Testing the Unconscious

Freud called dreams the "royal road to the unconscious," but the authors of the Implicit Association Test seem to claim an ability to measure "implicit cognition" (Is that a euphemism for unconscious?) by using a computer administered psychological instrument.

This approach was previously reported to uncover racial bias in the practice of medicine: http://www.ama-assn.org/amednews/2009/09/28/prsa0928.htm, but according to an article in a recent issue of Psychiatric News a variation of the test appeared to predict suicide risk more accurately than by traditional means such as psychiatric interview. I took one of the tests myself. The result was not what I would have expected. Did the test err, or do I simply not know or acknowledge my true attitudes? I suppose the authors might claim the result proves that my attitude is unconscious, but as far as I know no method of tapping the unconscious exists that might provide researchers with a way to validate the results of such a test, except perhaps by looking at my subsequent behavior.

The notion of a test of unconscious intent (Isn't that a contradiction in terms?) sends me on flights of fantasy. I imagine requiring psychiatric patients to undergo testing on a mobile device every 24 hours with results transmitted to a central clearinghouse. If the patient starts to lean toward suicide, the men in white coats home in on their GPS signal, pick them up, and hospitalize them until their attitudes right themselves, with or without treatment. Of course one would have to pass the test before purchasing a firearm, or razor blades, or matches. Or before being allowed to pilot an airplane or drive a car, or cross a street, or climb higher than the first floor of a building. Could we detect future suicide bombers?

Why limit the use of this technology to prediction of suicide, or to psychiatric patients? If such a test could detect intent to rob, rape or kill, to engage in insider trading, run a red light or shoplift, we could require everyone to take it and virtually eliminate crime. Maybe, rather than requiring formal testing, analysis of patterns of Internet use such as Web sites searched or visited could allow, for example, determination of how one might intend to vote in an election. Could such information be used to subtly influence attitude, intent or even religious belief by channeling selected stories through news sites and other media, or even what happens to you when you play World of Warcraft? And since it's all unconscious, how would you know? The possibilities for abuse approach infinity.

Somebody please make a movie!

You can take the tests yourself at: https://implicit.harvard.edu/implicit/, provided you can reign in your paranoia.

How Psychiatry Works

An admittedly oversimplified illustration of how psychiatry works:

Scenario One

You have been suffering from loss of energy and motivation for a month or so, so you visit your primary care physician. She orders a blood test and finds that your thyroid stimulating hormone (TSH) is high. She diagnoses hypothyroidism as the most likely cause of your symptoms, rules out more serious disorders with more tests, and prescribes thyroid replacement drugs. After you start taking them you get better. She recommends that you continue taking them indefinitely.

Scenario two

What doctors call the history of present illness is the same as in Scenario One, but this time when the doctor finds that all your blood tests were normal, she tells you she cannot find a physical illness that might explain your symptoms, diagnoses some kind of depression (i.e. it's all in your head) and refers you to me, the psychiatrist.

You have become a medical leftover. Specifically treatable physical illnesses do not explain your symptoms, so in many cases the only physician who will take care you is a psychiatrist. But not to worry: Psychiatrists generally like talking to people, are fascinated by mental and emotional problems, and like helping people like you solve them. In the past you might have been locked up in an asylum or referred for psychoanalysis, but today, fortunately, we have specific forms of psychotherapy that can treat mental disorders, and we have a host of drugs that for most people are relatively safe and effective, somtimes miraculously so.

Diagnosis

After collecting lots of information about your history and your symptoms I will probably have some vague idea of your diagnosis. Given all the recent controversy about DSM V you might think this is a critical step. In fact it is somewhat important. I don't want to treat someone with schizophrenia for panic disorder or someone with social phobia for bipolar disorder, but I usually make a mental jump to the most important phase which is to choose a treatment that is most likely to help you with minimal adverse effects and minimal delay. Another nice thing about many of the drugs we have today is that, for example, antidepressants, at least most of them, often work very well for anxiety as well. That makes it less critical to determine whether you suffer from, for example, dysthymic disorder, or generalized anxiety disorder. If I prescribe paroxetine and you come back two weeks later to tell me that you feel all better, who cares how we categorize your problem? (It may be important to rule out bipolar disorder since evidence suggests many drugs with antidepressant effects can exacerbate the condition.)

Over-diagnosis

Many people that get diagnosed with bipolar disorder or attention deficit disorder may have never had either. A researcher or two publish data suggesting that we have missed a few cases, and everybody jumps on the bandwagon trying to make sure they never miss the disorder. Often we overshoot the mark and apply the diagnosis inappropriately. What's wrong with that? Delay in getting the right treatment for the right problem and exposure to adverse effects of the wrong treatment. There can be other fallout from simply having the wrong label as well. For example, if a psychiatrist evaluates your child, and you tell her that Uncle Harry has bipolar disorder, this may influence how the psychiatrist diagnoses your child. So if Uncle Harry really did not have bipolar disorder, your child may get the wrong treatment.

Under-diagnosis

Missing diagnosis can cause problems too. Once more we can have delay in appropriate treatment. But when I tell a patient I don't believe they really suffer from a mental disorder, I can add that we can monitor the symptoms over time with a plan to reassess if they worsen.

Getting It Just Right

We would like to be able to do this all the time, but it just is not possible. When I hear psychiatrists talk about patients as suffering from this or that disorder as though they are absolutely certain of the diagnosis it always makes me wonder. To me, especially if the patient has not responded very well to treatment, and even sometimes when they have, I tend to think of the diagnosis as what we call a working diagnosis. This is a provisional diagnosis we assume to be correct until proven otherwise, often by treatment failure. If I get too confident or locked in to a particular diagnosis there is a risk of barking too far up the wrong tree, usually trying treatment after treatment, all doomed to failure. Better to keep an open mind.

Drugs

You may feel like a guinea pig, but really you're the director auditioning drugs instead of actors. If we get it right with the first one that's terrific, but often patients have to try several medications before finding one that works and has acceptable side effects. Everyone seems to respond differently. Be warned though: You could keep trying different psychiatric drugs and combinations for years and never find one that makes the grade. At some point you may want to figure the solution is not in the (pill) bottle. If you haven't tried it already, consider psychotherapy. For more serious problems ECT and other biological treatments can work wonders.

Once you find a drug that works you have to decide how long to continue it. Some psychiatric drugs can prevent recurrence of your illness. You wouldn't stop oral contraceptives just because you didn't get pregnant. Many patients benefit from lifelong preventive or maintenance treatment, like for the hypothyroidism in Scenario One.

Ask your psychiatrist what to expect in the way of risk of dependence on medications and risk of adverse effects and whether there are ways to manage those risks. Sometimes additional drugs help control side effects of the primary drug. Be sure to keep the psychiatrist apprised of all other medications, conditions, symptoms, and side effects. And make sure the psychiatrist knows if you are disappointed in the effectiveness of the treatment.

Psychotherapy

It works, but not necessarily for your illness. For example, there seems to be no method of psychotherapy that treats schizophrenia, bipolar disorder, or ADHD, and certainly not Alzheimer's. But psychotherapy can help you and your family cope with any of them. Some kinds of psychotherapy actually effectively treat disorders like generalized anxiety disorder and panic disorder. Your psychiatrist may or may not provide psychotherapy. If she does, make sure it's the kind of psychotherapy that best treats your condition. If she doesn't insist that the two professionals communicate about your treatment.

Ask your psychotherapist what to expect, particularly how long the treatment lasts, how it works, and whether family members can be involved. Some kinds of psychotherapy can go on so long you can't tell whether the treatment or tincture of time got you better. Be sure to make the psychotherapist aware of any disappointment in the treatment. And if you don't like your psychotherapist, tell them so. A good one won't hold it against you, and will want to address it as just another interesting problem to work toward solving together.

Disappointment and Failure

If none of the above has produced acceptable results, ask for a consultation or second opinion, or just look for a different psychiatrist or psychotherapist. Most of us want you to get better, even if someone else gets to take some credit. And if you do get better, give yourself most of the credit.

Psychological Testing and Firearm Permits

The article, “An Empirical Survey of Psychological Testing and the Use of the Term Psychological: Turf Battles or Clinical Necessity?” (Dattilio, Frank M.; Tresco, Katy E.; Siegel, Alex Professional Psychology: Research and Practice. 2007 Dec Vol 38(6) 682-689) includes the apparently erroneous statement:

“Most states in the United States will only issue a permit to carry a firearm to individuals who undergo psychological testing by a licensed psychologist and are approved.”

When I asked Dr. Datillio via email to cite a statute supporting this statement, he provided only a Pennsylvania statute requiring the applicant to undergo such an evaluation in order to obtain a permit to carry a concealed handgun for (non law enforcement) work. According to the National Rifle Association 48 states issue permits for concealed carry of handguns to ordinary citizens, and none of them requires psychological evaluation. An Internet search appeared to confirm this. Official documents, including statutes, application forms, and other listings of requirements of 35 states revealed not a single one requiring psychological evaluation. Almost all the states in some way restrict issuance of permits, purchase or possession of firearms for individuals with a putative history of substance use disorder or other mental illness.

The laws of at least two states provide for restoration of the right to be issued a concealed carry permit after it has been revoked. The state of Massachusetts allows a physician (not a psychologist) to restore the right of permit. The permit may be restored when the individual

“(ii) has been confined to any hospital or institution for mental illness, unless the applicant submits with his application an affidavit of a registered physician attesting that such physician is familiar with the applicant’s mental illness and that in such physician’s opinion the applicant is not disabled by such an illness in a manner that should prevent such applicant from possessing a firearm;
“(iii) is or has been under treatment for or confinement for drug addiction or habitual drunkenness, unless such applicant is deemed to be cured of such condition by a licensed physician, and such applicant may make application for such license after the expiration of five years from the date of such confinement or treatment and upon presentment of an affidavit issued by such physician stating that such physician knows the applicant’s history of treatment and that in such physician’s opinion the applicant is deemed cured;…”

The state of Mississippi allows a psychiatrist (not a psychologist) to restore the right of permit when the individual

“Has not been voluntarily or involuntarily committed to a mental institution or mental health treatment facility unless he possesses a certificate from a psychiatrist licensed in this state that he has not suffered from disability for a period of five (5) years;…”

In no state’s materials was there any basis for concluding that evaluation by a psychologist might suffice. But even the two laws quoted above presume the physician or psychiatrist is qualified to make this determination in the absence of generally accepted criteria and with assumption of considerable liability for a bad outcome.