A. James Giannini, MD

"Is that all there is?" may not be a question limited to recovering psychiatric patients. It is one that can be asked by any person, including those who do not meet diagnostic standards. Many psychiatrists tend to limit the application of their skills to those whose discomfort matches the phenomenological criteria of 

It is the mission of this profession to render assistance to any who seek relief from emotional illness. This noble mission, however, does not currently apply to people who seek only subjective perfection. These are people who, while not experiencing a psychiatric disorder, wish to minimize the emotional discomforts of everyday life, reducing any minute impairment in their work life, love life or play life. It is therefore valid to ask: Can psychiatry transcend the concept of "objective cure" and include "subjective perfection" as a goal? Is there a logical reason why the concept of "treatment pills" cannot coexist with that of "lifestyle pills" on the psychiatric prescription pad? Cannot there be both "cosmetic" as well as "reconstructive" psychiatry? Does one need a disease in order to be treated? 

and other official disease catalogues, the psychiatric profession achieves mastery of its domain. It defines disease and then limits treatment to those who have disease: the patients. But the D-word can be applied and withdrawn at will. Homosexuality can be a disease or not, depending on the votes. Premenstrual syndrome can be accorded or denied disease status or relabeled "L2D2." Nicotine use can mutate from non-disease status to a dependency to an addiction. The scarlet D can or cannot be bestowed. But if it is not bestowed, one cannot be defined as "patient." Without the proper definition, no treatment is available.

All diagnostic categories, even the "V" codes (for other conditions that may be a focus of clinical attention) require a disease or problem state. The sick can be cured and made well; there is no room for the well who have no disease or problem, but merely wish to pursue their subjective definition of perfection. This definition may be particular to the individual, and it may even be peculiar. However, if it requires the psychiatrist to do no harm, then individuals should be able to expect professional guidance in pursuing their self-defined ideal state of being.

This pursuit, however, is blocked by a wasteland of introjected ideology and professional inertia. The operational medical protocol encompasses diagnosis, prognosis and treatment. As such, it may be a quantum jump to practice in the absence of diagnosis and prognosis and then proceed immediately to treatment. What HMO will authorize treatment for a wish that is neither Axis I disease nor a V code problem? Indeed, how does a psychiatrist justify prescriptions for people who have unfulfilled ambitions, not diseases? How does the psychiatrist fill in the "diagnosis" line on mail-in prescription forms? For the strictly disease-oriented psychiatrist, it may be difficult to prescribe a medication without a 

-recognized indication or "minority school of thought" for support.

Well people seeking subjective perfection are discouraged by physicians wielding the persuasive powers of diagnostic definition--no diagnosis or label, no prescription, no pills. Acceptance of the label redefines the "well" as the "unwell."

By such transformative redefinition, the well are not seeking cosmetic change; rather, the sick are asking for cure. Now defined as "patients" who are ill, they can receive prescription medication. Well people are now diagnosed as "dependent," "addictive" or the all-encompassing "personality disorder not otherwise specified." Ideology is served. Choices can now be made on the basis of social coercion, not individual choice (Foot, 2002). Who, indeed, is to be master?

Cosmetic psychiatry may raise fears of a brave new world with a "pill for every ill." Yet, Huxley (1958) in his review of the drug-oriented society, 

, worried not about the use, but the overuse, of psychoactive drugs. It was the need for equipoise that drew his concern. Western philosophy does not allow emotions to be erased; the physical, intellectual and spiritual worlds exist to be "experienced." It is also a post-Enlightenment axiom that the full range of human emotion is the birthright of all. This birthright, however, is not always accepted. Physicians routinely mask the "experiences" of pain, insomnia, nausea and motion sickness. In addition, physical cosmetic pharmaceutical agents such as tretinoin (Retin-A), minoxidil (Rogaine) and α-hydroxy acid are used daily by well patients wishing only to blur the effects of aging by cosmetic physical pharmacology.

It is the use and not the abuse of psychotropic medication that forms the framework of cosmetic psychiatry. Cosmetic use is conceptualized as an adaptive, nonabusive approach to life. This is in contrast to the nonadaptive, abusing retreat of addiction. Cosmetic psychiatry can enhance but not distort memory and perception, increase performance but not create introversion, and establish conditions for an overall sense of enjoyment and fulfillment.

Many nonaddictive, relatively safe medications are available for the well person seeking subjective perfection. In some cases it is the side effect that provides the desired enhancement.

Propranolol (Inderal), an antihypertensive, has short-lived anxiolytic effects and can be cosmetically prescribed for people who do not meet criteria for an anxiety disorder but must, nevertheless, occasionally function in emotionally charged situations (Kohnen and Oswald, 1988). Overscheduled students could likewise benefit from the short-lived energy boosts and diminished sleep requirements associated with the early phase of bupropion (Wellbutrin) usage (PDR Drug Guide for Mental Health Professionals, 2002). Moderate weight reduction can be achieved with sertraline (Zoloft) in euthymic patients without amphetamine-like effects (PDR Drug Guide for Mental Health Professionals, 2002). End-of-workday ennui can respond to the γ-aminobutyric acid (GABA)-ergic effects of kava kava (

) without the intoxication of an evening nightcap (Singh, 1992). 

(The U.S. Food and Drug Administration advised consumers of the potential risk of severe liver injury associated with the use of kava-containing dietary supplements in 2002--Ed.)

A feeling of overall well-being, not quite realized in daily pursuit of the mundane, can sometimes be produced with St. John's wort (

) without addiction in people without depression (Hoffman and Kuhl, 1979). Bupropion can increase libido, while fluoxetine (Prozac) can decrease this drive depending on the requirements of the well person's lifestyle. Overstressed workers can "come down" with valerian (

), experiencing enhanced mood and diminished anxiety (Kohnen and Oswald, 1988).

Well people can use these substances with or without the guidance of psychiatrists. If this guidance is withheld, the users of these medications may be exposed to the dangers of side effects and misuse. It has been reported that self-prescribing individuals without guidance are less likely to follow directions and report greater toxic effects (Beckman et al., 2000; Chan et al., 1995). Our knowledge of psychopharmacology can be properly employed to achieve the greatest possible benefit. It is our responsibility to use that knowledge when harm is not done and well-being is enhanced (Glazer et al., 2001).

It may be further argued that acceptance of the concept of cosmetic psychiatry can also encourage recreational drug use. This argument, however, ignores the current availability of cosmetic psychotropics. Valerian and kava kava can be purchased in commercially bottled teas or tea bags. These botanicals, as well as St. John's wort, can also be purchased without prescription in capsule form at the neighborhood pharmacy or mall-based health food store. The public is ready for these agents. One need not embrace the libertarian agenda to accept that, in a free society, adults are capable of making informed decisions regarding their emotional status (Bentham, 1996). Psychiatry can respond to the legitimate needs and expectations of the public or be shunted aside. We can appropriately administer these medications to well people or allow such use to proceed without our guidance (Giannini and Giannini, 2000).

 Beckman SE, Sommi RM, Switzer J (2000), Consumer use of St. John's wort: a survey of effectiveness, safety, and tolerability. Pharmacotherapy 20(5):568-574.
 

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Articles

Many psychiatrists limit the application of their skills to individuals whose discomfort matches the phenomenological criteria of DSM-IV-TR. Can psychiatry transcend the concept of "objective cure" and include "subjective perfection" as a goal? Is there a logical reason why the concept of "treatment pills" cannot coexist with that of "lifestyle pills" on the psychiatric prescription pad? Dr. Giannini reflects on whether there can be both "cosmetic" as well as "reconstructive" psychiatry and if a disease is needed in order to be treated.

The Case for Cosmetic Psychiatry: Treatment Without Diagnosis

Lewis Carroll's Alice, like many psychiatric patients, could walk through either side of the looking glass without ill effect. She was able to experience both internal and external reality without using one as a defense against the other. Many adolescent and young adult patients can inhabit similar secret worlds in fantasy, spending parts of their lives in non-delusional bolt-holes wherein they may hide and grow. While they seldom have difficulty skipping across the twin planes of fantasy and reality, they--much like Alice--lack the ability to transport adults into their worlds (Giannini, 1991).

Similar to the kingdoms on the other side of the looking glass, adolescent fantasy worlds are an imperfect reflection of external reality. Their universes are entities unique to their creators, reflecting internal and external struggles as well as triumphs. Each such universe has its own terrain, creatures and symbolic language. By exploring and comprehending these universes, the therapist can come to understand the patient-creator. With this understanding, the therapist could then discover the root trauma and modify the results. Unfortunately, the patient-creator can reorder their personal universe at any time. In treating adolescents, this reordering often comes whenever a breakthrough is imminent. The world changes, and the therapist is lost.

Gaining entrance into this world is the first obstacle that a therapist encounters. After breaching the mental wall, the therapist enters a world without fixed reference points or stable terrain. A possible therapeutic approach, then, would be to assist the patient in the shaping of a world with both fixed reference points and an accessible gate by which the therapist might enter and leave.

While a psychiatrist resident at Yale University, I was initially unsuccessful in dealing with the fantasy worlds of young adults. Their personal fears and my inexperience removed me from their internal world. Working with my supervisors, I attempted to develop a premise from which I could access their fantasies. My goal was to explore their world before their defense mechanisms rearranged their internal reality beyond recognition and therapeutic intervention. I was directed to R. D. Laing's approach to schizophrenia as an alternative reality. My patients were not psychotic, but many carried pocket universes of fantasies in which lay buried the symbolic representations of the causes of their conflicts. Unfortunately, the patients were the sole masters of their fantasies; they controlled access and could defensively alter the forms to protect against an intruding therapist.

The defenses were not absolute. The fantastic universes, unlike delusional universes, were self-absorbed but not self-contained. I served my residency in the 1970s, a time of Marshall McLuhan, psychodrama, Lacanian criticism, and "Dungeons and Dragons." Perhaps influenced by this zeitgeist, my supervisors suggested that I adapt a role-playing paradigm to my therapeutic encounters.

Providentially, I discovered the World of Tiers book series by Philip Jos Farmer. This is a science fiction/fantasy collection of multiple private worlds and pocket universes. In the series, all of these worlds and universes were created by "Lords" of either gender. These creations were unique to each Lord and contained different geology and astronomy, flora and fauna, as well as different human and humanoid cultures. The folklore and morals differed in each secret universe. The only constant was the absolute supremacy of the Lord. This supremacy, however, did not bring security. Each universe was accessible via special gates. These gates were under the control of the Lord, but this control was not absolute. Using courtesy or stealth, both guests and intruders could access these entry points: the Lord did not have the capability of closing them. He or she could only employ defensive mechanisms: camouflage, false gates, archetypal beasts, and spatial and temporal booby traps.

In the initial phase of therapy, several withdrawn, non-psychotic patients were asked to read the World of Tiers series. Our therapeutic sessions then gradually shifted from an interpretation of each patient's activities to a discussion of the books' plots and characters. Gradually, connections and identifications developed between these patients and the fictional characters. 

The ever-mutable fantasies and fixtures of the patient's inner world were inexorably translocated to the World of Tiers. Stable fantasies generated stable symbolizations, and the symbolic language through which we communicated finally became comprehensible.

 With this common medium, misunderstanding decreased and mutual trust grew. I had sidestepped the myriad difficulties of dealing with ever-changing symbolic constructs on an unstable terrain. Instead, the patient transferred from their inner world to the World of Tiers, which was equally patient- and therapist-accessible and where symbols and fantasies were immutable. The elements of the inner life were now incapable of being altered whenever interpretations became uncomfortable. Having advanced to this preliminary phase, meaningful therapy could begin.

Because of the large amount of time absorbed by this form of dyadic therapy, I adapted it to group therapy. In group therapy, the content can be far less important than the process. Since each patient related singularly to the same novels, this de-emphasis on content adapted well to the group therapy format. Patients chosen for this group were all voracious readers and enjoyed reading either science fiction or fantasy novels. Trekkies abounded. None of the patients had ever been delusional. All were quite capable of distinguishing between their own fantasies and reality, but most simply preferred to avoid the latter and embrace the former.

Before the initial meeting, each prospective patient agreed to read 

 (Farmer, 1965), the first book of the series. After two weeks, those who had not completed the assignment were dropped from the group. The remaining patients brought their books to the first of our 20 weekly sessions.

 During the first session, I announced that all discussions would be limited to this book. We could discuss plot, author motivation, characters, setting, imagery and any other elements of shared interest. Feelings about self, others, group members and group interaction were absolutely prohibited. After every two sessions, another book in the series would be added. Each book would be subject to discussion in this patient-led format.

As the patients launched into their reading task, the therapeutic sessions gradually shifted in focus. We gradually moved from reporting and interpreting the characters' lives to a discussion of the novels' construction. We first explored these products of another's fantasy world (i.e., the author's), a world that remained fixed, no matter how intensely we scrutinized it. We discussed setting, plots and characters, moving from discussion to interpretation. We next moved to motivation: patients suggested goals and genesis of the characters. Gradually, tenuous identifications developed between group members and the chosen characters. Simultaneously, equally tenuous connections developed between the patients' mutable generated fantasies and the author's fixed, fictional worlds.

The tenuous nature of these links slowly became more solid. As each book was studied, its symbol passed from the world of the imagined into the reality of the group's joint experience. Beginning within the ninth session, the series' concept, rather than the individual books, came under collective scrutiny. The series' concept and character development were initially reviewed in this therapeutic phase. After a few more sessions, however, counterpoints emerged. During discussion of the series, primary issues and process spontaneously intruded into the literary discussions. Over time, themes of self, relationships and process were carried by the medium of literary analysis.

In designing these group interpretive sessions, I thought that, despite prohibitions, patients would move from overt literary discussions to a discussion of their own issues, as well as their interactions with group members. I hypothesized that patients would eventually feel comfortable focusing on their own issues. This, however, was not what occurred.

 Instead, overt interpretations of the books evolved into thinly disguised covert expressions of self, which were instantly apparent to other group members. The critical analyses of each other's interpretations of the series continued to mask self-revelatory comments about other group members, as well as the group process itself. Group issues never superseded literary issues; rather, the former were subsumed by the latter. Group issues were always expressed as book issues.

As the 20-week group ended its work, there was a noticeable decrease in the expression of self-absorption, antisocial behavior and somatic symptoms. This group therapy design was repeated in three subsequent groups with similar positive results. Farmer, inspired by this therapeutic approach, wrote another book in the series, 

, which projected fictionalized group-therapy patients into the World of Tiers (Farmer, 1991).

 The World of Tiers became a metaphor for external reality and a transforming agent for internal fantasy. Patients entered group therapy with their own unique fantasy world. Each such world, however, was in danger of being routinely obliterated and recreated as a defense against probing therapists. Using the books as a symbolic form of communication, a shared, immutable fantasy world was built. Both the language and terrain were fixed while the symbols were held as common property.

 When the therapy groups concluded, the physical books served as transitional objects, assisting the progress of the patients into other, more traditional, forms of therapy. This use of fiction is therefore not considered as a school of therapy, but a tool for psychiatrists who encounter therapeutic resistance in the world of fantasy and illusion (Giannini et al., 1997; Lacan, 1977).

Although the World of Tiers served as fertile terrain, it was by no means the only useful universe. Other worlds could equally serve as performance stages for this inward psychodrama of the mind, as they are also populated with characters drawn in archetypal primary colors that accented the finer shades of the patient's motivation and conflict. A favorite choice of nonreaders was the original "Star Trek" television series. The major and minor personalities who walked the corridors of the Enterprise were easily adapted as surrogates for the hidden aspects of the self. For those patients who were not attracted to science fiction, other books and films were chosen. The Horatio Hornblower series by C. S. Forester and early Clint Eastwood Westerns served a similar purpose. Nevertheless, whatever world was chosen, imaginative fiction was able to transform the inchoate mass of repression and cast it in the form of easily deciphered and apprehensible symbols (Lacan, 1977; Rand, 1975).

I later used fiction in a similar manner within a transcultural context. Working for what was then called the U.S. Information Agency of the U.S. Department of State, I conducted seminars in the Caribbean, Europe and Middle East (Giannini, 1993). Attempting to impart a consistent message to journalists, health care workers and government officials in disparate cultures and languages was a formidable problem. The solution required that the content be delivered as intended, while reducing misinterpretations of intent and eliminating subtle translation errors. To accomplish this, I centered my presentation around universally known fictional works that were emotionally charged but politically neutral. Since these works were universally understood, they successfully served as the sources of symbolic imagery that carried the content of each lecture.

Farmer PJ (1965), The Maker of Universes. New York: Ace Books.
 

 Farmer PJ (1991), Red Orc's Rage. New York: Tor Books.
 

Giannini AJ (1991), Afterword. In: Red Orc's Rage, Farmer PJ. New York: Tor Books, pp278-282.
 

Giannini AJ (1993), Tangential symbols: using visual symbolization to teach pharmacological principles of drug addiction to international audiences. J Clin Pharmacol 33(12):1139-1146.
 

Giannini AJ, Giannini JN, Melemis SM (1997), Visual symbolism as a learning tool: teaching pharmacology to international audiences. J Clin Pharmacol 37(7):559-565.
 

Lacan J (1977), The Four Fundamental Concepts of Psychoanalysis. London: Hogarth Press.
 

Rand A (1975), The Romantic Manifesto: A Philosophy of Literature, 2nd ed. New York: New American Library.

Since adolescent patients often retreat into fantasy worlds of their own making, they can be difficult to treat. Psychotherapists can create a common fantasy world for successful group therapy with the use of popular fiction books, television series and movies.

Author | A. James Giannini, MD

Articles

The Case for Cosmetic Psychiatry: Treatment Without Diagnosis

Use of Fiction in Therapy