How a Telescopic Lens Muddles Psychiatric Insights- NYT

[Mort Zuckerman]

http://www.nytimes.com/2011/05/24/health/views/24mind.html?_r=1&partner=rss&emc=rss

No sooner had Dominique Strauss-Kahn been arrested on sexual assault
charges in New York than a parade of psychiatrists stepped forward to
offer their expert opinion in the news media.
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This cover story in 1964 set a legal precedent that helped change
medical rules for psychiatrists for good.

Mr. Strauss-Kahn, who subsequently resigned as chief of the
International Monetary Fund, will experience “a terrible grief because
he is in prison,” said one. Another offered that he would have
“terrible mourning” for “the loss of social status, image and glory.”

Of course, it’s only natural for the media to seek comment from
experts. But as a psychiatrist, I cringe at statements like these, for
they cross an ethical line that goes back to a presidential campaign
nearly half a century ago.

Just before the 1964 election, a muckraking magazine called Fact
decided to survey members of the American Psychiatric Association for
their professional assessment of Senator Barry Goldwater of Arizona,
the Republican nominee against President Lyndon B. Johnson.

Ralph Ginzburg, the magazine’s notoriously provocative publisher, had
heavily advertised the issue in advance, saying it would call Mr.
Goldwater’s character into question.

A.P.A. members were asked whether they thought Mr. Goldwater was fit
to be president and what their psychiatric impressions of him were. It
was not American psychiatry’s finest hour.

The survey, highly unscientific even by the standards of the time, was
sent to 12,356 psychiatrists, of whom 2,417 responded. The results
were published as a special issue: “The Unconscious of a Conservative:
A Special Issue on the Mind of Barry Goldwater.”

The psychiatrists’ assessment was brutal. Half of the respondents
judged Mr. Goldwater psychologically unfit to be president. They used
terms like “megalomaniac,” “paranoid” and “grossly psychotic,” and
some even offered specific diagnoses, including schizophrenia and
narcissistic personality disorder.

Only 27 percent of the respondents said Mr. Goldwater was mentally
fit, and 23 percent said they didn’t know enough about him to make a
judgment.

There were several attempts at a psychodynamic formulation of Mr.
Goldwater’s character. One unsigned comment called the candidate
“inwardly a frightened person who sees himself as weak and threatened
by strong virile power around him,” and added that “his call for
aggressiveness and the need for individual strength and prerogatives
is an attempt to defend himself against and to deny his feelings of
weakness.”

Say what you will about their motivation, these doctors had given very
specific and damaging psychiatric opinions, using the language and art
of their profession, about a man whom they had not examined and who
surely would not have consented to such statements.

The remarks were immediately condemned by both the American Medical
Association and the A.P.A., and Mr. Goldwater brought a $2 million
libel suit against Fact and Mr. Ginzburg. The Supreme Court awarded
the senator $1 in compensatory damages and $75,000 in punitive damages
— and, more important, set a legal precedent that helped change
medical ethics for good.

In 1973, the A.P.A. defined a set of requirements for communicating
with the media — the Goldwater rule — stating that psychiatrists can
comment on mental health issues in general, but that it is explicitly
unethical for them to offer a professional opinion about an individual
without directly examining that person and getting his or her
permission to comment.

So it would be fine for a psychiatrist to say that someone who
experiences hallucinations and delusions appears psychotic, but to
offer a diagnosis of schizophrenia would cross the line.

The distinction between general description and diagnosis may seem
like splitting hairs. But for two reasons, the Goldwater rule is just
as important today as it ever was.

First, it is intellectually dishonest for a mental health professional
— or any physician — to give a diagnosis without examining the
patient. A professional opinion is supposed to reflect a thorough and
rigorous evaluation of a patient and all relevant clinical data
obtained under the protection of strict confidentiality. Anything
short of that misleads the public about what constitutes accepted
medical practice and invites distrust of the profession as a whole.

Second — and especially timely as we enter another presidential
campaign — the Goldwater rule prevents the misuse of medical authority
as a political weapon to denigrate an opponent.

Of course, there are exceptions to all rules. Patient confidentiality
is not absolute, for example: If a patient of mine told me he was
thinking of killing someone, I would have an ethical and legal duty to
violate confidentiality and warn both the person at risk and the
police.

And one could reasonably argue that an exception should be made for
psychiatric profiles of foreign political leaders, which United States
intelligence services (and those of other countries) have been doing
at least since World War II. An evaluation of Col. Muammar el-Qaddafi
of Libya, for example, might well be in the national interest because
it could help guide how we deal with this difficult figure.

Colonel Qaddafi’s ruthlessness, near-delusional grandiosity and love
of absolute power all suggest a severe personality disorder called
malignant narcissism. Because people with the disorder have a defect
in moral conscience, they lack empathy, so there is no room to appeal
to them on human terms. Instead, they are more likely to respond to
the right mix of flattery, power and a credible threat of force.

Whether the foregoing diagnosis is correct or useful, I have no idea,
but it is ethically defensible.

Despite what some of us might believe, though, none of our celebrities
or politicians is likely to rise to the level of a national threat
that justifies violation of the Goldwater rule.

It’s not sexy and probably won’t make headlines, but experts should
just stick to the facts and educate the public, and leave the pleasure
of diagnostic speculation to the amateurs.

Richard A. Friedman is a professor of psychiatry at Weill Cornell
Medical College.