The Value of Nothing

Teach thy tongue to say, “I do not know,” and thou shalt progress.
-Maimonides¹

Eastern philosophy and religion have always had what the philosopher Hajime Nakamura² called “a preference for the negative.” This stands in stark contrast to our Western penchant for the positive, and our proclivity for defining and intervening is most pronounced in the overactivist mode of modern American medicine."

In this column I briefly sketch the worldview of Asian philosophy in which no-thing is at least as valuable as some-thing. I then explore how the exponential growth in diagnoses and the extreme competition to develop and use new and more drugs in our culture has resulted in some serious consequences for patients and the med­ical profession. Finally, I suggest that the spiritual practice of discernment can help us recognize when doing less and being more may actually lead to better outcomes for patients and more fulfillment for us as clinicians.

In his classic book, Ways of Thinking of Eastern Peoples, Nakamura2 points out that in Indian thought and language, negative forms of moral conduct-such as nonviolence (ahimsa)-are considered more powerful than affirmative statements in the West of the virtues of peace or tolerance. This preference for the negative extends to metaphysics-the ultimate reality in Buddhism (sunyata) is translated as “emptiness” or “voidness,” and the Hindu ultimate principle, “Atman,” explained is neti, neti, “not this, not this.” Even the positive attainment of liberation is described in negative terms as nirvana, which is translated in some versions as the extinction of all the ego’s desires.³ The West does have its own mystical tradition of experiencing the divine “via negativa,” but this has had far less influence on philosophy and science.⁴

Wisdom gained from “nothing”
What wisdom can we take with us as we descend from these lofty heights to the more prosaic plane of contemporary psychiatric care? Our clinical practice is increasingly evidence-based, and it will come as no surprise that the neglect of the negative begins in research. A 2005 study in the American Journal of Psychiatry underscored the pervasive positive bias and its link to the pharmaceutical industry. The article examined funding sources and author conflicts of interest in all clinical trials published in 4 major psychiatric journals between 2001 and 2003. Of 397 published trials, 239 (60%) of the published disclosures reported receiving funding from a pharmaceutical company or other interested party, and in 187 studies (47%), a conflict of interest associated with at least 1 author was identified. Of the 162 double-blind, randomized, placebo-controlled studies analyzed, those that reported conflicts of interest were 4.9 times more likely to report positive results. However, this correlation was statistically significant only among industry-funded trials.⁵

The adverse impact of disregarding trials that report negative findings is often underappreciated. Most ethical scientists will be the first to tell you that a researcher learns more from the rejected grant, the flawed study design, or the erroneous hypothesis. Clinically, information that a certain drug is not effective or that it has adverse effects in a specific population for a particular illness can be enormously useful to practitioners who are trying to telescope the trial and error of treatment selection for a distressed individual in their office.

The sequela of the coalescence of pharmaceutical influence and a preference for the positive can be seen in everyday prescribing habits. When I first started as an attending, I inherited the patients of a respected psychiatrist who had moved on to another institution. I meticulously reviewed information on every patient in the Veterans Affairs computerized medical record before my initial visit with each person. After several weeks, I noticed that at each session my pre­decessor had either increased a drug dosage or, more often, changed medications in response to variegated symptoms from financial difficulties to somatic complaints. Bewildered, I finally asked my supervisor if there was a reason for all the switching that I was unable to grasp. His reply was instructive: “Dr X couldn’t stand not to do something when someone was distressed, and so he changed the medications.” This hyperreactive prescribing taught me some valuable early lessons in patient care:

• Carefully assess the obvious and hidden circumstances that underlie changes in symptoms.
• Be quick to offer psychological support and be slower to change the course of therapy.
• Time, observation, and watchful waiting are your allies in clarifying the situation and in determining whether a response is needed.

Turning negative into positive
This story is a microcosm of the larger forces that affect psychiatry, many of them with deleterious imprints. Among the most concerning is the overprescribing of antipsychotic med­ications for the behavioral disturbances of dementia. The Clinical Antipsychotic Trials of Interven­tion Effectiveness–Alzheimer Disease (CATIE-AD) found that atypical anti­psychotics used for the behavioral and psychiatric symptoms of Alz­heimer dementia did not improve cognition, functioning, care needs, or quality of life, although they did improve particular psychiatric symptoms such as anger or paranoia.⁶ Note that these results demonstrate an important form of the negative-the paucity and insignificance of results that would in itself argue against the widespread use of these agents except in very select cases. Add to this lack of effectiveness the more ominous recent findings that both typical and atypical antipsychotics may actually increase morbidity and mortality in patients with dementia-associated agitation and one has an even more powerful form of negation-the presence of harm.⁷

Finally, consider that nonpharmacological means of addressing the behavioral disturbances of demen- tia, such as not using restraints, not overstimulating, and not changing es­­tablished routines, urgently need to be studied, and the mandate to alter our positivistic and mechanistic assump­tions about treatment should become apparent.⁸ Note that my use of this term does not denote the philosophical movement of positivism de­­fined as a “system of philosophy based on experience and empirical knowledge of natural phenomena, in which metaphys­ics and theology are regarded as in­ade­quate and im­per­fect systems of knowledge.”⁹ Rath­­er, the connotation is in regard to the positivism that shares an intellec­tual lineage with this school that has contributed conceptually to the dichotomous expediency and imprudent interventionalism that I describe here as a positivistic approach.

We often do not appreciate that the diagnostic process is itself an action of definition and delimiting that initiates and shapes treatment. The Greek root of diagnosis means “to be able to distinguish, to set apart, to come to know or discern.”¹⁰ Ironically, before the second biological revolution in psychiatry, this art of understanding and differentiating had ascendancy, but it has become sadly subservient to the hegemony of technical ma­nipulation. This rigid interpreta­- tion that spawned the generations of DSM has no room for doing nothing, and only doing something, anything, is truly considered therapeutic. This has the unfortunate consequence of transforming abstract classifications into substantive and even material realities.

Recently I encountered the human toll of these abstractions when a nurse on one of the floors in the hospital where I work caught me in the hall and said in great distress, “For years they said my partner had bipolar disorder, and now they say she is schizo­affective. I am afraid everything in our life will change. I have known this person for 20 years, and I am sure she is bipolar.” I tried to reassure the nurse that this particular change in diagnostic labeling was, for all practical purposes, semantic and would have no real impact on their relationship nor would it likely even alter the drug regimen that had provided her significant other with a measure of stability.¹¹ However, witnessing the distress anxiety that this near deification of a man-made system created in a fellow health care professional was deeply disturbing.

Discernment
The categorical nature of DSM produces an inherent diagnostic momentum that culminates in the not otherwise specified (NOS) diagnoses- the tentativeness and tenuousness of which makes them virtually meaningless except that they stigmatize the patient. I teach my residents to try to avoid assigning an NOS diagnosis and, instead, to take a stand on their best clinical thinking and allow collateral information, the course of the illness, and the work of colleagues to refine or, indeed, redefine their initial theorizing. In psychosomatic medicine, where symptoms respond fluidly to the ebb and flow of physical illness, hospital stressors, and weakened defenses, we often use the codes for Psychological Factors Affecting Medical Conditions.¹² These designations are more open to the uncertainty and dyna­mism of psychosomatic illnesses than the closed cardinal codes but still satisfy the pragmatic demands of institutional and payment mechanisms.¹³ The categorical logic of DSM, with its exclusions, hierarchies, and decision trees, is diametrically opposed to the plastic reasoning of the East that can embrace the unknown. The editor of Psychiatric Times and my mentor, Ronald Pies, MD, has suggested that this ability to live with ambiguity and contradiction is akin to what John Keats called “negative capability.” In an 1817 letter to his brother, Keats explained, “I mean Negative Capability, that is, when man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.”¹⁴

Like scientific studies, all essays have their limitations, particularly when the author is discussing something as nebulous as the presence of absence. To avoid misunderstandings, let me be definitive and say I am not advocating that we abandon serious mental illness to a tincture of time or that we jettison the many beneficial medications the academic-industry collaborations have developed. What I am arguing for is that we use the virtue of discernment that is common to the spiritualities of most great world religions. Discernment as a virtue in bioethics is closely related to Aristotle’s practical wisdom of phronesis, or prudence, that I suggested in a much earlier essay may be one of our most important guides in the coming decades.¹⁵

Beauchamp and Childress16 pre­sent discernment as 1 of the 5 focal virtues: “The virtue of discernment brings sensitive insight, acute judgment, and understanding to action. Discernment involves the ability to make judgments and reach decisions without being unduly influenced by extraneous considerations, fears, personal attachments, and the like.”¹⁶ A psychiatrist of discernment will return to the ancient intention of diagnosis as an entre to therapy and not a denouement to treatment-seeing a person as someone “with depression” rather than a “depressed person.” A discerning clinician will not avoid interventions, be they drugs or procedures, but will find the most rational and economical therapy with the least burden and most benefit. Discerning clinicians would not feel compelled by third parties to diagnose a disorder where only a life problem exists or would not refrain from recommending a range of modalities, from psychotherapy to exercise, when it is appropriate for a milder form of treat­ment. Dedication to prudent practice would amount to a paradigm shift in clinical care in which “I don’t know” or “I am not sure” would not be a sign of scientific inadequacy but of professional integrity.

References:

1. Maimonides. Cited in: Pies R. Wisdom from the 12th century. Psychiatr News. 2007;42:30.
2. Nakamura H. Ways of Thinking of Eastern Peoples. Honolulu: East-West Center Press; 1964.
3. Moore CA. The Indian Mind. Honolulu: East-West Center Press; 1967.
4. Richardson A, ed. A Dictionary of Christian Theology. Philadelphia: Westminster Press; 1969.
5. Perlis RH, Perlis CS, Wu Y, et al. Industry sponsorship and financial conflict of interest in the reporting of clinical trials in psychiatry. Am J Psychiatry. 2005; 162:1957-1960.
6. Sultzer DL, Davis SM, Tariot PN, et al. Clinical symptom responses to atypical antipsychotic medications in Alzheimer’s disease: phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry. 2008; 165:844-854.
7. Kales HC, Valenstein M, Kim HM, et al. Mortality risk in patients with dementia treated with antipsychotics versus other psychiatric medications. Am J Psychiatry. 2007;164:1568-1576; quiz 1623.
8. Opie J, Rosewarne R, O’Connor DW. The efficacy of psychosocial approaches to behaviour disorders in dementia: a systematic literature review. Aust N Z J Psychiatry. 1999;33:789-799.
9. Positivism. Microsoft Encarta Online Encyclopedia. Positivism. Published 2008. http://encarta.msn.com/
encyclopedia_761563139/positivism.html. Accessed January 8, 2009.
10. Hollon MF. Direct-to-consumer marketing of prescription drugs: a current perspective for neurologists and psychiatrists. CNS Drugs. 2004;18:69-77.
11. Malhi GS, Green M, Fagiolini A, et al. Schizoaffective disorder: diagnostic issues and future recommendations. Bipolar Disord. 2008;10:215-230.
12. American Psychiatric Association. Diagnostic