a product of a great deal of experience or mastery in something (with the acquisition of "formal operations" in one's area of specialty, in a Piagetian sense), such that pattern recognition and responses can happen very quickly. We can see this in chess players, musicians, auto mechanics...any type of acquired expertise. Things appear to happen effortlessly, seemingly without a thought--certainly without the laborious calculations or stilted rumination which a beginner might apply to the task. These "formal operations" though, represent a great efficiency of weighing evidence and decision-making, not an absence of reason. Those who reject formal evidence in favour of their supposed "intuition" are in a different camp. This would be like the chess player or musician who does not pay attention to his or her weaknesses of technique, or like the auto mechanic who doesn't bother to check the oil. I consider this practice to be inefficient and potentially quite dangerous. There are studies which show that "intuitive" diagnostic impressions in psychiatry are often inaccurate (I'll have to find some references); yet I return to my claim that intuition can be a manifestation of our ability to process information quickly, efficiently, even subconsciously, and often with a natural grace and ease which can be a joy of life to practice or witness.

But intuition cannot be used recklessly or with disregard for other types of evidence.

Conversely, over-reliance on non-intuitive evidence can also be stilted and inefficient. The musician who has note-perfect technique, without grace, is uninteresting. A physician who goes through a symptom checklist meticulously, but fails to attend to alarming non-verbal cues, may entirely miss the underlying problem--a problem which is not detectable by a checklist, because checklist data may not be valid or relevant in cases where process is not attended to.

Metaphors

Here's another question from a visitor:

You note that you like using metaphors in psychotherapy. Can you elaborate more on the use of metaphor. I personally find that using metaphors can have its downside. Some metaphors, once useful--or helpful to those who never heard of them--can become quite trite and cliché. They may even take on negative connotations if associated with unpleasant memory or a disagreeable person from the client's past.

To some degree it is a personal indulgence on my part to attempt to use metaphors. I think you're quite right that this could be unhelpful or annoying to others, and at the very least trite or cliché. I would need to keep this tendency of mine healthily reigned in when necessary. It is, however, very characteristic of me, and a pleasure of mine, to seek out a new metaphor, and therefore an aspect of genuineness that I would attempt to share with patients at times.

Theoretically, it has been part of a larger world-view of mine, that a great deal of wisdom is couched in metaphorical language, yet this language is often taken literally by dogmatic adherents. The dogmatism intensely suppresses the wisdom. This happens frequently in religion, politics, and even in science and medicine. Joseph Campbell was one of my influences: I think he had a great balance of wisdom, humour, and story-telling ability--these are qualities of a good physician, thinker, or healer. Campbell himself was influenced by psychoanalytic thinkers such as Freud, and particularly Jung, but in my opinion his writing never had the annoyingly dogmatic and preachy tone characteristic of these psychoanalysts. Yet, Campbell's ideas are intellectually limited, and I think one should be wary of going too far with them (I find many styles of therapy which are overtly about "exploring myths", etc. to be tiresome, ignorant of modern scientific evidence, and overburdened with jargon). But I liked Joseph Campbell's style, and maybe this is one of the reasons I like "indulging in metaphor" at times as part of my work.

Psychologists Prescribing Antidepressants?

Here's another question from a visitor:

Your views on psychologists' obtaining the right to administer antidepressant.

I don't have any problem with this. If psychologists, or anyone else, were to have prescribing privileges, I do think there should be an educational program with a licensing exam, with continuing education requirements for maintaining licensure, etc., to ensure that the prescribers are up-to-date and knowledgable about the medications and risks, etc. At that point, it could be up to an informed patient to decide whether to trust and accept a prescription from a psychologist. As far as I'm concerned, this is a fair balance between regulation and individual rights in a freedom-oriented society.

I think some psychiatrists' opposition to psychologist prescribing has a lot to do with wanting to hold on to more influence, authority, power, or perhaps a greater sense of importance or exclusivity. There may be elements of narcissism and insecurity which underlie this position. It reminds me of the history of modern medical opposition to midwifery.

While many patients need complicated regimes of medication, may have complex comorbid medical problems, and may therefore require a highly specialized expert in psychopharmacology to prescribe for them (actually, the level of expertise in this area among psychiatrists is very inconsistent), the majority of patients who might benefit from antidepressants require a very simple regimen. Such a regimen does not require many years of advanced education to competently administer. It seems a waste of time and health-care expense for those individuals to have to seek out an MD for their prescriptions.

Furthermore, many antidepressant prescriptions are currently written by a gp who may have only seen the patient for a few minutes--if psychologists were prescribing, this would most likely be in the context of knowing the patient very well, with hour-long appointments, and offering very good follow-up care.

There are risks associated with prescription antidepressants, and there are bound to be patients who run into problems after being prescribed antidepressants from a psychologist. But I am doubtful that these risks would be higher than if antidepressants were only available from an MD, particularly if prescribing privileges required passing a licensing exam, etc.

Future of personalized antidepressants

Another question from a visitor:

Advances in psychiatrist medications: Holsboer has recently elaborated on the future of personalized antidepressants designed using genotype and biomarkers. Where do you think psychiatry is headed, in terms of ideology, but also medications and treatments?

Here's the reference:
http://www.ncbi.nlm.nih.gov/pubmed/18628772

It's an interesting and important subject. In current practice, it can be hard to find medications or other types of therapy which are helpful. It would relieve a great deal of suffering much more quickly to have some way of determining, in advance, which particular treatment for psychiatric illnesses might help best.

Also, the article emphasizes the need to search for treatments outside of the current pharmacological paradigms; we probably have enough medication choices affecting serotonin uptake, etc. It will probably be important to search for pharmacological treatments which affect other systems in the brain.

I don't feel very well-informed about the cutting edge of this science (translating genetic research into pharmacological treatments), but I can see this being a huge advance in the coming decades.