Sharon Packer, MD

 (COVID-19) crisis continues, we hear more and more about the current—and projected—mental health fallout from illness, lockdown, job loss, forced relocation, loneliness, loss of friends and family, and death. Data about the direct neuropsychiatric sequelae of COVID-19 infection in addition to the indirect social or economic consequences are also mounting. Yet we do not hear about individuals with social anxiety disorder, or individuals on the high end of autism spectrum disorder (ASD), who are also socially anxious and relieved to be working from home.

Free from the social pressures of the job site, many of these individuals report feeling less distress overall. They are not necessarily free from anxiety altogether; their anxiety focuses on fears of being forced to return to offices when the epidemic ends. They are perturbed by the prospect of sacrificing the social obligation-free sanctuary that they have serendipitously and unexpectedly enjoyed during this strange time.

 taken of a group of workers; it found 80% wanted to continue to work remotely at least part of the time after the pandemic. Individuals with social anxiety disorder presumably comprise some small part of the 80%, yet it is unlikely that all 80% of the WSJ sample want to work remotely for the same reasons as the patients I am discussing. The article, “Is a Home Office Actually More Productive? Some Workers Think So,” detailed the motivations of generic employees, focusing on financial and family drivers of their choice of workplace, but does not break down data by personality type or DSM diagnosis.

Before commenting on experiences relayed to me by the aforementioned subgroup of my patients, let us first look at the better publicized psychiatric fallout from the COVID-19 crisis. Centers for Disease Control and Prevention (CDC) 

 from late June 2020 state that 40% of the American population were facing COVID-related depression, anxiety, stress-related disorders, or substance use.

high-risk groups, noting that financial stressors, including epidemic-related job loss, along with limited savings to cushion the blow, increased an individual’s risk for mental health sequelae.

 about increasing drug and alcohol use are equally grim from a medical and mental health point of view, given that liquor sales skyrocketed during lockdown, as per several articles in the WSJ.

 Anonymous liquor store owners have said that demands for their stock during the epidemic rivals sales seen only during weeks between Christmas and New Year’s.

We can estimate the long-term mental and medical impact of alcohol overuse, even though many medical consequences of alcohol overuse do not surface for 20 years. The potentially lethal cardiovascular, oncological, as well as gastrointestinal consequences are not as obvious or immediate as motor vehicle accident-related deaths or fatal subdural bleeds from slip-and-fall accidents that occur while intoxicated. Yet those later sequelae are just as deadly in the long run, so much so that 

 is twice that of the better-publicized opioid-related mortality,with alcohol claiming over 95,000 lives per year,

 compared with 46,800 annual opioid overdoses.

Opiate overdoses have already exploded. If we extrapolate from data related to September 11, 2001, when 

 in Manhattan remained high long after posttraumatic stress disorder symptoms subsided,

 we can anticipate (but not guarantee) similar consequences from this epidemic.

Alarmist claims about projected increases in suicide hit the press, having borrowed data from CDC websites and embellished it with artistic license not appropriate to scientific studies. Some of the most ominous predictions have been refuted; after reading the fine print, we can see that these highly publicized numbers about suicide pertain to individuals who were contemplating suicide rather than to completed suicides. In response to those data, some British medical journals 

 readers that “supposition, however, is no replacement for evidence,” and that “the literature on the effect of COVID-19 on suicide should be interpreted with caution.”

Although reports of increased suicidal ideation since the start of the COVID-19 crisis were striking enough to enter the CDC logs, we must recall that suicidal ideation is not the same as attempted suicide, and that attempted suicide is not identical to completed suicide.

In addition, a New York City Health Department 

 “Mental Health in New York City: Impact of COVID-19 on Mental Health in New York City,” published in September 2020 and emailed widely in January 2021, offered even more 

 It dissected the data, breaking it down by race and ethnicity, and ferreted even more risk factors for anxiety and depression. It focused on the greater New York area, where most of my patients reside. Similar to the 

data, the 3 top drivers of psychological distress included “feeling cut off or distant from people,” “job loss or reduced hours,” and “overwhelming or above-average financial stress.” Interestingly, many individuals on the spectrum specifically prefer to be “distant from people,” although individuals with pure social anxiety disorder often lament their limitations in partaking in such social activities.

What do these data tell us about the socially phobic individuals who report less stress during the lockdown, but experience more stress when contemplating the possibility of a return to onsite work? Let me point out that although the data showed that 40% of the American population endorsed symptoms of depression, anxiety, or trauma during the shelter-in-place mandates and work-from-home policies, this is not the same as saying that 100% of the population is suffering similarly.

My clinical experience indicates that some individuals are benefiting from limits on social interactions; they prefer the work-at-home policies and appreciate convenient excuses to avoid after-work get-togethers and sit-down holiday dinners.

Admittedly, I cannot offer elegant statistics to rival numbers garnered from formal population-based quantitative studies. All I can share are anecdotal reports gleaned from my large private psychiatric practice, originally based in New York City, but now relocated offsite to upstate New York. Yet those anecdotal reports are impressive. Gainfully employed but socially phobic patients and those on the high end of the autism spectrum (who also tend to be debilitated by social anxiety) are doing better than baseline now that they are freed from the pressures of office politics, enforced personal interactions, and water cooler–style conversations.

In many instances, such individuals experienced an unexpected sense of relief, as well as a sense of accomplishment, after seeing that they could meet their work responsibilities even better without expending extra mental energy ruminating about social interactions, wondering if they said the right thing, and worrying about being forced to speak up in meetings. Having witnessed how much easier their lives can be without the usual social stresses, they identify a different source of anxiety: fear of forced return to the workplace.

Before proceeding, I must point out that the patients to whom I refer are actively and gainfully employed—and so they do not fall into the high-risk categories identified by the 

article. They did not experience the stressors, such as job loss or lack of savings, that predispose individuals to COVID-19–related psychological distress. Because they were working before the pandemic, they likely accrued savings that further buffer them from the financial stressors listed in the 

Recall that socially phobic individuals are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations.

And that is where we as psychiatrists can help. Selective serotonin reuptake inhibitors (SSRIs) and supportive therapy go only so far in ameliorating their symptoms and relieving their distress. Advocating for changing their external environment—while we change their internal environment through psychotropic medications and psychotherapy—can offer them so much more relief.

 accommodations that may allow them to continue to work from home even after the epidemic ends (with some caveats). Familiarizing ourselves with the Department of Labor website (

) will enable us to educate our patients and to direct them to standardized sources without offering legal advice that exceeds our clinical training or purview.

At a time when so many psychiatrists are concerned with climate change and its impact on mental health, should we not also concern ourselves with adapting workplaces to meet the needs of our patients? We can advocate for change, simply by following the laws that are already in place for such purposes.

 is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

1. Stamm S. Is a home office actually more productive? Some workers think so. 

https://www.wsj.com/articles/is-a-home-office-actually-more-productive-some-workers-think-so-11609563632

2. Centers for Disease Control and Prevention. Coronavirus disease 2019. Accessed February 10, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/index.html

3. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. 

4. Chaudhuri S. Coronavirus closed the bars. America stocked the liquor cabinet. 

https://www.wsj.com/articles/coronavirus-closed-the-bars-america-stocked-the-liquor-cabinet-11586511001

5. Jakab S. The WHO are a bunch of party poopers. 

https://www.wsj.com/articles/the-who-are-a-bunch-of-party-poopers-11587046692

6. Chaudhuri S. Online beer sales soar at brewers of Budweiser, Miller Lite. 

https://www.wsj.com/articles/online-beer-sales-drinking-at-home-boosts-budweiser-brewer-11603968729

7. Centers for Disease Control and Prevention. Deaths from excessive alcohol use in the US. Accessed February 15, 2021. 

https://www.cdc.gov/ALCOHOL/FEATURES/EXCESSIVE-ALCOHOL-DEATHS.HTML

8. Centers for Disease Control and Prevention. Drug overdose deaths. Accessed February 15, 2021. 

https://www.cdc.gov/drugoverdose/data/statedeaths.html

9.Packer S. Tele-teatime during the quarantine. 

https://www.psychiatrictimes.com/view/tele-teatime-during-quarantine

Trends in suicide during the covid-19 pandemic

. 2020;371:m4352. doi:10.1136/bmj.m4352.

11. New York City. Mental health in New York City: Impact of COVID-19 on mental health in New York City. September 2020. 

https://www1.nyc.gov/assets/doh/downloads/pdf/covid/covid-19-mental-health-impacts-hop.pdf

Articles

Patients who are report social phobia are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations. That is where psychiatrists can help.





The Other Side of the COVID-19 Crisis: The Silent, Socially Phobic Minority 

There is always something to celebrate, even in the worst of times. In December 2020, we celebrated the 100th anniversary of the first staged production of 

” Originally written around 1914, and adapted from Eastern-European Jewish folklore, “The Dybbuk” made history in Yiddish theater. The story sheds light on the histories of the mind sciences and neurosciences, which were on fast-forward in the early decades of the 20th century, as Ansky was perfecting his play.

“The Dybbuk” has lived on in many other incarnations since its stage premiere, appearing in film, opera, ballet, and even puppetry.

 In the United States, George Gershwin was commissioned to adapt “The Dybbuk” for the Metropolitan Opera, but could not secure rights, (so he created his equally immortal “Porgy & Bess” instead).

 Ansky based his play on folktales about miracle-working 

. Apart from its entertainment value, it highlights the vast differences between folkloric versus scientific (or pseudo-scientific) explanations for behavior changes and it can aid our understanding of non-science-based attitudes toward neuropsychiatry to this day.

Let me explain the story behind “The Dybbuk,” which was originally entitled “Between Two Worlds

” The play was created by a man who himself lived between 2 worlds, if not more. Shloyme Zanvl Rappoport, better known by his pen name S. Ansky, was born into a pious but impoverished Jewish family in Russia’s Pale of Settlement, but he was born with a wandering soul that sent him in search of worldly experiences. He left his insular home in the 

 after receiving a limited religious education, but he became self-taught enough to work as a tutor. At one point, he became infatuated with the socialist movements that were sweeping Russia, and he went to work among coal and salt miners, who epitomized his downtrodden Russian compatriots. He shared his revolutionary writings with his co-workers and published extensively—but did not live to see the 1920 staging of his immortal play.

Before his death in 1920, Ansky lived even more lives. He was expelled from Russia for his revolutionary activities and moved to Paris, where he attended literary salons that were far afield from his insular upbringing. Although he had previously published political polemics and revolutionary poems, the fiction for which he is most remembered took off in earnest after a philanthropist subsidized an ethnographic expedition. Ansky collected folktales, songs, and artifacts from simple and often superstitious small-town 

 Jews, whose way of life was in danger of extinction as modernity crept into Russia. While traveling about the poverty-ridden Pale, where Jews were confined, he came upon the story of the Dybbuk.

dwelling friends meet as their wives are awaiting childbirth. The men vow that their unborn son and daughter will marry one another someday. They disregard a mysterious stranger’s ominous—yet eerily accurate—warnings against vows made for the unborn. Indeed, the wife of the first man dies while giving birth to a daughter, Leah, while the other man drowns in a storm just as his wife gives birth to a son, Chanon. The children grow up, neither knowing of their fathers’ promises and neither knowing of the other. In the interim, the surviving father grows wealthy, and seeks a more prosperous husband for his daughter, in spite of his long-forgotten vow. The surviving son of the deceased man returns to town as a penniless yeshiva scholar. His religious and scholarly pursuits are respectable enough to earn him an invitation to the wealthy man’s table, yet his financial limitations cannot satisfy the young woman’s father. 

As fate would have it, young Leah and the destitute yeshiva scholar Chanon meet, and they feel an instantaneous attraction for one another, as if their shared destiny had been decreed by an unshakable unearthly force. Despite Leah’s father’s objections, Chanon still hopes to marry Leah, even though Leah’s father already announced her betrothal to a more prosperous potential mate.

Hoping to offset these nuptial plans, the crushed Chanon immerses himself in the study of forbidden mystical Kabbalistic texts, which are off-limits to unmarried men under 40, lest they suffer psychosis, or even suicide, as happened to unprepared Kaballah students many centuries earlier. The sages’ warnings about the risk of Kaballah study prove true, and Chanon dies (possibly by suicide) after his Kabbalistic rites fail to thwart Leah’s prearranged marriage.

The wedding between Leah and the rich man’s son almost proceeds as planned—until Leah is inhabited by a disembodied 

, or the clinging spirit, of her deceased lover Chanon. Possessed by Chanon’s wandering soul, which cannot enter paradise, Leah suddenly speaks in a deep, gruff voice as she stands at the 

Her behavior is outlandish and inexplicable—until a specially qualified rabbi is called in to consult. After explaining the circumstances, the rabbi exorcises the 

 from the young woman’s body. Even though the rabbi successfully extracts Chanon’s 

 Leah is so enervated by the ordeal that she faints and falls dead. Upon her death, Chanon’s spirit reunites with Leah’s, and the lovers are together in the hereafter, in true Russian Romantic era style. Leah’s father, who failed to honor his vow to his friend, is now bereft of his daughter. Inconsolable, he agrees to the penance prescribed by the rabbi-exorcist and shares half his wealth with less fortunate individuals. 

This play premiered in 1920, when important developments in psychiatry, psychoanalysis, experimental psychology, and neuropsychiatry were percolating. At the turn of the century, Sigmund Freud, MD, had promised to override superstition, and to supplant popular supernatural theories with his scientific study of dreams, and much more.

 Psychodynamic explanations for Leah’s bizarre behavior seemed world’s away from the occultist exegesis of “The Dybbuk

In fact, there are real parallels between Freud and the play, especially when one compares Freud’s theories to other psychological theories of the day. Freud’s star was rising as Ansky was perfecting his story, even if his star does not shine so brightly today. In 1918, Freud participated in a different kind of drama: he testified at the trial of Julius Wagner-Jauregg, MD, held after the Great War. Freud’s testimony impressed the audience because he acknowledged the suffering of shell-shocked soldiers and did not dismiss their physical or psychological disabilities, even if a demonstrable medical cause could not be found for their deafness, paralysis, or muteness.

Freud was calling the Kaufmannization techniques employed by the illustrious psychiatrist Wagner-Jauregg and several other military psychiatrists into question. The Austrian doctors stood accused of torturing suffering soldiers by subjecting them to painful electric shocks (not electroconvulsive therapy), to goad them into foregoing their allegedly “feigned” symptoms and returning to the front.

Although Wagner-Jauregg was not the only psychiatrist who stood trial, his name was attached to the highly publicized trial because of his renown (he went on to win a Nobel Prize in 1927). Inviting Freud to function as an expert witness, in turn, allowed the one-time neurologist turned psychoanalyst to showcase his new talking cure and the abreaction that occurred when distressed patients verbalized their conflicts and apparently purged the psychological equivalent of clinging spirits that were responsible for hysterical symptoms that had no demonstrable biological basis.

There are clear-cut parallels between Freud’s newfound talking cure and the expulsion of the dybbuk (or demons, as the case may be), and the disinhibited vocalizations made by the dybbuk, even though the supernatural explanations of thefolk healer were worlds away from Freud’s psychological explanations. Although the credibility of many Freudian case reports has been challenged, as have his claims of cures, Freud alleged that he could relieve (mostly female) patients of their hysterical symptoms through free associations. Curiously, like Freud’s hysterical patients, dybbuk possession most commonly afflicted women, who did not have a legitimate “voice” to express themselves during daily life.

Yet even those “innovative” ideas were not so novel. A millennium before Freud formulated his theories, tales of demons and dybbuk-like creatures abounded, both in Jewish lore and in the Gospel stories, which were composed in the first century CE, when the Second Temple still stood in Jerusalem. The dramatic New Testament story of the exorcism of the Gerasene demoniac, also known as Legion, inspired many artistic depictions over the centuries, including an iconic scene in 

 where the demon is expelled from Linda Blair’s mouth.

Another influential mind science researcher of the same era—the behaviorist John B Watson, PhD—also lost stature over the decades, perhaps even more than Freud, albeit for different reasons. Watson’s conclusions about behavioral conditioning have not been disproven and were published in book form in 1920, in the same year as the premier of “The Dybbuk.” Yet the methodology that Watson used to test his theories is totally unacceptable, if not downright horrifying, today.

To demonstrate the far-reaching effects of behavioral conditioning, Watson used a human child subject, “Little Albert.” Besides the fact that the toddler could not provide informed consent as we know it today, the boy suffered permanent psychological damage (and by some reports, was already neurologically compromised). His fear response, which was originally conditioned to a white mouse, generalized to other white furry objects, including Santa Claus’ beard. Albert reportedly remained a fearful child in the aftermath of superficially successful psychological experiments, even though he had no conscious awareness of the source of his distress because behavioral conditioning bypasses higher cognitive processes and produces reflexive reactions.

In both Watson’s experiments, and in Ansky’s story, innocent children suffer for the sins of their fathers—or their father figures, as in Watson’s case, in true Old Testament fashion. Yet the past experiences that haunt Leah and Chanon are unrelated to their own memories and are solely the result of their fathers' forsaken vows, which existed, at best, as buried memories from the distant past. Perhaps a die-hard Jungian could claim that Jung’s hypothetical inheritable “racial unconscious” transmitted the father’s repressed memories to his ill-fated progeny. However, that highly contested Jungian concept is one of the many reasons why Jungian ideas carry more cache among occultists and folklorists than among neuroscientists and most contemporary psychiatrists. Still, it is curious that Ansky wrote “The Dybbuk” soon after Jung published his controversial theories of the unconscious. While we have no reason to believe that Ansky was directly influenced by Jungian ideas—and we have every reason to believe that Ansky based his ideas about “The Dybbuk” on Eastern European Jewish folklore encountered during his ethnographic expedition—we can see how these recurring mythological motifs given credibility to concepts expressed in the 1909 writings of psychoanalyst Otto Rank

So, what is left? So much of yesterday’s science becomes tomorrow’s superstition, and the scientific scruples of one generation may be repugnant to later generations, as seen in the Wagner-Jauregg trials and in Watson’s Little Albert experiments. Yet “The Dybbuk” story endures and provides testimony to the natural inclinations of the human imagination, unbridled by science or psychology. And, as atavistic as the play’s premise sounds to psychiatrists, we cannot forget that 42% of Americans believe that “people on this earth are sometimes possessed by the Devil,” as per a 2005 Gallop poll quoted in a 2014 

 Apparently, it is not accidental that dybbuk

like tales resurface for new generations.

Take “The Exorcist,” for example. “The Dybbuk” does not enjoy the name recognition of “The Exorcist” although the play and movie share superficial similarities. Both invoke the paranormal and play upon psychiatric themes. “The Exorcist,” William Friedkin’s 1973 film, based on William Peter Blatty’s best-selling 1971 novel by the same name, is among the most recognized films of all time. “The Dybbuk,” on the other hand, is among the most recognized Yiddish stage productions of all time, which attracted much smaller audiences than American movies. 

In “The Dybbuk” the rabbi functions as an exorcist of sorts and was modeled after a real life 

 who was reputed to possess such powers. He successfully expels occupying spirits that induce behavior changes in living individuals. He is a folk healer, and could conceivably be called a “baal shem

” but neither he nor his followers compare the rabbi-exorcist to a medical doctor, much less to a psychiatrist. Medical anthropologists rightfully draw parallels between shamans and Jewish “baali shem” (plural of baal shem), who employed prayers, invocations, magic words, amulets, and unidentified herbals native to the area. (The famed Baal Shem Tov who started the Chasidism movement within Judaism was just 1 of many such baali shem who worked as herbal and spiritual healers.)

There are significant points of departure between “The Exorcist” and “The Dybbuk

” Most obviously, “The Exorcist”revolves around Roman Catholic rites, whereas “The Dybbuk” is undeniably Jewish, even though its author originally wrote his story in Russian before translating it into Yiddish. Equally importantly, the priest-psychiatrist in “The Exorcist”is pivotal to the plot. “The Exorcist” includes a comprehensive and impressively accurate neuropsychiatric work-up for the troubled Regan, who was suspected of having a seizure disorder or even attention-deficit/hyperactivity disorder (which was then called minimal brain dysfunction). “The Dybbuk” does not feature any psychiatrist at all and does not attempt a psychiatric (much less a neurological) differential diagnosis. It does not even hint at the existence of psychiatrists, even though psychiatry was gaining greater recognition (and notoriety) in Central Europe when Ansky’s play premiered and even though the 1920 release of the enduring German Expressionist masterpiece about a charlatan psychiatrist, 

, testifies to the growing significance of psychiatry in the West.

The story of “The Dybbuk” and the purging of clinging spirits will undoubtedly remain a tale, told in some form or another, that lives on both in fiction and science. 

is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

Dybbuks and Jewish Women in Social History, Mysticism and Folklore

The Myth of the Birth of the Hero: A Psychological Exploration of Myth

7. Harris J. Exorcism: the miracles of St. Ignatius of Loyola: Peter Paul Rubens

Cinema's Sinister Psychiatrists: From Caligari to Hannibal

High (and low) points in the history of mind sciences can be explored through folklore. 

Demons, Dybbuks, and Other Psychic Maladies 

When the email from “Sam” arrived asking about adding a natural weight loss product to his more mainstream prescription medications, I was not surprised. Binge eating was his bête noire. A onetime college athlete who lost his scholarship because of an ankle injury, he had since sat around eating while watching sports on TV and lamenting his lost career. He desperately wanted to shed unwanted weight, but treatments that control bingeing do not guarantee weight loss. He had tried 

 with no success. So, when he heard about a new natural weight loss concoction, he was understandably excited yet skeptical because he knew of the government’s crackdown on hoodia.

Sam forwarded me a laundry list of ingredients without hoodia but with 

 (Pausinystalia yohimbe). Years had passed since I had seen that word in print.

“Was it safe?” was all he wanted to know. Whether it worked seemed to be a secondary concern. My short answer was no, and I promised a longer explanation at his next appointment. In the interim, flashbacks of another patient from long ago popped up. Although psychopharmacology has quickly evolved in the decades since the 

, that related case was too dramatic to forget.

I remember the frantic call from the ED staff, begging me to see their patient posthaste.

“Maybe you can prescribe lithium or haloperidol or something like that. We cannot contain him here, but we have nowhere to send him,” said the pressured voice on the phone. “He saw a psychiatrist, but that is all we know.”

“Was it safe?” was all he wanted to know. Whether it worked seemed to be a secondary concern. My short answer was no, and I promised a longer explanation.

It was Sunday midmorning, late summer, when many Manhattanites escape town leaving side streets empty and opening tables at New York City’s unending array of eateries. Uninterrupted by impatient New Yorkers demanding seats, out-of-towners could enjoy unhurried brunches, fussed over by glamorous waitstaff who were patiently anticipating their Broadway debuts. The tidy townhouses lined side by side behind the hospital conveyed an extra sense of calm that contrasted with rowdy Saturday nights.

 which was nearly abandoned. I peered through the window of the make-do quiet room and could see that the doctor who called the consult was not exaggerating. A tanned, middle-aged man stood a few feet behind the door. He looked to be 50-something, but he jumped and hopped like a child, in sync to the beat of an invisible drum. His thinning silver hair swung wildly. Most strikingly, his suit jacket was draped around his waist, hiding his backside and little else. Empty sleeves looped across the front, dangling like a loincloth, albeit one with a shiny—probably pricey—silk lining. Where he left his pants, shoes, socks, and shirt was anyone’s guess. All I knew is that he wore nothing else.

Per protocol, I checked the chart before walking into the room, not just for safety’s sake but to

 by skimming the demographics. He was, in fact, middle-aged, married, and, in hindsight, possibly a vestige of the 

 had not aired yet. For that matter, sildenafil had not been invented, nor had the now-ubiquitous second-generation antipsychotics that are often used to treat bipolar disorder. Per the intake sheet, “Mr Smith” was a senior vice president at a name-brand advertising firm, even if his present posture suggested otherwise.

The history mentioned that his private psychiatrist, who had retreated to the Hamptons for the summer, referred all emergencies to the hospital, as per his answering machine message. Before leaving, said psychiatrist started him on lithium, then carbamazepine, maybe even 

, but now everything spiraled out of control. Experience told me that advertising executives with bipolar disorder tendencies are not uncommon, because advertising takes high energy, unabashed enthusiasm, and lots of chutzpah, which are abundant in 

. Yet it was also unlikely that someone with uncontrolled bipolar disorder could rise so high through the corporate ranks, even if his prescriptions screamed bipolar. It was also unlikely that this behavior represented garden-variety bipolar disorder, because the nurse noted that he was disoriented to time and place, distracted, and responding to unseen stimuli. His rapid, jerky movements put me on high alert for impending seizures, even though a cursory 

I scrolled through the medication list, checked the charted vital signs, scanned all labs listed, and looked for clues to explain this seemingly sudden deterioration. Even the toxicology screens were negative. The medications included several antihypertensives, which opened the possibility of a recent cerebrovascular accident secondary to hypertension, but he was moving all 4 limbs without restrictions, and his frenetic, dancelike activity functioned as a makeshift 

 stress test, making it unlikely (but not impossible) that his strange symptoms followed hypoperfusion. There was only 1 odd entry, a little, nearly illegible word: Yocon.

In those days, we checked prescription pharmaceuticals through big, bulky Physicians’ Desk Reference editions with thin pages and small print. And that was where I found the culprit: that little word was the trade name for 

, a reputed (but disputed) aphrodisiac used in fertility rituals in Cameroon, Central Africa, according to a memorable medical school ethnopharmacology lecture. I called the man’s internist, who had hospital privileges and even made rounds on weekends. The internist checked his chart and confirmed that a urologist had started the man on prescription yohimbine a few weeks earlier. The doctor noted that he added more antihypertensive medications soon after, which made sense, given that this herb can increase blood pressure and interfere with the efficacy of blood pressure medications.

The nurses crowded outside the room, eager for an explanation, and appreciative of the colorful story behind this mystery. Yohimbine was an α1-adrenergic agonist, a product of an East African tree with a similar name. It was marketed as an 

 and subsequently approved for this purpose, despite equivocal evidence. Whether yohimbine helped in this regard was unclear, but its psychoactive properties were apparent. I wondered whether prescriptive yohimbine (or nonmedicinal yohimbe bark) directly increased libido as advertised, or whether it simply induced 

 in susceptible individuals, with the attendant hypersexuality of mania.

That theory was within the realm of possibility, especially because recent reports confirm that the stimulant especially affects individuals who are predisposed to bipolar disorder, as well as schizophrenia, panic disorder, and 

. Even popular online consumer medical websites warn against its use in cases of depression because it can precipitate manic reactions.

 The National Institute of Health’s National Center for Complementary and Alternative Medicine, now the National Center for Complementary and Integrative Health, has since taken a 

, warning against its use in individuals with any psychiatric history.

Over time, we learned much about yohimbine and its positive and negative effects. Although it fell into disuse after the invention of the much more predictable 

 indicated for erectile dysfunction, online marketers still promote it for a wide range of problems, including appetite suppression and obesity. Yohimbine gained greatest use as a veterinary antidote to animal tranquilizers. It has been misused by some humans, as was the case with ketamine, a onetime animal tranquilizer turned club drug that has recently been repurposed as a treatment for depression. No comparable success stories have been reported for yohimbine, although bodybuilders cite anecdotal evidence that the herb enhances exercise endurance. In contrast, forensic medicine journals 

 and note that yohimbine can cause delirium, hallucinosis, seizures, and sometimes deaths. An 

article in American Journal of Psychiatry

confirms that it can switch depression into mania.

Importantly, dangerous interactions can occur with 

—so it was fortunate that the patient quieted down with a dark, soundless room and intravenous diazepam, prescribed by the neurologist to stop seizures should they occur. Aided by the tincture of time, and a short stay upstairs once a bed opened, he reportedly returned to baseline. When I checked on him a few days later, he did not recall this episode.

In hindsight, our mystery man escaped easily. Who knows what tragedies could have occurred had strong psychotropics been added to his medication mix without stopping the clandestine culprit? At worst, lethal medication interactions could have followed. And, at best, he would have been condemned to a lifetime’s treatment for a condition that might not have emerged without this botanical boost.

, and we must consider the big picture, without reflexive and thoughtless prescriptions for psychotropics—even if the general public, as well as other medical professionals, assume that is all we do. As for Sam, I expect him to appreciate this warning story about yohimbine, even if the negative studies about its efficacy for weight loss disappoint him.

is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

Three cases of manic symptoms following yohimbine administration

2. Yohimbe. National Center for Complementary and Integrative Health. Updated November 2020. Accessed December 21, 2020. 

3. Anderson C, Anderson D, Harre N, Wade N. 

Case study: two fatal case reports of acute yohimbine intoxication.

As physicians first, psychiatrists must consider the big picture, without reflexive and thoughtless prescriptions for psychotropics—even if many, including medical professionals, assume that is all we do.

Never Forget the Fine Print: From Fertility Rites to “Miracle Med”

The reflection of her face in the mirror has faded from memory, although I often recall the red yarn that held her hair away from her face. The red hue was impossible to ignore.

I cannot remember her name and would never recognize her facial features if I saw her again—which I would not and could not. All I see in my mind’s eye is a static image, like a cut-out paper doll that never changes, forever fossilized in time.

She tied the yarn loosely behind her head, in tune with the fashion dictates of the day. It was not the yarn that grandmothers used to knit sweaters or socks—this yarn was made from many twines. That yarn became a bow, with loose ends trailing down, but not too far down. The yarn turned a low-slung 1950s-era ponytail into a professional woman’s fashion statement. It was worlds away from the high-perched ponytails of bubble gum-chewing bobbysoxers of yesteryear. This ponytail was perfect, without a hair out of place. According to the male chief resident, who reminded me to mirror this same woman whom I saw in the mirror, that was the way female physicians should dress—or so he said.

Loose locks left over from the free-wheeling 1960s, when women wore flowers in their hair, San Francisco-style, were discouraged, if not disdained. The only thing worse, that same senior resident mused, was a Jewfro, which was too ethnic for poker-faced psychoanalytically trained psychiatrists. Yet tight hair buns were too severe; psychiatrists-in-training were expected to project some empathy—but not enough to break tight boundaries.

The woman in the mirror was a senior resident, about to complete her program at a time when American women were still relatively rare in medicine. A few outstanding female physicians had made inroads in psychiatry. This young woman was also said to be outstanding, or so I was told—but not by her, for she never said a word.

More than once, I calculated how much time she devoted to perfecting her appearance, since she always seemed to be standing in the same place, like a mannequin, whenever I entered the anteroom to the restroom. She never spoke and never even turned her head; she merely nodded as she looked me in the eye, via that ever-present intermediary: the mirror. And I nodded back, too intimidated to start a conversation with a senior resident and one, at that, who was identified as “perfect.”

A short grosgrain ribbon encircled her collar and crisscrossed above the top button, somewhat like a man’s necktie, but feminized, as per the dictates of the day. In another era, that part of her “uniform” would have screamed Catholic school girl, especially if accompanied by a plaid skirt. But in this era it said “professional woman’s apparel,” which evolved into a uniform of its own. In hindsight, that picture-perfect ribbon that wrapped around her neck, like a noose, foreshadowed events to come.

There was something film noir-ish about this silent reflection, but film noir was not on my radar yet. Yet film noir was intimately linked to psychoanalysis, with Freudian-informed dream scenes and psychoanalytic-style voiceovers that simulated internal monologues or unconscious ideas. Voiceovers—rather than direct dialogue—narrated acts from the past or expressed unspoken thoughts in the present. Yet, there were no sounds in our superficial exchanges, no conversation at all. To this day, I wonder what that voiceover might have said or what she herself was thinking, had she chosen to speak. And I wonder if I should have spoken first.

For now, what I do know is that she died by her own hand, hanging herself some months later, shortly before finishing residency. As typically happens in the aftermath of 

—years or even decades later—we wonder what we could have said or should have seen. Perhaps tears had been streaming down her face, carefully concealed by makeup before modeling in the mirror.

Apparently, no one saw this coming, for surely someone in charge might have said something or done something. I can say nothing with certainty, save for the fact that a Jungian term, persona, and not a Freudian concept, best explains the indelible impression she made on me back then and decades later.

The reasons behind her suicide remain as mysterious as her reflection in the mirror. I first heard of the tragedy through a billing clerk, who dashed about frantically, checking on the residents’ well-being, and looking relieved whenever she saw someone alive. It was she who said that a young female resident had died, whose name was still unknown. The concept of copycat suicides had not been coined, but this middle-aged, motherly woman intuited this possibility. Other information arrived via rumor only. Post-suicide debriefings were not part of the protocol back then, although they are now standard when residents or medical students take their lives. The chief resident—the one who anointed her as the chosen one, the one to be emulated, for she was perfect in appearance—never said another word.

Perfection is one trait that is most closely linked with depression. Perfectionists are always operating at a deficit, because it is impossible to be perfect. The unquenchable need to be perfect at all costs and under all circumstances has been loosely linked to 

 in general and to physician suicides as well.

Physician suicides have been on the radar for decades, if not for centuries, but these tragic events are attracting even more attention today. More and more doctors complain about burnout and many chose early retirement, even in the face of physician shortages. Statistics show that half of all physician 

Today’s buzzword is burnout—perhaps to soften the fear of impending suicide and perhaps to prevent the worst consequences. There are many reasons for physician burnout, including among other factors, dissatisfaction with unwieldy electronic health records, loss of professional autonomy in the face of managed care, overwhelming medical school loans, declining prestige or power in society, and stigma associated with seeking psychiatric help. Age-old scourges of drugs and alcohol may also be involved; although doctors are no more likely to develop alcohol problems than non-doctors, they can access lethal drugs more easily.

There are many contributors to professional dissatisfaction, just as there are many contributors to depression itself (besides plummeting dopamine levels). And there are many contributors to that final act of suicide. However, this is not news, even though contemporary stressors have changed. According to a recent Medscape article, the high rate of physician suicide, compared with the general population, was known 150 years ago.

The numbers are striking, yet most suspect that the rates of doctor suicides are underestimated and that many unexplained deaths are not recorded as suicides. Between 300 and 400 physician suicides occur each year. To put it differently, about one doctor dies by their own hand every day. The size of an entire medical school class completes suicide every year. Male physicians have twice the risk for suicide as men in the general population, even though they care for their medical health better than average, with lower rates of smoking, cardiovascular disease, or cancer. 

 by female physicians approximate the number of male physician suicides but, because women overall are half as likely to complete suicide as men, the comparisons between rates of suicides of female physicians and rates among female members of the general population is glaring. Female physicians are 4 times as likely to die from suicide as women who are not physicians. (Computing the statistics gets confusing, but it is worth doing.)

What does this say about this unnamed resident whose reflection I saw in the mirror? That her untimely death was consistent with statistics? Yes, but no. She was in a program that mandated personal analysis, which may or may not have been helpful, so we cannot blame stigma for avoiding psychiatric treatment. What can we blame, if anything at all? Perhaps nothing, or perhaps our own refusal to see past the mask and to admit that outward perfection is not necessarily perfect.

What I can say with near certainty is that I never saw her personal reflection in the mirror. I saw only the reflection of her persona, the theatrical mask presented to the public used to conceal the inner anima or soul or authentic being. Jung borrowed this term from Greek theater, where masks established an actor’s fictional identity on stage. Thousands of years later, this word remains relevant.

Perhaps this persona also hid an unexpressed and unacceptable shadow side, to use Jung’s vocabulary. As per Jung (and I have no proof that he was even remotely correct), each of us has a shadow side, which we must confront and eventually reconcile. Yet it is probably extra difficult for people who must be perfect to come to terms with such imperfections.

What can we learn from this sad story, other than the fact that perfect poses may be nothing more than poses and that the poseur may be enduring greater distress than is apparent to the untutored eye? Perhaps this vignette can remind us of the need to pay even closer attention to those who appear perfect—and to avoid imposing demands for perfection at every step along the way.

 is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. LoboPrabhu S, Summers RF, Moffic HS, Eds. 

Combating Physician Burnout: A Guide for Psychiatrists, 

1st ed. Washington, DC: American Psychiatric Association Publishing; 2020.

3. Gold KJ, Schwend TL. Physician suicide—a personal and community tragedy. 

4. Duarte D, El-Hagrassy MM, Castro e Couto T, et al. Male and female physician suicidality: a systematic review and meta-analysis. 

As typically happens in the aftermath of suicide—years or even decades later—we wonder what we could have said or should have seen.

Of Personas and Perfection—and Physician Suicide

is Assistant Clinical Professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

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