Elliott B. Martin Jr, MD

“Dude,” the medical student said with an informal millennial drawl, “do you even like psychiatry?”

He stared at the books that line my office shelves. Mixed among the Freuds (both Sigmund and Anna), the Jaspers, and the textbooks are any number of works by Foucault, Laing, and Szasz. Between my 

. I have a number of books on philosophy, history, and scientology. This particular student finally picked up the nearly extinct first American edition of 

I, Pierre Rivière, having slaughtered my mother, my sister, and my brother…

“Dude, why?” he asked semi-innocently.

“OK,” I said to him. “I’ll let you in on the dirty, little, ill-kept secret of psychiatry.”

He leaned in and I, looking shiftily left then right, confessed in a stage whisper, “Psychiatrists have an inferiority complex.”

Psychiatry–and do not let its more blustery practitioners kid you–is a pseudo-science. A fact that makes some neuroscientists, historians, sociologists, and generations of Freud-haters dance almost gleefully. A fact that makes some practitioners in the field tomato-faced and defensive. I never quite understood why. Frankly, this uncertainty–and the impossibility of certainty–is the reason I went into the field. In fact, I would counter that most of medicine today at best remains pseudo-scientific, relying on an ‘evidence-base’ that changes on a near-daily basis

, and is easily manipulated by any number of industries. At worst, it is dogmatic–think Al Capone, “It’s right because I say it’s right”–and this makes for far more potential danger.

But more to the point, I would wager that more than half of the patients in any given general hospital at any given time are there for vague somatic symptoms with no known medical illness. Or, if there is a medical issue, it is not one that would typically require acute stabilization. Instead, the issues are either directly related to, or exacerbated by, underlying psychiatric issues.

The bottom line is that pseudo-scientific psychiatric treatments are no less effective than any scientific treatments in medicine.

But–especially in these end of days–there are many psychiatrists who do so desperately wish to be neuroscientists. They do so want to be “real” doctors. They call themselves 

 establish departments of neuropsychiatry, and even hide behind journals titled 

. They want to point to an MRI with confidence and say, “See. There. We have isolated the source of your self-loathing to the right frontal cortex. A simple excision, and you’ll be fine.”

Witness the current bandwagon of interventional and neuromodulatory psychiatry.

 The parade includes the tried and true ECT along with the shinier, newer transcranial magnetic stimulation, side by side with the rebranding of the old deep brain stimulation, psychosurgical ablations, vagal nerve stimulation, IVIG, and ketamine infusions. All of which are potentially well and good, if not nearly as miraculous as once hoped or advertised, except that these techniques mislead both patient and psychiatrist away from the heart of the patients’ problems. That is, they lead once again toward neurology and away from psychiatry, ignoring the inconvenient fact that what ties psychiatry and neurology together is that neither field can offer lasting cures.

Perhaps better put, like every other American specialty, what psychiatry wants more than anything is corporate respectability. Case in point: The National Institute for Mental Health has inaugurated a multi-billion dollar enterprise called the “

 There is a complicated website, well-disguised in untranslatable jargon, in an effort to subsume psychiatry under neurology.

No real definition of the project is provided anywhere on the website. As of this writing, the best I can find is a description of their framework. In their words, at least as of this writing, it is a matrix, or matrices, I suppose, that “represent specified functional constructs… characterized in aggregate by the genes, molecules, circuits, etc (sic) used to measure it. Constructs are in turn grouped into higher-level domains of functioning.” These domains are as follows: negative valence systems, positive valence systems, cognitive systems, systems for social processes, and arousal/regulatory systems.

This model was proposed just before the founder of this enterprise abruptly up and took off for the artificially greener pastures of Silicon Valley. Initially accepting a job offer from Google Life Science (now Verily), he has since hightailed it yet again, to a start-up ominously called Mindstrong. There he designs mental health apps

, an endeavor now boosted by the ethically questionable volunteering of his time as mental health czar of California.

The founder’s personal peregrinating issues aside, billions of dollars have now been devoted in these recent years to exploring what amounts to various euphemisms: molecular psychiatry, genetic psychiatry, translational psychiatry, all subheadings of the grander movement toward so-called biologic psychiatry.

What is the grander motive? (Or, perhaps more appropriately, what was the motive, as the guru has since jumped ship.) Whatever the tense, the answer remains: potential procedural dollars on par with other specialties. Never mind that for all the investment not a single meaningful new treatment has emerged, and never mind that few have suggested at least some of that money be diverted toward social or educational or vocational programs for the severely and chronically mentally ill, programs that have a proven track record of efficacy; the bureaucratic foundation has been laid. Another inquisitorial framework is in place, and Lord help the poor shrink who points out the obvious: that psychopathology, at bottom, remains a social disease.

“Embrace it!” I cry from my lonesome perch here in the wilds of suburban Boston.

The fact that psychiatry is so openly out there as a pseudoscience is the beauty of psychiatry.

Psychiatry, at this moment anyway, remains blood-test and imaging-free. It offers the last frontier of semi-free thought to the thinking person who wishes to enter medicine, to try to understand people, to try to understand really what makes people sick, to understand their need or desire to be sick. Hence my eclectic collection of books, and my ongoing admonition to my students–those who actually wish to understand their patients better–to continue to read as widely and broadly as they can.

Psychiatry is also, it should be noted, the only specialty with a political and social movement specifically directed against it. The so-called anti-psychiatry movement

 was initiated and has been maintained over the years, for the most part, by none other than psychiatrists themselves, with healthy assists, of course, from the legal trade, Hollywood intellectual heavyweights, and the ludicrously well-funded scientologists. How cool is that?

And, well, that at least makes me feel, however ineffectually, somewhat like a resistance fighter.

For one thing, where would all the hopeless cases go? Because believe me, there is no clamor from the other side to subsume psychiatry.

Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

1. Little M. Book Reviews: Miriam Solomon, Making Medical Knowledge, Oxford University Press, 2015. 

https://kiej.georgetown.edu/miriam-solomon-making-medical-knowledge-oxford-university-press-2015/

2. Ioaniddis JPA. How Many Contemporary Medical Practices Are Worse Than Doing Nothing or Doing Less? 

https://www.mayoclinicproceedings.org/article/S0025-6196(13)00403-5/fulltext

3. Dubovsky S. How Well Do Psychiatric Treatments Work? 

https://www.jwatch.org/na34660/2014/05/21/how-well-do-psychiatric-treatments-work

4. Mass General Neuroscience. Massachusetts General Hospital. Accessed September 17, 2020.

5. Williams NR, Taylor JJ, Kerns S, Short EB, et al. Interventional Psychiatry: Why Now? 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4221242/

6. Research Domain Criteria (RDoC). National Institute of Mental Health. Accessed September 17, 2020. 

https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml

7. Rogers A. Star Neuroscientist Tom Insel Leaves the Google-Spawned Verily… For a Startup? 

https://www.wired.com/2017/05/star-neuroscientist-tom-insel-leaves-google-spawned-verily-startup/

8. Sheridan K. California names former Google scientist as the state’s ‘mental health czar.’ 

https://www.statnews.com/2019/05/22/tom-insel-california-mental-health-czar/

9. Horwitz A. Social Constructions of Mental Illness. In: Harold Kincaid, ed. 

The Oxford Handbook of Philosophy of Social Science

. Oxford, Oxford University Press; 2012. 

https://www.oxfordhandbooks.com/view/10.1093/oxfordhb/9780195392753.001.0001/oxfordhb-9780195392753-e-23

10. Desai N. Antipsychiatry: Meeting the Challenge. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921130/

Articles

Dr Martin shares psychiatry's "dirty, little, ill-kept secret..." 

Is It Time to Do Away With Psychiatry?

“You guys must be twiddling your thumbs these days, huh?” This was the ill-informed question posed to me by one of our outpatient primary care doctors moonlighting as a hospitalist in this “all-hands-on-deck” time of ours. I looked at him and only laughed.

During the early stages of COVID-19 in my state of Massachusetts, we experienced frequent emergency department referrals of brief psychosis related to severe anxiety in the context of what was then 

 Now that we are in a full-blown surge, the 2 most striking pathologies we are seeing on the medical side are a much greater volume than usual of refractory delirium, both in COVID-19 and patients without-COVID-19, punctuated by less common but puzzling cases of persistent encephalopathy seemingly related to COVID-19 infection.

The biggest challenge we have faced thus far has been the requests for assistance in managing persistent delirium. These have increased about three-fold and continue to rise. The requests have been split roughly in half between patients with COVID-19 and those without COVID-19, mirroring where we are at this point with regard to inpatient populations, with actually only about a quarter having been intubated at some point in the ICU. Almost all the patients are older than 75, and about three-quarters are male. About three-quarters have pre-existing cognitive decline. About a quarter are non-native English speakers. Many have required significantly higher doses of antipsychotic medications than are typically prescribed. Most have required augmenting agents such as anti-epilepsy drugs, benzodiazepines, barbiturates, dexmedetomidine, opiates, and/or ketamine.

The question, of course, is why are these cases so refractory? Never in my experience have we had to resort to such trial and error, and really for the safety of the patients and staff, as many patients have been unwittingly violent.

We have collected the following contributors to this phenomenon:

1The hospital has not been allowing any visitors. There have been no family or other social supports at the bedside on a consistent basis to orient and reorient patients appropriately.

2Staff are required to wear masks at all times. On the medical and surgical floors, most are wearing much more, including all manner of goggles, face shields, and surgical caps. In other words, every person these patients see looks like something out of a science fiction movie. There are no faces to read and no way to gain a sense of the situation.

3There is no touch. I never noticed how much I touch older patients until now. We all catch ourselves as we instinctively reach to touch a shoulder, to hold a hand, to press someone back down gently into bed. None of this happens any more.

The lack of technological experience in the older population has made communication between patients and their spouses, siblings, and peers difficult. Many family members with whom we have spoken do not have smartphones or computers. This has also made applications for Medicaid and other assistance exceedingly slow and difficult to arrange.

Closure of the courts impacts care. Court closures have delayed cases of guardianship, thereby lengthening duration of hospital stays.

The language barrier complicates matters.Obviously, language issues make the experience that much more isolating.

Staff fatigue and burnout are evident. Both are playing a role in care, as there seems to be little patience for agitation and confusion. The immediate requests for assistance are invariably for sedating medications.

Bottlenecking on discharge continues to be a problem. With the COVID-19 crisis, there have been very few available skilled nursing facilities and long-term care facilities for patients. This also results in much longer hospital stays.

Persistent encephalopathy, although much less common than the delirium, has been more difficult to explain and thus far unresponsive to all attempted treatments. The 5 cases we have seen were aptly described by an ICU team as “different than the typical different we have been seeing.” (This piece explores the 2 earliest cases, but all cases have been similar.) In the 2 earliest cases, the patients were admitted for COVID-19 infection with subsequent complications. One patient was female in her late 50s, and the other was male in his early 60s. Both patients had significant psychiatric histories with previous psychotic symptoms and had been on longstanding chronic antipsychotic medications. The patients were both intubated during their respective hospital courses—3 days for our female patient and 3 weeks for our male patient—and both required tracheostomy due to complications. Both had type 2 diabetes, hypertension, and chronic obstructive pulmonary disease, and both were smokers. They both had been living in skilled nursing facilities and had previous strokes. The patients had remote substance use history, having used alcohol and cannabis. At baseline, prior to their hospitalizations, both had been fully cognizant and conversant as well as fully ambulatory with only minimal motor deficits.

The differences in their behavior were noted soon after extubation. As their pulmonary function improved and organs generally recovered, they remained mentally altered, mostly staring off and non-interactive. The patients appeared conscious and awake, but they would not eat or drink on their own nor would they respond to any commands. Their pupils were sluggish but reactive, but their eyes could not track. They had intermittent episodes of rigidity, mostly in their upper extremities and neck. The differential included stroke, status epilepticus, catatonia, hypoactive delirium, and neuroleptic malignant syndrome (their antipsychotic medications had been discontinued abruptly in the setting of treatment with hydroxychloroquine and azithromycin due to risk of QTc prolongation). Inflammatory markers were persistently elevated, consistent with COVID-19 infection as well as neuroleptic malignant syndrome. Vital signs were unremarkable.

Stroke and seizure were ruled out. Further infectious causes were ruled out. Metabolic causes were ruled out. Antipsychotics were held, and empiric treatment with lorazepam and bromocriptine were initiated. Some improvement was noted in rigidity, but nothing else. Gradual reintroduction of antipsychotics had no effect. Inflammatory markers stabilized, but there was no improvement in mental status. Both patients are still with us, but they are vegetative, on total parenteral nutrition, now total care, and are awaiting long-term care placement.

At this point the differential includes anoxic brain injury due to complicated intubation, chronic delirium, or direct neurotoxic effect of the COVID-19 virus on the brain. There are 

case reports, but presently these cases remain a mystery.

Other issues with which the psychiatry consultation-liaison service is contending are the management of acute substance withdrawals in critically ill patients with COVID-19 (often mimicking symptoms of the illness itself), collaborating with our palliative care colleagues in determining the futility of care, and the management and placement of patients who are psychiatrically decompensated and COVID-19-positive (but asymptomatic) for whom there are very few placement options.

We are not exactly twiddling our thumbs. In my particular hospital, we have been working inspiringly, tirelessly, and exceedingly well together throughout this crisis.

director of medical psychiatry, Newton-Wellesley Hospital, Newton, MA, and clinical assistant professor of psychiatry at Tufts University School of Medicine, Boston.

1. Martin Jr EB. Brief psychotic disorder triggered by fear of coronavirus? Psychiatric Times. May 8, 2020; Epub ahead of print. 

https://www.psychiatrictimes.com/coronavirus/brief-psychotic-disorder-triggered-fear-coronavirus-small-case-series

2. McNamara D. Neurologic symptoms and COVID-19: what’s known, what isn’t. The Hospitalist. April 6, 2020. Accessed August 10, 2020. 

https://www.the-hospitalist.org/hospitalist/article/220289/coronavirus-updates/neurologic-symptoms-and-covid-19-whats-known-what

3. Wu Y, Xu X, Chen Z, et al. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun. March 30, 2020; Epub ahead of print. ❒

The biggest challenge we have faced thus far has been a three-fold rise in requests for assistance in managing persistent delirium. Needless to say, we are not twiddling our thumbs.

Delirium, Encephalopathy, and COVID-19: An Update From the Field

Back in July 2015, I wrote an article for 

Managing Ebola: The Archaeology of a Disease

” at the early stages of the burgeoning Ebola outbreak. I quoted Dr Adrian Hill, director of the Jenner Institute on vaccine research at Oxford: “We know there will be more outbreaks . . . Many viruses are lurking, and then there are going to be new viruses.”

 Here we are, only 5 years later, in the face of a pandemic, literally tracing the archaeology of a new disease.

As across the country, COVID-19 has become the primary focus of hospitals in my geographic region (the greater Boston area). At time of this writing, we have not yet been overwhelmed, but cases are growing. The psychological warfare waged by this virus has been overwhelming, both for patients and for health care providers. Patients are afraid of contracting and transmitting the virus. But health care workers, especially those used to a degree of predictability, seem to be susceptible to the stress of uncertainty and loss of control engendered by the COVID-19 pandemic.

Since the declaration of the pandemic, we have had several cases in our emergency department (ED) of what I have referred to as corona psychosis; 3 of which are presented here.

“Dr Smith” is in her 40s; she is a practicing physician and administrator at a medical center. She was brought unwillingly to the ED by her husband. She had no prior documented psychiatric history and no significant medical history. She was almost 2 years out of the postpartum period. She did not drink alcohol or use other psychoactive substances. Her husband learned of staff concerns that she was becoming increasingly irrational and erratic at work, corresponding to the dramatic increase in media coverage of the coronavirus.

Upon psychiatric evaluation, Dr Smith’s speech was pressured and she was paranoid. Despite being asymptomatic, she convinced staff at another hospital to test her for the virus; the test came back negative. Dr Smith then became belligerently mistrustful of “the system,” refusing to believe she did not have the virus. Dr Smith became convinced that not only was she infected, but her family was infected as well. She believed that the Center for Disease Control had specifically targeted her and her family, transmitting the disease surreptitiously by means of drones while they slept.

As a result, Dr Smith had not slept for 3 days. She denied any hallucinations; she maintained good behavioral control throughout the exam, but she clearly was delusional. When asked about her plans, she stated only she “would monitor the situation.” When asked why she returned to work if she believed she was infected, she said, “I have to find the cure.” Although we encouraged her to admit herself to the psychiatric unit, she refused. She responded well to lorazepam in the ED, and her husband, also a medical professional, insisted on taking her home. Dr Smith did not meet criteria for involuntary commitment, and she was discharged.

“Ms Rogers” is a nurse in her mid-40s. Married with teenage children, she had a history of depression and anxiety, as well as some concerns for a possible alcohol use disorder. She had no documented history of psychotic symptoms. She self-presented, complaining of worsening depression since the expanded media coronavirus coverage. Ms Rogers noted she was feeling quite hopeless and suicidal.

Ms Rogers wrote a detailed suicide note to her husband, making it clear that she “was already in the process” of committing suicide. She explained, both in her note and to us, that she had infected herself with coronavirus with the intent of dying. She tested negative for the virus at an outside hospital. When asked how she had infected herself, Ms Rogers explained that she “went 24 hours without washing her hands.” She was not intoxicated, and there was no evidence of withdrawal.

Although she was convinced that she would die within 2 weeks, Ms Rogers agreed to a voluntary admission to the psychiatric unit. She responded well to low-dose lorazepam in the ED. Her symptoms are currently being treated with a combination of an antipsychotic and an antidepressant medication.

“Ms Greene” presented while still working her shift as a hospital custodian. She was in her 40s, and married with grown children. Ms Greene worked on the hospital housekeeping staff for many years without incident. She had a long history of intermittent anxiety treated well by her primary care physician with minimal use of as-needed alprazolam.

Ms Greene was cleaning a patient’s room on the psychiatric unit when a nurse entered the next room, gowned, gloved, and masked, to perform a routine influenza/RSV swab on a different patient. Upon witnessing this, Ms Greene became convinced that she had contracted coronavirus. She became quite agitated, started pulling at her hair and shouting nonsensically in her native language. She could not be calmed down verbally, and she had to be escorted to the ED by hospital security.

Upon examination, there was no indication that Ms Greene was at increased risk of coronavirus; and she was asymptomatic. Due to Department of Public Health guidelines, therefore, she was not tested for coronavirus. She partially responded to lorazepam, but she remained delusional that she was “infected.” Family members took her home. Ms. Greene has been on medical leave since then.

Although this is a small series of patients from a single community hospital, I anticipate as this crisis unfolds-and as people are more socially isolated-there will be an increase in these brief psychotic reactions. Based on these cases, anxiety (and perhaps depression) may be a contributing factor, the more acute symptoms responding (at least temporarily) well to lorazepam.

What is otherwise striking is the commonality of all 3 patients working in hospitals at the frontline of the current crisis. I am concerned about the toll this crisis is taking on those in the trenches. There have been many subtle signs of stress vulnerability in providers, increasingly outward signs of a more generalized helplessness at the loss of control.

The anxiety is growing more palpable-both for patients and health care professionals-and I would urge everyone involved in these efforts to seek and to provide ongoing support for you and your teammates. As psychiatrists, we need to be attuned to colleagues as this drama unfolds. Like all crises, this too will end, and hopefully, these and other “corona psychosis” cases and anxiety will resolve.

The cases discussed here are composites and not meant to identify any one person. 

This article was originally posted on March 25, 2020, and has since been updated.

 is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

1. Researchers warn G7 leaders on disease preparedness. University of Oxford. June 3, 2015. 

http://www.ox.ac.uk/news/2015-06-03-researchers-warn-g7-leaders-disease-preparedness-0

2. The Authorized G7 Publication. Ebola: global health threats need a global research and development solution. G7: Beyond. 2015.2015:90-91.

Some health care workers have been particulary vulnerable to the stress of uncertainty and loss of control engendered by the COVID-19 pandemic, illustrated by 3 cases presented here.

Brief Psychotic Disorder Triggered by Fear of Coronavirus?

 the focus of much national debate has once again pivoted toward gun control, and the role of mental illness in creating the mass murderer. The arguments have taken a predictably 

 turn, focusing less on understanding why a human being would do such a thing and more on why such acts are not considered acts of domestic terrorism.

Recognizing these murders as “acts of domestic terrorism” may allow for more resources to be allocated to subsequent investigations but will contribute nothing toward our understanding of the mental processes that drive such a killer.

Identifying mass murderers as “disenfranchised white males” only plays into identitarian politics-that is, post WWII, far right ideology-and keeps the discussion skin deep. Branding these acts as “hate crimes” is also woefully inaccurate, unless the “hate” refers to the almost certain self-loathing of the perpetrator. Most mass murder victims are people wholly unknown to the murderer. Unlike crimes of passion, there is almost certainly no personal animosity between a mass murderer and his victim. These crimes are more analogous to video games. The killing is more metaphorical than fueled by any particular “hatred.” The murderers are racking up points more than anything, as many as possible before their own (expected) demise.

Stepping back a bit, with a critical and historical eye, mass murder was an anomaly until the 1990s, accelerating tremendously through the early 2000s until now. Weaponry has not really improved much during that span. The logical question is what happened during those years to spur such an increase in violence? Did mental illness explode? One may argue so, I suppose, as the rates of suicide have 

in dramatic step with these homicides during this same period, if in fact suicide is also an end result of purported mental illness.

Again, this would depend on one’s definition of hatred. Generally, people who kill in cold blood are not fueled by hatred of their victims, but more perhaps by self-hatred, or hatred of an ideal.

 Planned, well-executed mass murders cannot really be viewed as crimes of passion. If anything, these are more crimes of ambivalence, with the flesh and blood victim providing the same transient “rush” as the virtual-victim, again, in a video game.

I come back to the video game analogy on purpose. The World Wide Web came into existence in 1991. It gained international traction in 1993, erupting in infinite directions with absolutely no restriction or regulation. And although the “smart”-phone was invented in 1992, “social” media-the most massive collection of pornography, hatred, violence, and vitriol the world has ever known-was unleashed without restraint with the development of the “I”-phone in 2007.

No one had any idea what all this might do to the collective human psyche.

In this context, much effort is being made now to demonize the mass murderer as a product of “white supremacist” “ideology,” somehow considered a “logical” extension of several hundred years of eroding “white privilege.” Of course, this contention, dubious as it is, only works for the “white” mass murderer. It does not account for the roughly 

 committed by non-white people over the past 37 years.

 Frankly, these discussions of white nationalism and the like are red herrings, easy media fodder, and distractions from more profound considerations, in my opinion. Throw in a perpetrator’s supposed “mental illness” and “hate,” and the awkwardly proposed picture, though it may then be condensable to 144 characters or less, is utterly nonsensical.

The historical course of “eroding white privilege” is really the logical progression of the then neoliberal ideals come to fruition during the 18th century, the so-called Age of Enlightenment, culminating in the American and French Revolutions. The grievance with monarchy at the time was, at its core, the middle class, the business class, desire for increasingly liberal economic policies, the desire to “spread the wealth” more from the kings, the government, to the people. This was a gradual process at first, co-occurring with social welfare laws designed to keep this burgeoning “capitalism” from spinning out of control.

Predictably, exploitation became the rule, and resistance to this generally dehumanizing process was stiff. The 19th and 20th centuries were obviously riddled with brutal conflicts over this single principle. The word “terrorist” first emerged during this revolutionary age, used to describe both right- and left-wing political extremists.

With the collapse of the Soviet Union and its satellite communist states in the 1980s, neoliberal capitalism won the day. History ended in 1989, according to some,

 coinciding with the birth of virtual culture. And with this incredibly powerful new tool, really an economic doomsday device, capitalist forces in their most brutal, pure, and exploitative forms were suddenly unleashed without an ounce of forethought.

“Globalization” became the new buzzword. 

 is perhaps more apt. And the corporate state was born. Governments have increasingly shrunk before corporate board rooms in the face of a virtual Leviathan beyond anyone’s control. In the virtual marketplace, humans are merely data points, and there is little regard for anyone’s humanity anymore except in the most superficial of ways (ie, race, ethnicity, gender). Demographic points easily crunched into the algorithms.

The human brain has changed accordingly. Desperately trying to process the 24-7 stimulation of the virtual world, is there really much wonder at the stupendous rise in autism rates over this time period, the steep rise in ADHD, the general fragmentation of personality and identity, and the increase in suicide? There is certainly little wonder at the appeal of intoxicating substances and the lure of a virtual existence over a real one. Frankly, there is little wonder at the inability to consider more deeply than the surface, and the disproportionate passion invested in single issues.

The virtual world is tremendously isolating. It is brutal and unforgiving. German-Korean critic Byung-Chul Han

 the fiction of online “community,” or “multitudes,” characterizing the virtual world as a vicious “swarm” of individuals wrapped up in their own self-righteousness and inability to step out of the present moment, with the vast majority of social media content becoming increasingly nasty and self-serving, characterized by vitriolic snark. He in fact refers to the internet as “the s-storm.”

Just prior to the digital age, moral philosopher Philip Hallie

 wrote extensively on the nature of cruelty, distinguishing between episodic and institutional cruelty. Episodic cruelty is the easy kind, where the victim and perpetrator are both aware an act of cruelty is occurring. Institutional cruelty applies more to one’s daily existence. A debt-credit culture, a skewed judicial culture, an unfair contract culture. A bureaucratic culture epitomized early in 

 come to full fruition in the era of Big Data.

The question may well also be inverted as to why such acceleration in suicide? The superficial profile of the suicide and homicide is essentially the same: the “disenfranchised white male.”

The answer probably lies within the tremendous self-loathing at the heart of the otherwise impotent virtual psyche. The “swarm” is a virtual id with no constraining cyber-superego. It needs victims. The easiest, safest, and fully sanctioned target at this point, is the now faceless and colorless, so-called “white male”-by now come to represent everything the swarm hates about itself. And the cyber-realm is the perfect stage for projective identification. The victimizer is victimized to the point that he honors the unconscious fantasy of his perceived tormenters. And he does so at times with the drama the swarm demands.

None of this, of course, allows for any meaningful discussion. Politics, on all sides, has degenerated into such profound immaturity and snark, in embarrassing efforts to appease the swarm, that who would dare offer or entertain contrary opinions? Look at psychiatry’s own historical tendency to blow with the political winds, intensifying as well as in recent years, in the face at times of mountains of contrary evidence that cannot be acknowledged over concerns for digital retaliation.

Disconnecting from the storm, and encouraging our patients to detach from the fray, is the first logical step.

Editor's note: The views expressed in this article are those of the author and do not necessarily reflect the opinions of 

is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

https://www.gunviolencearchive.org/reports/mass-shooting

2. Center for Disease Control. Suicide rates rising across the U.S. 

https://www.cdc.gov/media/releases/2018/p0607-suicide-prevention.html

The Myth of Martyrdom: What Really Drives Suicide Bombers, Rampage Shooters, and Other Self-Destructive Killers.

4. Follman M, Aronsen G, Pan D. US Mass Shootings, 1982-2019: Data From Mother Jones’ Investigation. 

https://www.motherjones.com/politics/2012/12/mass-shootings-mother-jones-full-data

5. Francis Fukuyama, The End of History and the Last Man, The Free Press, New York, 2006.

7. Hallie P. From cruelty to goodness. In: Sommers C, Sommers F, Editors. Vice and Virtue in Everyday Life. San Diego: Harcourt College Publishers; 1989: 9-24.

8. Reiner S. Death by Data: How Kafka’s The Trial Prefigured the Nightmare of the Modern Surveillance State. 

https://www.newstatesman.com/2014/01/death-data-how-kafkas-trial-prefigured-nightmare-modern-surveillance-state

Recognizing violent incidents as “acts of domestic terrorism” contribute nothing toward our understanding of the mental processes that drive such behavior. More in this commentary.

Mass Murder in the Digital Age

Two cases illustrate the dilemma of the duty to warn. The intricacies of Tarasoff involve so many variables, from state to state, scenario to scenario, case to case. How does one practice good clinical judgment? Following this piece, James L. Knoll IV, MD, provides a forensic analysis, in 

Psychiatric Malpractice Grand Rounds: The Tarasoff Dilemma

I would like to present for consideration and discussion two personal stories in which the so-called Tarasoff Rule, or the “duty to warn” a threatened third party, was invoked. One was arguably appropriate; the other, arguably not. In my experience, invoking Tarasoff remains quite contentious, and even legal specialists are often indecisive. For patient confidentiality, details in the cases presented have been changed.

When I was an intern, we had a young man committed to us for attacking his mother, and for continuing to threaten her. This was especially problematic in that he lived with her, had no intention of living without her, and his mother was firmly set on his continuing to live with her. We held him for weeks, into months. He had several forensic evaluations along the way.

At first resistant, he eventually agreed to take medication. He learned “to say all the right things,” such that the forensic specialist assigned to his case agreed with the judge in the case that there were no longer grounds to hold him against his will. I, and others who had worked closely with him, did not agree, and so the Tarasoff rule was invoked.

I sat down face-to-face with the young man’s mother. I discussed at length with her that the patient would have to be discharged, and the reasons why. I explained as concretely as I could that although he had previously repeatedly made physical and homicidal threats toward her, he recently had been taking medication with superficial improvement such that a judge, as well as a specialist in criminal mental health, had advised us that we could no longer hold him against his will. She acknowledged all this with tears in her eyes and stoic resignation on her face. She absolutely understood what I was telling her, but she made it quite clear that she would welcome him back home regardless.

Two days later, he was arrested for stabbing his mother several times in the face. She survived the attack. He was eventually committed to a state forensics facility.

When I was a fellow at a major pediatric hospital, we had a very disturbed young man who had been sent to us by his outpatient therapist after he had revealed to her several notebooks detailing the many gruesome ways he was planning on eviscerating and alternatively torturing and taking apart piece by piece a particular older boy at his high school. The notebooks were filled, front to back, with minute, bizarre scribblings, macabre poems, as well as several hand-drawn pictures of a mutilated young man in various stages of deconstruction and decomposition. Here and there were very large printed words, “DIE! DIE!” followed by the intended victim’s name.

The victim was a student in the same school, two years older. He reportedly had no idea this younger boy, whose eroto-manic delusions had utterly gotten the best of him, felt this way about him. The patient’s target was captain of the football team, a major player on the debate team, highly ranked in his class, of a well-known and popular local family, and apparently destined for great things, not least of which was having the most popular girls in school hanging off both arms.

This younger boy was not popular. He was homely and overweight, suffered from psoriasis and acne, and was withdrawn and isolative. He had few, if any friends. His parents had put him in therapy for what they saw as depression related to his sexual orientation. It was clear over the weeks we had him in the hospital, however, that his depression was complicated by significant delusional thinking. He believed he in fact had had some sort of relationship with this other boy.

These delusions, in fact, were so intense, that our patient initially believed the older boy impregnated him. More importantly, and frighteningly, he believed he had been most grievously wronged by this boy. We never did learn what this great insult was. But, in lieu of his love/hate-object, he made frequent threats against his perceived unborn baby. He was determined to make “the father” pay for the perceived transgression.

By all accounts otherwise, the older boy had no idea this younger boy even existed. Again, we kept the patient as long as we legally could. He did seem to improve with the combination of medication and “milieu therapy.” Eventually we had no reason to keep him. His parents wanted him home; he wanted to go home. He was different than the young man in the first case, in that no one really believed he would now actually harm anyone. He seemed to have developed some insight, and he eagerly approached therapy. He had been in the hospital nearly three months.

My supervisors, in consultation with the hospital’s legal team, debated long and hard over whether Tarasoff needed to be invoked in this situation. It was illuminating to learn just how gray this area is. The legal team was mostly noncommittal. But eventually, and at the hapless trainee’s (namely, my) expense, my clinical supervisors came to view this opportunity to invoke Tarasoff as a “teaching moment.”

I notified the local police where this boy lived. I notified, with parents’ permission, the school administration. (The parents did not want their son to transfer to another school-our first, most insistent, and best recommendation.) And then I had to call the older boy’s parents.

“Yes, hi. My name is Dr Martin, and I’m calling from the hospital. You don’t know me, but I’m calling about your son.”

“Oh, my goodness, what about him? Is he okay?”

“Oh, yes. And I do apologize. He’s not here. In the hospital, I mean. In fact, I’ve never met him.”

“Mrs Smith, I am required by law to inform you that we have a patient here who will be discharged tomorrow, and this patient has made repeated homicidal threats toward your son.”

“No, no, Mrs Smith. I work on the psychiatric unit here at the hospital, and we have been working with this patient for months now. It is our opinion that this patient is no longer dangerous, but we are required by law to inform you of the threats made earlier to your son.”

“Who is this person?” I could hear the panic.

“What do you mean, you ‘can’t tell me that’?!”

“I apologize, Mrs Smith, and I know this is awkward-”

“No, no, no, no. You call me out of the blue, tell me you’re from a hospital, and then tell me you’re about to release a patient who has made threats to kill our son?! And worse, you tell me you cannot let me know who this person is!”

“You’ve got a lot of nerve, Doctor. Do you know who my husband is?”

“Ma’am, I once again apologize; and believe me, if it were up to me, we wouldn’t be having this conversation, but-”

 you! How dare you call me like this! I’m calling our attorney right now! What did you say your name is?! We are going to find out who this psychopath is, and we are going to be sure this nutcase is not allowed anywhere near the school!”

“I have already notified the local police.”

“So they know the name of this psycho.” (I believe this was a statement).

“I’m going to call Bob right now. And 

, Doctor so-and-so, believe me, you haven’t heard the last of this.”

That, in fact, was the last I heard of her, and honestly, I totally saw her point.

In the emergency department setting, we mostly turf cases in which there is a question of invoking Tarasoff. In other words, we commit patients to the hospital and let the inpatient folks deal with it. We work under a (creative) assumption that by doing so, we absolve ourselves of the duty to warn.

But again, I’ve never gotten a straight answer on that one either.

Dr Martin is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.

The author reports no conflicts of interest concerning the subject matter of this article.

The author presents for consideration and discussion two personal stories in which the so-called Tarasoff Rule, or the “duty to warn” a threatened third party, was invoked. One was arguably appropriate; the other, arguably not.

To Invoke or Not to Invoke: Tarasoff Is the Question

There has been a lot of talk about reforming medical education. Reading through the American Medical Association’s “

” proposals to reform both medical school and graduate medical education, “innovation” certainly remains the buzzword of the day.

 Ironically, this seems to reflect more of an old-fashioned “keeping up with the times” mentality, with a general premise of breaking away from perceived dogma. As to specifically what these “times” are that seem to be passing the rest of us by, and what has become problematically dogmatic in training, I admit I have been unable to locate in any of the proposals other than the broader, “timely” rubric of change for change’s sake.

Granted, the “times” have spun violently out of control over the past 20 years: witness the digitization and corporatization of medicine. The training process itself, for physicians, has remained relatively unchanged. And it is almost certainly the growing disconnect between the end of medical school and the start of residency that is driving the movement to reform training now. The old “medical” world is now the “health care” world, with many different hands in the pot. And whereas physician training remains conservatively geared toward creating “good doctors,” administrative training is often diametrically opposed to this.

Proposals for changing physician training, especially as more corporate entities tinker under the health care hood, rather than suggest administrators broaden their own education more humanistically, focus on aligning physician training more with corporate goals. That is, replacing the time-worn critical-dialectical process with the informatic-algorithm. Less art, more “science”; less wisdom, more analytics.

In these algorithmic times, then, how is it that we can broaden and make medical education more fulfilling? Currently the clinical training-an experiential mix of bedside lecture, bedside quizzing, and bedside suffering-can be demoralizing, dehumanizing, and humiliating. It can also be inspiring and uplifting. It is a training highly dependent on trust and chance, on both teamwork and individual decision-making. “It could always be worse,” is the telling mantra, and mistakes are not tolerated. In other words, clinical training resists what makes the informatic-algorithm work best: standardization.

And this illustrates the critical difference between medical school and post-graduate training. The greater appeal of medical school today, and especially the pre-medical path, is almost certainly that it offers a rigidly disciplined structure against a tide of otherwise increasingly fragmented and unfocused learning options, especially through adolescence and young adulthood. This phase of training does lend itself well to standardization, at a time in training when it is absolutely necessary.

Residency, on the other hand, is all about the art of mastering chaos. Only worse. Doing so while suddenly crushed with soul-numbing debt, while suddenly scaling impossible learning curves and juggling major teaching responsibilities. It is about mastering the pretense of knowing everything while rapidly absorbing new technological and administrative requirements. All the while studying for licensure exams, applying for fellowships, starting families. All the while negotiating the gauntlet of abuse and bullying from seniors, attendings, nurses, administrators, patients, families.

We used to half joke in residency that this generally “miserable way of being” had evolved as a means of helping one learn about suffering through suffering. Many of my previously jovial colleagues, however, soon found themselves subsisting on the increasingly standard pharmacologic stew of stimulants, “benzoes,” and antidepressants. 

 Learned helplessness, PTSD, and the victim mentality are ubiquitous, and one may justly wonder whether “education” is even really the right word.

Our ability to speak freely regardless of role, training, or experience is one element that allows psychiatrists to discuss their fears and limits as clinicians.

Author | Elliott B. Martin Jr, MD

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