Two articles listed on Google news today address the issue of validity in psychiatry. That is, they deal with the question of how ‘real’ psychiatric disorders and diagnoses are. Both articles (“Psychiatry Confuses Distress with Disorder” in the Vancouver Sun, and “If Everyone is Ill, then No one is” in the Taipei Times) address the rapid increase in psychiatric diagnoses that has occurred during the last decades. The ‘bar’, or ‘threshold’ has been lowered, they contend: more and more people are being diagnosed not because mental illness is truly on the rise, but because the scope of pathology has been widened. In other words, what used to be considered normal variation in human behavior is increasingly medicalized and pathologized. The result is over-diagnosis and over-medication. The pieces don’t address the underlying causes for this medicalization (elsewhere, writers commonly attribute it to the power of the pharmaceutical industry, and consumers’ increased familiarity with the scope of psychiatric knowledge and treatment – the latter is actually suggested in the Vancouver Sun), but both trace it back to the rapid expansion of disease categories in the DSM and its attempts to increase its scientific and medical legitimacy.
Legitimacy, in this case, involves two things: reliability and validity. The DSM is a classificatory system that attempts to diagnose disorders on the basis of presented symptoms. In the absence of medical tests, diagnosis relies on a doctor’s interpretation of standardized lists of symptomatic criteria of which a patient must meet a specified number in order to classify as ill. Horwitz and Wakefield, the authors reviewed in the Vancouver Sun, accept the reliability of these standards (that is, they accept the idea that the same patient will be given the same diagnosis by any doctor who uses the diagnostic manual), but reject their validity, because the criteria disregard the various possible etiologies of disorder. That is, while a person mourning a recent loss (not only of a loved one, but of a job perhaps, or one’s good health) might display enough ‘symptoms’ of depression for a diagnosis, this diagnosis would not be valid, because this person’s sadness is not pathological (he has good reason to be sad). According to these two authors the problem, then, is that an emphasis on reliability has compromised validity, and consequently gives rise to over-medicalization. They suggest that a bit of subjectivity might solve much of the problem: a doctor who uses the manual would do well in keeping the patient’s background in the back of his mind and making an informed, unreliable but all the more valid, judgment on the basis of these personal considerations.
For Christopher Lane on the other hand, these ‘subjective standards’ are precisely the problem. He argues that overdiagnosis arises from the incorporation of subjective judgment into the diagnostic criteria of the DSM. Who has the authority, he claims, to determine what kind of symptoms ‘impair’ normal functioning? Who has the authority to judge what constitutes that normal functioning? His proposed solution involves setting the thresholds for diagnosis much higher, thus clarifying the line between ‘mild suffering’ and ‘disorder’. This, of course, never eliminates the ‘problem’ of subjective standards. How is a higher threshold any less subjective than a lower one and what makes this writer’s standards (being an English professor) any more authoritative or valid than that of any psychiatrist? Neither seems to me ideal – a higher threshold may eliminate over-medication, but will also deprive many people who legitimately suffer from any relief. Sure, Lane makes a valid point, and over-diagnosis is certainly a problem that must be addressed, but his call to set the thresholds higher is too simplistic.
Psychiatric diagnosis is difficult, and in the absence of medical tests these diagnostic criteria are all that doctors have to work with. Of course their validity and reliability are flawed, but any medical diagnosis is ultimately guesswork to some extent. The standards used to judge blood tests are not incontrovertibly valid, either. Just like psychiatric diagnoses, they were set, at some point, by doctors who decided that a certain concentration of a particular hormone constituted the threshold for pathology, and a certain amount of antibodies indicated the presence of disease. These, too, are random numbers designed to increase the reliability of a test. They are not necessarily biological givens.
And by means of update on the gendered thought processing issue I brought up a few days ago, Science Daily published a discussion of brain transformations in schizophrenia that actually brought up the existence of slight brain differences between men and women. These differences mostly involve the circuitry that processes emotion, which (of course…) are more elaborate in women. No mention of thought processes or rationality, and so this article is only tangentially related to my discussion earlier – unless we make use of cultural beliefs about the impact of emotion on rationality (‘you can’t think straight, you’re too emotional’. Or ‘you can think logically, you don’t let your emotions get in the way’), which are themselves to blame for the common judgment that women’s rationality is inferior to that of men. But either way, it might add something to the overall discussion… it suggests, in any case, that there might be some biological grounding for our culturally created differences in behavior.
Monday, March 31, 2008
Monday, March 24, 2008
The Gender of Rationality
Jill Lepore wrote an article in this week’s New Yorker (“Just the Facts, Ma’am: Fake Memoirs, Factual Fictions, and the History of History) about the difference between ‘history’ and ‘fiction’. Tracing the twin development of historiography and novels, Lepore’s main point is that the two genres are more similar than we would commonly believe – no more than two different kinds of history, each with its own form of truth. History books are, like novels, a form of “literary art” (pp. 80) and are never as ‘objective’ and unbiased as they claim to be; fictional stories on their part often convey larger truths about the human condition (they can ‘ring true’). What has separated them in the public mind has less to do with objective than with cultural standards of ‘truth’. Our standard looks for neutrality and empiricism: this means that we accept the outsider’s perspective and emotional distance of historiography as ‘fact’, while the personal perspectives and passions that take center stage in novels become its antithesis.
What is interesting to me is that this divide between two kinds of truth came to be drawn along gendered lines as well as literary ones. As Lepore recounts, the history of novels had by the eighteenth century become a women’s history. That realm of histories told through the eyes of individuals and through the stained-glass of affect and motivation, whose truths lie in the plausibility and universality of the experiences they recount, appealed to women’s processes of thought and experience. History, on the other hand, did not interest them – this ‘objective’, ‘neutral’ account of events that became men’s domain. Add to this, of course, the common rejection of novels as fancy and fantasy, the consequent fear of novels’ power to corrupt the minds of young women, and you not only ‘prove’ that men and women think differently, but also that women’s thought is somehow less true than that of men.
This is an incredibly interesting issue, but one I never know what to make of. These theories about gender differences in patterns of thought comes up in (cultural) psychiatry as well. It is invoked to explain gender differences in the prevalence and course of disease (are women more prone to depression or bipolar disorder because they are more sensitive to emotional mood swings?), and sometimes even factors into treatment decisions (as in, it informs the doctor’s goals of treatment. What is considered ‘normal’ affect for a man differs from what is considered ‘normal’ for a woman. An interesting discussion of this is Sara Starks & Joel Braslow’s historical overview of psychiatry in the post WWII-decades. They show that doctors were more likely to perform lobotomies on women because its side-effects interfered a lot less with women’s ideal behavior than with men’s).
No doubt there is some truth to all this – I am willing to accept the idea that women, in general, may tend to think more concretely and relationally than men do. I won’t bring up the critique of overgeneralization here, because as much as that critique should always be kept in mind, this article really does not intend to suggest that all women think in similar ways – and that they are categorically different from men. Nor, I think, do psychiatrists intend to do so (not all of them, anyway). But what I do want to bring up – because I think this article facilitates this question – is the issue of causality, or better said, the question of the chicken and the egg. That is, if these ‘generalizations’ are true, why are they true? What came first? Are women born with different wiring, that then gives rise to different ways of socializing and different domains of cultural activity (as some evolutionary psychologists would argue)? Or do culturally prescribed gender roles and expectations socialize men and women – born with equal potential – to develop their patterns of thought in different ways to match these expectations? Many anthropologists will argue that the impact of socialization is significant: women learn in large part to think more relationally and concretely because as girls they are socialized immediately into caretaking roles. They are taught to view the world and their actions in the terms of their relationships to others (a woman acts not just for herself, but for her children, and her husband), while a man is trained to pursue his own goals.
Even if there were some different wiring at birth – which I think we should not assume at all until it can be in any way ‘proven’ – the second scenario (the constructivist viewpoint) seems to me much more plausible and realistic. We are social beings who are not determined fully by our biology at all. We cannot disregard the incredible shaping force of our cultural environment. (Of course, much of my own work critiques this viewpoint, arguing that we are not fully or passively shaped by our environment. My point is that we are not passive blocks of clay but rather active intakers who confront and respond to the cultural environment in ways that are not always predictable. Nevertheless, a shaping influence is always there – that I assume to be true).
In any case, all this means that women did not ‘dislike’ history because they were born with a relational and concrete mind that eschewed ‘facts’, but rather because they were trained and expected to dislike it. Their consequent focus on novels as models of truth cannot have had a negligible effect on the solidification of even more relational, emotionally oriented, perspectives on ‘truth’ and ‘history’.
The article does not address this question directly – when I mentioned above that it facilitated the question, I meant to suggest that I think the article leaves the issue open. It does not unequivocally accept the idea that women are ‘naturally’ anything, and suggests through its wording and use of quotes that it disagrees, at least, with historical judgments of women as aversive to history.
Of course, the very reason for writing this article, as Lepore suggests, is the fact that these boundaries between history/men and novels/women have been blurring. Historiography has begun to tackle ‘alternative’ histories: personal accounts and relationships, the stories of subaltern populations, ‘social history’, ‘family history’, and so on. In other words, it has begun to tread back onto the territory traditionally claimed by novels. What hasn’t changed, according to the article, is the gender divide. Women still make up the bulk of fiction buyers, and men buy the bulk of history. What drives the changes in historiography, then, seems to have little to do with changing gender relations and patterning of thought. Lepore suggests that what is really going on is an emerging rejection of ‘objective’ and ‘neutral’ history altogether – that not only women, but men too, miss the element of storytelling, emotion, and personal accounts that novels provide. Can we conclude that men, perhaps, aren’t so different from women in their patterns of thought at all?
What is interesting to me is that this divide between two kinds of truth came to be drawn along gendered lines as well as literary ones. As Lepore recounts, the history of novels had by the eighteenth century become a women’s history. That realm of histories told through the eyes of individuals and through the stained-glass of affect and motivation, whose truths lie in the plausibility and universality of the experiences they recount, appealed to women’s processes of thought and experience. History, on the other hand, did not interest them – this ‘objective’, ‘neutral’ account of events that became men’s domain. Add to this, of course, the common rejection of novels as fancy and fantasy, the consequent fear of novels’ power to corrupt the minds of young women, and you not only ‘prove’ that men and women think differently, but also that women’s thought is somehow less true than that of men.
This is an incredibly interesting issue, but one I never know what to make of. These theories about gender differences in patterns of thought comes up in (cultural) psychiatry as well. It is invoked to explain gender differences in the prevalence and course of disease (are women more prone to depression or bipolar disorder because they are more sensitive to emotional mood swings?), and sometimes even factors into treatment decisions (as in, it informs the doctor’s goals of treatment. What is considered ‘normal’ affect for a man differs from what is considered ‘normal’ for a woman. An interesting discussion of this is Sara Starks & Joel Braslow’s historical overview of psychiatry in the post WWII-decades. They show that doctors were more likely to perform lobotomies on women because its side-effects interfered a lot less with women’s ideal behavior than with men’s).
No doubt there is some truth to all this – I am willing to accept the idea that women, in general, may tend to think more concretely and relationally than men do. I won’t bring up the critique of overgeneralization here, because as much as that critique should always be kept in mind, this article really does not intend to suggest that all women think in similar ways – and that they are categorically different from men. Nor, I think, do psychiatrists intend to do so (not all of them, anyway). But what I do want to bring up – because I think this article facilitates this question – is the issue of causality, or better said, the question of the chicken and the egg. That is, if these ‘generalizations’ are true, why are they true? What came first? Are women born with different wiring, that then gives rise to different ways of socializing and different domains of cultural activity (as some evolutionary psychologists would argue)? Or do culturally prescribed gender roles and expectations socialize men and women – born with equal potential – to develop their patterns of thought in different ways to match these expectations? Many anthropologists will argue that the impact of socialization is significant: women learn in large part to think more relationally and concretely because as girls they are socialized immediately into caretaking roles. They are taught to view the world and their actions in the terms of their relationships to others (a woman acts not just for herself, but for her children, and her husband), while a man is trained to pursue his own goals.
Even if there were some different wiring at birth – which I think we should not assume at all until it can be in any way ‘proven’ – the second scenario (the constructivist viewpoint) seems to me much more plausible and realistic. We are social beings who are not determined fully by our biology at all. We cannot disregard the incredible shaping force of our cultural environment. (Of course, much of my own work critiques this viewpoint, arguing that we are not fully or passively shaped by our environment. My point is that we are not passive blocks of clay but rather active intakers who confront and respond to the cultural environment in ways that are not always predictable. Nevertheless, a shaping influence is always there – that I assume to be true).
In any case, all this means that women did not ‘dislike’ history because they were born with a relational and concrete mind that eschewed ‘facts’, but rather because they were trained and expected to dislike it. Their consequent focus on novels as models of truth cannot have had a negligible effect on the solidification of even more relational, emotionally oriented, perspectives on ‘truth’ and ‘history’.
The article does not address this question directly – when I mentioned above that it facilitated the question, I meant to suggest that I think the article leaves the issue open. It does not unequivocally accept the idea that women are ‘naturally’ anything, and suggests through its wording and use of quotes that it disagrees, at least, with historical judgments of women as aversive to history.
Of course, the very reason for writing this article, as Lepore suggests, is the fact that these boundaries between history/men and novels/women have been blurring. Historiography has begun to tackle ‘alternative’ histories: personal accounts and relationships, the stories of subaltern populations, ‘social history’, ‘family history’, and so on. In other words, it has begun to tread back onto the territory traditionally claimed by novels. What hasn’t changed, according to the article, is the gender divide. Women still make up the bulk of fiction buyers, and men buy the bulk of history. What drives the changes in historiography, then, seems to have little to do with changing gender relations and patterning of thought. Lepore suggests that what is really going on is an emerging rejection of ‘objective’ and ‘neutral’ history altogether – that not only women, but men too, miss the element of storytelling, emotion, and personal accounts that novels provide. Can we conclude that men, perhaps, aren’t so different from women in their patterns of thought at all?
Friday, March 21, 2008
The Newest Addiction?
Apparently the American Journal of Psychiatry has suggested that text messaging and emailing may be a new form of addiction. Individuals develop a dependency (“it’s like a security blanket. I just feel really bare without it,” one quoted woman says) on ‘online communication’ that takes on addictive qualities, they say: it can be an expensive habit (equipment needed), it can be a destructive habit (not just because it takes time away from actual social interaction, but also because it takes your attention away from other important things, like driving), and, apparently, there are withdrawal symptoms in situations of deprivation.
This is interesting on so many levels. First of all it calls into question the definition of ‘addiction’. Is being ‘addicted’ to email the same phenomenon, neurologically speaking, as being addicted to alcohol? If so, when are you addicted? When you’re dependent on something? When your dependence on this ‘something’ takes on a destructive quality? Do you need to display withdrawal symptoms to prove you’ve been addicted? And is it always something biological? That is, is addiction always about a chemical transformation in your brain? A chemical dependence? If it were provable that a dependence on email and text-messaging has chemical effects on your brain, that would be amazing.
But there are other questions. The article apparently only talks about text messaging and emailing. What about people who spend most of their waking hours talking on the phone? The fact that the article talks only about ‘online communication’ – that is, indirect forms of communication – suggests to me that their pathologization of this ‘addiction’ is at least as much cultural as it may be biological (assuming, and hoping, that the APA will direct research toward the latter question, if they’re going to make statements like this). That is, dependency on email may be less of a biological pathology than a cultural taboo. Because I do think that our cultural standards have not quite caught up with our reality yet.
We seem to be right in the middle of the age of technology and information, leading lives so electronically mediated that it seems only natural that social interaction, too, should be digitized – and leading lives that leave us no time for any other, ‘old-fashioned’ forms of interaction. If I work 90 hours a week, get my entertainment from television and netflix, my music from an iPod and my news from the internet, why not use that same internet to network with other people in similar situations? Yet we refuse to accept these changing circumstances. We hold on to tradition, and face-to-face interactions remain the norm. Despite the fact that so many of us have no time for such networking outside of the work sphere, we stigmatize alternative forms of communication – and apparently, now, pathologize it as well.
We live, once again, with contradictory expectations. If we want to participate in any meaningful way in this fast-paced world – or even if we simply wish to keep up – we need to work: think about the single mother or minimum wage earner who needs to hold three jobs just to survive, the college graduate who is considered unambitious if she doesn’t snag a 90-hour-a-week consulting job in New York, or the woman who will never be taken seriously as a professional if she indicates any intention to have children (and thus, god-forbid, indicates she might be requesting maternity-leave at some point). Our industrial, technological, free-market society requires its citizens to become efficiency-machines.
Yet we value tradition, family, and ‘quality-time’. Time the free market doesn’t afford many of us. If we value face-to-face social interaction and old-fashioned social networks of support like people had 50 years ago, when no-one moved far from home and the economy allowed its working population more free time, that’s great. I applaud it. And if we believe all those studies that suggest physical contact with loved ones boosts our immune system, we have every reason to. But if we do, we need to make it possible. We need to have the time and opportunity to forge social connections. We need to recognize that we can’t have it all.
We can have something very close to it – the structure of social welfare that many North-Western European countries provide for their citizens really is not all that bad. A company CEO will never make as much as he could in the United States, but alternatively, everyone – including him – is assured of basic benefits and a liveable minimum wage, which means everyone can afford to work a little less.
Of course, North-Western Europeans are as ‘addicted’ to text messaging as Americans are…
This is interesting on so many levels. First of all it calls into question the definition of ‘addiction’. Is being ‘addicted’ to email the same phenomenon, neurologically speaking, as being addicted to alcohol? If so, when are you addicted? When you’re dependent on something? When your dependence on this ‘something’ takes on a destructive quality? Do you need to display withdrawal symptoms to prove you’ve been addicted? And is it always something biological? That is, is addiction always about a chemical transformation in your brain? A chemical dependence? If it were provable that a dependence on email and text-messaging has chemical effects on your brain, that would be amazing.
But there are other questions. The article apparently only talks about text messaging and emailing. What about people who spend most of their waking hours talking on the phone? The fact that the article talks only about ‘online communication’ – that is, indirect forms of communication – suggests to me that their pathologization of this ‘addiction’ is at least as much cultural as it may be biological (assuming, and hoping, that the APA will direct research toward the latter question, if they’re going to make statements like this). That is, dependency on email may be less of a biological pathology than a cultural taboo. Because I do think that our cultural standards have not quite caught up with our reality yet.
We seem to be right in the middle of the age of technology and information, leading lives so electronically mediated that it seems only natural that social interaction, too, should be digitized – and leading lives that leave us no time for any other, ‘old-fashioned’ forms of interaction. If I work 90 hours a week, get my entertainment from television and netflix, my music from an iPod and my news from the internet, why not use that same internet to network with other people in similar situations? Yet we refuse to accept these changing circumstances. We hold on to tradition, and face-to-face interactions remain the norm. Despite the fact that so many of us have no time for such networking outside of the work sphere, we stigmatize alternative forms of communication – and apparently, now, pathologize it as well.
We live, once again, with contradictory expectations. If we want to participate in any meaningful way in this fast-paced world – or even if we simply wish to keep up – we need to work: think about the single mother or minimum wage earner who needs to hold three jobs just to survive, the college graduate who is considered unambitious if she doesn’t snag a 90-hour-a-week consulting job in New York, or the woman who will never be taken seriously as a professional if she indicates any intention to have children (and thus, god-forbid, indicates she might be requesting maternity-leave at some point). Our industrial, technological, free-market society requires its citizens to become efficiency-machines.
Yet we value tradition, family, and ‘quality-time’. Time the free market doesn’t afford many of us. If we value face-to-face social interaction and old-fashioned social networks of support like people had 50 years ago, when no-one moved far from home and the economy allowed its working population more free time, that’s great. I applaud it. And if we believe all those studies that suggest physical contact with loved ones boosts our immune system, we have every reason to. But if we do, we need to make it possible. We need to have the time and opportunity to forge social connections. We need to recognize that we can’t have it all.
We can have something very close to it – the structure of social welfare that many North-Western European countries provide for their citizens really is not all that bad. A company CEO will never make as much as he could in the United States, but alternatively, everyone – including him – is assured of basic benefits and a liveable minimum wage, which means everyone can afford to work a little less.
Of course, North-Western Europeans are as ‘addicted’ to text messaging as Americans are…
Tuesday, March 11, 2008
More Testosterone, from Ira Glass This Time
This week’s episode of This American Life was about testosterone. It had no direct relevance for anything psychiatry or anthropology, but it was fascinating, and tied in to the recent publications about the role of testosterone in the onset of depression. In a number of different stories, the program explored people who lost testosterone or who had started taking supplements to boost their levels, and discussed what happened – implicitly trying to get at the question of its link to gender, and ultimately of what it means to be a man or a woman. In a third story, all staff of the show decided to test their testosterone levels to see what personality traits it correlated with. The actual results were a small part of the story – much more central were the people's expectations, fears, and finally reactions. Where the first two stories had suggested that what makes us ‘act’ is more about biology than about ourselves, the emphasis this last story put on participants’ reactions to the correlation between hormone and traits returned to the more culturally constructed aspects of what makes a gender. Ultimately, of course, the test results did not match expectations whatsoever. This ultimately left the question about the real impact of testosterone unanswered. Having it does not make you a man, just as not having it does not make you effeminate.
Exploring the impact of hormones on our behaviors and drives brought up questions about the relationship between mind and body in a very acute way. Testosterone is a hormone that we often associate (I think) with unconscious sexual drives. Yet here, in these stories, its impact on personality became acutely visible. A man who temporarily stopped producing testosterone due to a medical issue saw the totality of his interests and ambitions vanish. A woman who took testosterone supplements in preparation for a sex change operation suddenly, miraculously, began to understand physics (this in itself is a fascinating question… what does this suggest about our fanatic attempts to defend women by arguing that what makes women less adept at the hard sciences is not an issue of innate ability but rather the impact of cultural expectations?). If these hormones have such a profound effect on our dreams, our thoughts, and our cognition, what does this say about the nature – and location – of our personality?
The general message about testosterone's effect seems to be that it fosters a sense of boldness. As Ira Glass said, it incites desire. Not just sexual lust, but desire overall. It makes you jealous, it makes you competitive, it makes you predatory, ambitious, and prone to take more risks. This ‘desire’ was the most acutely felt loss by the man who lost his testosterone. He described his state of being as a complete lack of interest and desire, and his outlook as “the most literal interpretation of the world ever.” He appreciated the world’s beauty in an unprecedented way, he told the listener, but with a complete and utter detachment from it. The ideal form of objectivity and neutrality, I thought. The kind anthropologists strove for until they decided around the 1960s that it didn’t exist.
… Maybe all it takes is a little less testosterone? Then again, who would want to be completely objective and detached? How could you make any decisions, or choices, if the world around you didn’t elicit some kind of emotional response? Wouldn’t it be an empty kind of life if nothing ever really touched you? Even the man without testosterone decided the life of detachment was no kind of existence…
In any case, these thoughts make me re-think the recent findings of the role of testosterone in depression. If lower testosterone really is involved in depression, its link to desire becomes really interesting. I immediately think about the woman who came into the outpatient psychiatric clinic this week, and who described her depression as a complete inability to make decisions. Or about Andrew Solomon, who included a similar sense of complete emotional lethargy in the phenomenology of his depression (The Noonday Demon, 2001). If depression involves a lack of desire, and desire is linked to testosterone, would hormone supplements be a useful form of therapy?
… But it’s probably not that easy… nothing involving mental illness ever is… and just think about the side effects…
Exploring the impact of hormones on our behaviors and drives brought up questions about the relationship between mind and body in a very acute way. Testosterone is a hormone that we often associate (I think) with unconscious sexual drives. Yet here, in these stories, its impact on personality became acutely visible. A man who temporarily stopped producing testosterone due to a medical issue saw the totality of his interests and ambitions vanish. A woman who took testosterone supplements in preparation for a sex change operation suddenly, miraculously, began to understand physics (this in itself is a fascinating question… what does this suggest about our fanatic attempts to defend women by arguing that what makes women less adept at the hard sciences is not an issue of innate ability but rather the impact of cultural expectations?). If these hormones have such a profound effect on our dreams, our thoughts, and our cognition, what does this say about the nature – and location – of our personality?
The general message about testosterone's effect seems to be that it fosters a sense of boldness. As Ira Glass said, it incites desire. Not just sexual lust, but desire overall. It makes you jealous, it makes you competitive, it makes you predatory, ambitious, and prone to take more risks. This ‘desire’ was the most acutely felt loss by the man who lost his testosterone. He described his state of being as a complete lack of interest and desire, and his outlook as “the most literal interpretation of the world ever.” He appreciated the world’s beauty in an unprecedented way, he told the listener, but with a complete and utter detachment from it. The ideal form of objectivity and neutrality, I thought. The kind anthropologists strove for until they decided around the 1960s that it didn’t exist.
… Maybe all it takes is a little less testosterone? Then again, who would want to be completely objective and detached? How could you make any decisions, or choices, if the world around you didn’t elicit some kind of emotional response? Wouldn’t it be an empty kind of life if nothing ever really touched you? Even the man without testosterone decided the life of detachment was no kind of existence…
In any case, these thoughts make me re-think the recent findings of the role of testosterone in depression. If lower testosterone really is involved in depression, its link to desire becomes really interesting. I immediately think about the woman who came into the outpatient psychiatric clinic this week, and who described her depression as a complete inability to make decisions. Or about Andrew Solomon, who included a similar sense of complete emotional lethargy in the phenomenology of his depression (The Noonday Demon, 2001). If depression involves a lack of desire, and desire is linked to testosterone, would hormone supplements be a useful form of therapy?
… But it’s probably not that easy… nothing involving mental illness ever is… and just think about the side effects…
Saturday, March 8, 2008
Gendered Madness?
Speaking of gender and madness/psychiatry, look at this article ("Mad, Bad, and Sad: A History of Women and the Mind Doctors from 1800 to the Present by Lisa Appignanesi"). It’s a book review – on a book about the historical association of madness with women. “The evidence as to whether women really do suffer from mental illness more than men is unclear, though it seems that today, at least, more women than men seek help at the sad end of the spectrum. It may be that society more often defines disordered men as bad, sending them to prison rather than to hospital. In other cases, men may self-medicate with alcohol and avoid diagnosis.” There’s a clear suggestion here that our standards of what constitutes ‘madness’ is different between genders. Which in turn suggests that psychiatric knowledge is not objective, but informed by cultural and social influences. Which of course is precisely what I as an anthropologist am interested in.
Indeed, the book (according to the article) traces the relationship between ‘fashion’ and psychiatric diagnoses. “Mental illness is much less static than physical disease; it is protean in its external expression and culturally infectious, so that once a particular diagnosis catches on, whether it’s hysteria in the 19th century, or multiple-personality disorder in the late 20th, the number of sufferers balloons. Illnesses also reflect society at large: the Victorian neurasthenic unable to rise from her sofa was symbolically enacting the limited life opportunities for women. Today’s epidemic of eating disorders reflects the media’s obsession with body image, though Appignanesi also suggests, worryingly, that feminism may have made an unwitting contribution by overemphasising the female body in its attacks on the beauty industry.” In other words: what we consider madness depends on what we consider normal and desirable human behavior at any given point in time.
The financial times published a reaction to the recent news that many antidepressants may be ineffective ("The End of 'Normal' Sadness"). The main point made here is that depression may be over-diagnosed in the first place: feelings of sadness or worthlessness and loss of appetite are symptoms of depression, but can also constitute very normal occasional reactions to the “vagaries of life.” The DSM has limited our view of human experience. The article goes so far as to say that the fact that drugs don’t work may be because many people are put on drugs while they don’t actually *have* depression.
Whether or not this is plausible I don’t know, but such a statement sort of presumes that there is a ‘real’ depression that exists somewhere organically, on which medication has an effect. If you don’t have the disease, the medication does nothing but provide some kind of placebo effect. What? This is in no way proven and seems like kind of a big assumption to base any argument on.
Indeed, the book (according to the article) traces the relationship between ‘fashion’ and psychiatric diagnoses. “Mental illness is much less static than physical disease; it is protean in its external expression and culturally infectious, so that once a particular diagnosis catches on, whether it’s hysteria in the 19th century, or multiple-personality disorder in the late 20th, the number of sufferers balloons. Illnesses also reflect society at large: the Victorian neurasthenic unable to rise from her sofa was symbolically enacting the limited life opportunities for women. Today’s epidemic of eating disorders reflects the media’s obsession with body image, though Appignanesi also suggests, worryingly, that feminism may have made an unwitting contribution by overemphasising the female body in its attacks on the beauty industry.” In other words: what we consider madness depends on what we consider normal and desirable human behavior at any given point in time.
The financial times published a reaction to the recent news that many antidepressants may be ineffective ("The End of 'Normal' Sadness"). The main point made here is that depression may be over-diagnosed in the first place: feelings of sadness or worthlessness and loss of appetite are symptoms of depression, but can also constitute very normal occasional reactions to the “vagaries of life.” The DSM has limited our view of human experience. The article goes so far as to say that the fact that drugs don’t work may be because many people are put on drugs while they don’t actually *have* depression.
Whether or not this is plausible I don’t know, but such a statement sort of presumes that there is a ‘real’ depression that exists somewhere organically, on which medication has an effect. If you don’t have the disease, the medication does nothing but provide some kind of placebo effect. What? This is in no way proven and seems like kind of a big assumption to base any argument on.
Monday, March 3, 2008
Testosterone and Depression
The Times of India published an article today ("Depression, male sex hormone linked") about a study that found lower testosterone levels in men to correlate with higher levels of depression. I wish these articles would include more information about how these studies were conducted, because there is nothing whatsoever to evaluate with such a brief sound-byte of information. The article assumes that the study has elucidated a causal link between testosterone and depression, because it suggests that testosterone may therefore be used in treating depression among men (and I think, what about women?). However, this assumption completely glosses over the more important questions about methodology, reliability, and validity: Did the researchers even study the nature of the link between testosterone and depression, or did they just see some kind of correlation? How would you even study the exact nature of the link, without some kind of elaborate research program where you took men, controlled their entire social and economic environment, and then lowered their testosterone to see if it led to depression?
For all we know the link may be completely circumstantial - there could be a million social or economic factors that may relate to both lower testosterone and depression, without the two being causally related at all. Of course this question is valid for any kind of study - especially for something as complex as psychiatric illness, there's just no way of definitively determining if a certain biological factor is directly causative of mental illness, or if it may be causative of certain socio-economic conditions that in turn may be involved in mental illness. Or perhaps a socio-economic factor is to blame for the biological phenomenon as well as the psychiatric illness. Alternatively, of course, there's the likelihood that both biological conditions and socio-economic factors are involved in the onset of psychiatric disorders.
And what about an inverse causal relationship? What if the psychiatric illness - or the psychiatric medications one takes to manage it - are the cause behind the biological issue?
The point: these things are difficult, if not impossible, to determine definitively, and that caveat needs to be included in articles like these.
And something else isn't sitting well. The whole idea of linking testosterone back to depression sort of tastes like easy theories about the gender discrepancy in the incidence of depression. 'Findings' like these reported here only help to solidify the idea that there is something inherently 'female' about depression - that the higher incidence relates not to the particular stressors that women may face (keep in mind that women are also more likely than men to be poor, single parents, and bear other burdens that often entail a lower socio-economic status) but to something in our biology - something that makes us 'weaker', of course... A man with less testosterone is less of a man, and apparently thereby more prone to depression.
But of course, any study that points to a biological factor involved in mental illness is likely to get a lot more attention than some discussion about the complexity of mental illness...
A study like the one reported in Science Daily ("Gene Variants May Increase Risk of Anxiety Disorders") is a much better example, and actually describes its methodology in some detail. Of course the audience for this source is much more scientifically oriented than the readers of Times of India, so maybe I should cut the latter a bit of slack. But still, without some kind of explanation you only mislead your audience about what these studies mean, and aren't newspapers supposed to inform and educate? To some extent, at least?
The following makes me feel hopeful about a career in psychiatry: In a discussion about what restrictions on the amount of hours residents can work have done for patient care and the medical profession, an article states about psychiatry: "In contrast to the experiences of many surgical and some primary care and pediatric subspecialty programs, for many decades psychiatric training programs have rarely if ever required residents to work 80 or more per week. The major impact of work-hour regulation in psychiatry has resulted from the continuous on-site duty rule that limits residents to 24 consecutive hours of patient care with up to an additional 6 hours available to participate in didactics and to transfer care of patients, and from the requirement that residents have at least 10 hours off between shifts." Medicine seems like a fraternity world sometimes. The main critics of restrictions to 'duty-hours' seem to be the older generation who had no such restrictions when they went through residency, and labor under the philosophy that 'if I went through it, you have to suffer through it' - sounds a lot like hazing to me... How will you ever make progress with a mindset like that?
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