“Listening to Prozac” and What People Really Want

I was in my specialty training when I read Peter D.Kramer’s “Listening to Prozac.”

I remember thinking he was articulate and observant and all kinds of wonderful things, riding the cusp of a great change in psychiatry, doubting him to be a “real” scientist who would hang out at a meeting of the Society for Biological Psychiatry as I once did.

I was wondering what to do with the result of his observation that certain character traits, such as “rejection sensitivity,” could be somehow changed for the better with psycho-pharmacology.

Somewhere between that naive time of my life and deciding that no allegedly scientific data about biological psychiatry should be examined without a thorough knowledge of who paid for (and who performed) the research, I remember a woman coming into my private office in San Diego asking if I could prescribe her adolescent offspring some Ritalin to raise his SAT scores.

I tried to hold my temper, thinking I would like to keep her as a patient despite her obvious lack of ethics or judgment.  How else could I have gotten through her entreaties?  Her argument ended with “Other psychiatrists do that kind of thing,” or something of that nature.  I did manage to repress my outrage until after she had left my office.  I went on to express it, as I do all too often, to my loving husband – who was my office manager.

I believe one of the great ways to reach insight is to ask “what is missing” or “what is lost” when anger — or even just a feeling of discomfort — hits.  When you have worked hard to learn things, playing abstract thought like the “can you find the seven differences between these two pictures” — games that were always beneath the crosswords when people regularly did such things in printed newspapers — well, it just makes sense.

In both examples, the diagnosis is missing.

A diagnosis does not exist where there is no illness, where a person who wants treatment does not appear “sick.”

I mean in general, normalcy has been defined by medicine as simply the absence of pathology — the absence of disease.

Of course, in the wonderful world of psychoanalysis from which Peter D. Kramer came, it has always seemed to me as if everybody had some neurosis somewhere and a dedicated analyst could find some in, for example, a happily flowering tree.

There is a really deep question here that may be central to the fabric of society.

If it is helpful to make sick people well, might it not be even more helpful to make normal people supra-normal? Webster’s Unabridged Dictionary defines this as, “transcending the normal: greater than expected or usual. ”

Is it right or wrong, licit or illicit, and who gets to decide?

This question has been the unspoken undercurrent since Kramer presented his views of psycho-pharmacology in “Listening to Prozac.”  Sometimes science can travel as much — or more — with observation than it can with structured (granted) research.

How about the world which America seems to value even more than SAT scores?  How about the doping of athletes?

I have the vague memory, somewhere in prep school or college, trying to read about male behavior.

I fully realized that my brother was physiologically and psychologically abnormal, thus the source of little generalizable information.

My motivation was simply that I had the normal physiological interest in men, but no understanding, from my brief exposure at mixers, of why they acted as they did.  I read the work of a few feminist psychologists.  I probably fail to honor them by failing to remember their names.

What I do remember was what I learned about men.

There is — and experience has confirmed that there is — a certain ethos, a certain culture of men, that male-dominated worlds such as athletics and the military exemplify most clearly to the female observer.

The ideal is, quite simply, to perform as much pleasure-enhancing and otherwise self-serving behavior as possible without getting caught.

I remember being surprised that this was so primitive a behavior that I could observe my brother.

Harry — My Brother-Of-Blessed-Memory — would cheer when a pro football player did something blatantly against the rules, seen by the television camera but missed by the official in the black and white striped shirt.  The commentators resonated with him on this sort of thing, frequently asking such piercing questions as “Do you think they are going to throw down a flag on that one,” which Harry quickly obliged me by explaining that it meant, “Are they going to see a rule was broken and dish out a penalty?”

Much of my dealing as a U.S. Army psychiatrist dealt with adolescents who had thought themselves clever enough to smuggle alcohol or some other contraband into the barracks, or sometimes even more simply, to cavort after the “lights out.”

I certainly found no such behavior to be “clever” or “funny” enough to cite an example here, but such values were brilliantly portrayed to the (safe at home in their living rooms) public by Phil Silvers as Sgt. Bilko.

The easiest way to be a millionaire is to have a nickel for every time a man, when asked why he cheated on his wife, answers “because I could.”

The boyish affirmation of covert power against an overtly-restrictive system is, I am convinced, somehow central to male identity.

This may or may not have something to do with the fact that I don’t much care about it –and the people in the “cosmetic psychopharmacology” movement that has followed Kramer are all males.

Anjan Chatterjee, in a much cited article, calls it “cosmetic neurology,” but has brilliantly identified the causes, nature, and risks of this movement that is as real as that woman patient who came into my office wanting ritalin for her unseen son, but never discussed, ever, by any clinical practitioner known to me (or Chatterjee).

(NOTE: this link opens to a PDF file, which can be read with the free Adobe Acrobat reader.  In some web browsers it will give you a “save file” prompt, to be downloaded and read later.)

Just as steroids could indeed help athletes succeed more dramatically in physical tasks, drugs with a neurological or psychiatric intent could make people stronger or more coordinated or happier or smarter.

The advantage is to the individual and clearly not to the species.  With current level of knowledge, it seems unlikely anybody’s DNA is going to change from this one.

Drugs are generally not without risk.  I mean, I doubt insurance would pay for this thing.  This might be where the notion of “informed consent,” which seems to have faded into some kind of a too-generic computer document, gets reawakened into something dynamic that at least makes an attempt to approach Truth.

To his credit, Chatterjee sees the social problems.  The shadows of coercion loom here.  How much money would a parent pay to get a kid a drug that may send him to a “better” college?  How much would you pay to fly on an airline whose pilots were taking drugs that had been shown to increase their ability to function effectively in emergencies?

What would you do if your boss offered you a substantial raise to take a drug ( the presence of which in your body would be almost certainly verified by urinalysis) that would increase work productivity?

Does this fit into the American ideal of life, liberty, and the pursuit of happiness?  Maybe, maybe not.

I am concerned about going with what I now see as a typical American response to a problem; making rules.  So far, this has made lawyers rich very effectively.  But it seems to actually perpetuate that strange male ethos of football penalties and Sgt. Bilko.  Still, the opposite — running amok with drugs that can give people “advantages” in life sounds scary to me, too.

I can muse about what it would be like without rules.  For example, there is  a very strong part of me — I am convinced now it is a very female part — that believes if we suddenly removed all of the rules about ethics and doping from an athletic competition, if that would not be the best impetus to spur research to improve human athletic performance?  A sort of cheaters competition — an analogy to something I have heard of but never seen, “cheaters poker.”  Of course there is a personal risk to taking, say, steroids for athletic competition.  I for one, never quite understood why so many males would take something that screwed up male sexual performance so thoroughly.

Perhaps some of the drive is that strange male value. Maybe those adolescents who seem at least superficially interested in the “challenge” of getting caught actually need that challenge.

Oy!

I have been “grand-mothered in” to lifetime board certification in psychiatry, and any other intellectual accomplishments I might call my own.  No interest in performance enhancement here.

As for developments in the human body, I think robotics is the way to fly.  I can easily see substitutes for pro football, roller derby, and yes, the military.

And I fervently PRAY for these violent and harmful things are taken over from humans.  Root, Root Root For The Robots!