Home » history of psychopharmacology
Category Archives: history of psychopharmacology
Elizabeth Wurtzel (1967–2020) died at the age of 52 on January 7th in New York City of metastatic breast cancer. Wurtzel became a notorious “bad girl,” with a wicked sense of black humor, sparing few, least of all herself, and a disarming “tell all” candor in her break through memoir Prozac Nation.
Full disclosure: I am catching up on my reading. Triggered by Wurtzel’s passing
away, I had not read her best selling Prozac Nation until earlier this week (01/14/2020). I acknowledge I need to get out more.
Now I am familiar with pathographies – autobiographies and biographies of mental pathology – having read Kay Redfield Jamison’s An Unquiet Mind, Jamison’s “Robert Lowell: Setting the River on Fire: A Study of Genius, Mani, and Character,” and Elyn Saks’ The Center Will Not Hold, all worth reading – as is Prozac Nation. Thus, I bring an innocent reading – and eye – to a work that is anything but innocent.
Wurtzel is credited with putting the funny but self-lacerating memoir on the literary map, with its account of her emotional struggles against the Black Wave of depression, volatile internal conflicts, and acting out in the form of cutting, starting at age eleven. Subsequent attempts to attain emotional equilibrium through substance abuse and volatile relationships with members of the opposite sex, the narrative actually turns into a coming of age story. Some coming; some aging.
Not quite stream of consciousness, but definitely a rapid fire, back-and-forth conversation of Wurtzel with herself, it puts me in mind of the cliché: your mind can be a bad neighborhood; if you go there, you are going to get mugged, albeit in a comical way; mugged by negative self-talk, devaluing self assessments, and rage at the narcissistic slights inflicted by intimates, strangers, and intimate-strangers alike.
Wurtzel’s writing is shot from a cannon. The character sketches are wickedly funny and just as cutting as her own practices of self-injury. One example: “If Archer weren’t so good-looking, I’m not sure he’d exist at all, since he lacks most vital signs [….][H]e is the best opportunity to hang out with a gorgeous man and be certain that there will be no sexual tension whatsoever” (p. 224).
Wurtzel literally calls out the elephant in her family’s living room early in the narrative (p. 58): her parents are fighting, from the time Elizabeth is two years old, when her mom divorces her dad. The parents continue to fight (including in court) throughout her childhood, adolescence, and emerging adulthood, all the while “telling me that their [hostile] feelings for one another shouldn’t affect me,” blaming the victim if she feels affected, making the child an unwitting pawn.
Usually an emotion will shift after a few hours and a depression will shift after a few months, even if no intervention is undertaken other than good rest and good nourishment. To keep the disorder in place, active measure must be undertaken by the person, environment or both. The ongoing family situation is a significant contributor to the extraordinary duration of the distress.
It gets worse. The dad has access to health benefits through a good, albeit low level, corporate job; but it seems that every time the growing Wurtzel gets into an emotional crisis (chronic emergency would be more like it), the dad stops paying for psychotherapy, telling her its nothing personal. The real reason is usually a dust up with the mom.
Queue up the late rock-and-roller Stevie Ray Vaughn: Caught in the cross fire. Elizabeth is. She cannot help but internalize the conflict. Any kid would. This is the way it is. It starts so early and continues so unremittingly, that one must be positively as blind as the parents not to see it: this is an invalidating environment.
Another example of invalidation that might be straight out of Heinz Kohut, MD: “For instance, I’ll walk into her [mom’s] apartment and she’ll just blurt out, Those shoes are so ugly! And I never asked her. And I like my shoes […] The concept of Who asked you? does not exist in my family […] We’re all meshed together” (p. 231). Unremitting, serial breakdowns in empathy, resulting in emotional contagion, conflict, and enmeshment with the toxic self-object and hostile introject. Ouch!
Abandonment comes up early and often. In year-after-year of being sent off to a different camp, depending on which one offers a discount to her and her mom, who are living in a kind of genteel poverty. It induces a real panic about abandonment in the young Wurtzel, resulting in dozens of calls requesting rescue. Having been dutifully rehearsed during latency, this fear takes on a life of its own. “[…] [B]eing alone turns into a terrible fear that I will have no friends” (p. 89).
In several relationships with college BFs (at Harvard College) Wurtzel cries and cries sad tears, angry tears, at the prospect of separation such that the behavior creates the dreaded self-fulfilling prophecy. She goes well beyond “high maintenance” into the land of continuous confrontation, just plain crazy shit, and the bottomless pit of infinite upset all the time. Meanwhile, the guy wants a friend with whom he can go to the movies and party, maybe perform some consensual sex acts between reading about Derrida and Marxism. Enough.
Years later it comes out. The man Elizabeth thought was her dad, who was divorced after two years by the mom, and who also thought he was the dad, is not the biological father. Even though he did not have the DNA data, somehow he was never able to relate to Elizabeth in quite the proper parental way. (See the article by Wurtzel entitled Bastard, cited at the bottom of this post.)
Wurtzel has a gift for zingy one-liners, coming out of the blue, and yet creating their own context instantaneously. As regards the above-cited elephant, “We went to Alaska and we froze to death” (58) – emotionally. More like the abandoning, ice box father and the bonfire mother. Things heat up, especially with her mom: “I come from a family of screamers” (p. 185). Balance is hard to find.
The subtitle is “Young and depressed in America,” and one can sees Wurtzel’s editor’s skillful hand in connecting the dots between individual suffering, of which there is an abundance, and the breakdown of communities, ongoing, whether due to globalization, an opioid epidemic, or the malling / mauling of America.
The reader learns the difference between sadness and negative self-talk and what we might call existential depression: “I’d been expelled from the place where possibility still existed” (p. 60). Depression is the loss of the possibility of possibility. It is not just that I lose love and long for love; I lose the possibility of the possibility of love. This is gonna be tough going.
This is definitely a page-turner. Hard to put down. However, there are also some loose ends. I mean in the narrative, looser than Wurtzel herself.
The title is premised on the interpretation that Wurtzel suffered between the ages of eleven and twenty one from a hard to treat Black Wave. Tons of talk therapy – finally she can’t stop crying for days – and not for the first time – and her shrink prescribes an anti-psychotic – Mellaril [thioridazine] – and its anticholinergic effects promptly dry up her mucus membranes, allowing her “to get a grip on it.” She is able to stop crying.
I am reading this passage and scratching my head. This is an emergency measure, right? Wurtzel is a lot of things, but her reality testing of the everyday is good enough. I know nothing, really, and am not a prescriber. However, I have been know to echo Lou Marinoff’s saying, “Plato, not Prozac!” And yet: An actual antidepressant such as imipramine or disiprimine would have had the same anticholinergic effects, have dried up the tears physiologically, and it might actually also operate as an antidepressant, would it not?!
Perhaps it was because of the unremitting of suicidal ideation that Wurtzel endorsed and expressed that no medical doctor recommended a tricyclic antidepressant. A person can actually hurt themselves with the tricyclic antidepressants, as with any powerful drug, which can cause a fatal heart arrhythmia if consumed contrary to proper guidance and in volume. But if this is supposed to be an emergency measure, a small number of pills in small dosages, closely supervised, would also have been possible would it not? Was Wurtzel getting adequate medical treatment even by advanced 1994 care standards? We may never know.
I am not one noted to value psychiatric labels, seeing them as getting in the way of being fully present with the other person as a possibility. Yet Wurtzel has a breakthrough towards the end of her narrative when she gets one – a label – along with the newly available fluoxetine (Prozac). Her psychiatrist gives her a diagnosis of atypical depression. I would add, demonstrably treatment resistant. “Atypical” because years of talk therapy and first line antipsychotics have barely made a dent in her unremitting self-abuse, inclination to self-medicate with weed, alcohol, and acting out with a series of boy friends, a couple of whom are the target of an intense romantic idealization combined with a neediness calculated eventually to drive them all away. However, at this point, the Prozac seems to work – except that about two weeks after starting to take it, she is feeling a tad better, and her only serious suicide attempt reported in the book occurs. Hold that thought.
One thing lifted Wurtzel’s work head and shoulders above your average narrative of suffering and redemption for me. Wurtzel is working through her invalidating environment and she gets it: “…[M]y addiction to depression …involved the same mental mechanism as someone else’s alcoholism” (p. 23).
Suffering is sticky. The risk of suffering is that it becomes an uncomfortable comfort zone. The body and the mind adapt to chronic pain and chronic stress. Even when the result is still pain, not numbness, the entire messy complex takes on a life of its own and becomes: suffering. If you water the tree of your sorrows, the tree grows. It grows until the suffering becomes the man-eating plant in the back of the Broadway play Little Shop of Horrors. That seems to have been going on here.
Empathy lessons occur in abundance in Prozac Nation, but they are mostly in a privative mode – that is, empathy is conspicuously missing.
Wurtzel is hungry for someone to respond to her as a whole person, writing: “I love you and I support you just the way you are because you’re wonderful just the way you are. They don’t understand that I don’t remember anyone ever saying that to me” (p. 231).
Wurtzel’s mother “loves” her as long as (if) she is brilliant, gets into Harvard, and they can continue intermittently to tear at one another’s guts on special occasions. He dad “loves” her as long as she does not make herself too needy, will pose for his photos, and otherwise leave him alone. Her friends “love” her as long she as is funny and amazing and the life of the party. Her boy friends “love” her as long as she continues to put out, which she does all too casually, leaving her feeling cheap. The impingements come fast and thick; here “love” means acknowledging someone as a whole human being, i.e., empathy; but no one gets her as a possibility.
My take on it? If, at any point, someone would have given her a good sustained listening, something important would have shifted. Nor is it quite so simple. Her suffering would not have been magically disappeared; but it would have been decisively reduced. Once again, we will never know for sure.
Page after page of this page-turner, Wurtzel is explicitly crying out for “love,” and people are trying to love this individual, who seemingly inevitably gets caustically cutting towards others or becomes a needy emotional sponge, an unlovable rag of self-pity, albeit with a sense of humor, driving them away. Thus, Wurtzel’s ultimate test of love: love me even when I am deep down unlovable. It doesn’t work that well.
One can have empathy with the loveable but loving the unlovable is a high bar, by definition impossible. This person needs the firm boundaries of a rigorous and critical empathy. But instead Wurtzel’s friends and counselors efforts are lost in translation and become emotional contagion, projection, and inconsistent efforts to force compliance and conformity.
Finally, Wurtzel does get some empathy from the shrink disguised in the narrative as “Dr Sterling.” She was. Wurtzel writes: “Dr Sterling knew that somewhere in my personality there was a giggly girl who just wanted to have fun, and she thought it was important that I be allowed to express that aspect of myself (pp. 211–212). Predictably the breakdowns and out-of-attunements are frequent. The cutting remits but the acting out – street drugs, sexual misadventures (including the “accidental blow job”), and repetitive, endless phone calls – ramp up.
So what happens? Along comes Prozac [fluoxetine] and Dr Sterling gives it to her. Wurtzel is feeling better as a result of the medicine. But “better” is relative. Wurtzel gets into it with her psychiatrist, and she locks herself in the bathroom and takes the whole bottle of Mellaril [thioridazine], knowing that her shrink is waiting outside the door for her. As Wurtzel feels herself going under from the effects of the drug and she hears her shrink shouting outside the door, she unlocks it.
Now never say that someone who threatens suicide or actually swallows the pills is not suicidal. Never. People have been known to be all-too-unlucky in such situations and succeed where they are using a bad method to try and solve the problem of their suffering. I suggest this was one of those, and arguably as a result of the un-inhibiting effects of the Prozac.
Those are such facts as reported in the narrative. Throughout the book, Wurtzel is plagued by suicidal thoughts, she cuts herself and engages in taking street drugs and crazy sex, but not until she gets the Prozac does she actually take action and make a serious attempt at suicide. Hmmm.
I am not making this up. It is in the book. Has anyone read it since 1994? This is the book entitled “Prozac Nation” and is regarded as some kind of strange endorsement for Prozac. Wurtzel subsequently and consistently denied it was an endorsement of fluoxetine [Prozac], emphasizing her commitment to being self-expressed. That she succeeds in doing in spades. Definitely. What some authors won’t do to move some copy!
I read Wurtzel’s memoir for the first time ever upon learning of her passing on January 7, 2020. We can measure the distance between the publication in 1994 and today in that of all the reviews between then and now no one – not one – mentioned that the fear of abandonment, the invalidating early environment and ongoing invalidating entanglement with the warring parents, the volatile emotions (especially atypical depression), volatile relationships, volatile self-identity, and para suicidal behavior are the check list for borderline personality disorder. I hasten to add checklists are overrated, and I acknowledge I might have missed something.
However, it does put me in mind of a quotation from Marsha Linehan, innovator in Dialectical Behavioral Therapy (DBT), and who, in the video cited below, is talking on camera with permission with an avowedly suicidal patient. Linehan says: “I think it is good that you see it as a problem that you feel suicidal and want to fix that; but suicide is not so much a problem as a solution.” Pause for jaw dropping effect. “People’s lives are so messed up that they want to check out as away of solving the problem. What our program does is help you find a better solution – so it is not really a suicide prevention program so much as a life worth living program.”
Elizabeth Wurtzel succeeded in having one of those lives worth living, even without a formal program and in spite of all the challenges put in her path by accidents of biology, early experience, and her own demons. She had gifts aplenty and she managed to use them to attain a good measure of power, freedom, and full self-expression. Above all, self-expression. We are enriched by Wurtzel’s comet-like trajectory through our post-modern modernity and diminished by her passing. It is truly an ask-not-for-whom-the-bell-tolls moment.
Elizabeth Wurtzel, (1994) Prozac Nation: Young and Depressed in America, New York: Mariner Books (Houghton Mifflin Harcourt (paperback edition), pp. 339, $16.99.
‘I believe in love’: Elizabeth’s Wurtzel’s final year, in her own words by Elizabeth Wurtzel, https://gen.medium.com/i-believe-in-love-elizabeth-wurtzel-s-final-year-in-her-own-words-e34320e41ee0
Bastard Neither of my parents was exactly who I thought they were by Elizabeth Wurtzel, https://www.thecut.com/2018/12/elizabeth-wurtzel-on-discovering-the-truth-about-her-parents.html
Elizabeth Wurtzel by Liz Phair, June 16, 2017, https://www.interviewmagazine.com/culture/elizabeth-wurtzel
Lou Agosta, (2018), Empathy Lessons, Chicago: Two Pears Press: https://www.amazon.com/Lou-Agosta/e/B07Q4XX6PF/ref=dp_byline_cont_book_1
Marsha Linehan talks with a patient about borderline personality disorder and dialectical behavioral therapy: https://www.youtube.com/watch?v=tgzw50SbokM
© Lou Agosta, PhD and the Chicago Empathy Project
In spite of the many patients who have been helped to lead emotionally stable, more productive lives thanks to two generations of psychopharmacological medicines, psychiatry is facing an ongoing challenge of its foundation and legitimacy. That is the take-away in Anne Harrington’s Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (W.W. Norton, 2019, 366 pp., $27.95).
So what is the “trouble” with the “troubled search”? Thereby hangs the tale. The optimistic biological psychiatry of the 1980s and 1990s is beginning to unravel in the new millennium. Harrington’s is an equal opportunity debunking.
All the new drugs that eventually displaced the Freudians, whose pride in the 1950s through 1980s preceded their fall, were developed during that period of time. “All
the major categories of drugs still used today in psychiatry were discovered then [….] no minds were changed that did not want to be changed” (p. xvi).
Meanwhile, in 2013 some thirty years after the biological psychiatrists declared victory, Thomas Insel, Director of the National Institute of Mental Health (NIMH), reported with concern that all of psychiatry’s diagnostic categories were still based, not on biological markers of disease, but “on a consensus about clusters of clinical symptoms.” This was, according to Insel, “equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever” (p. xv).
With a characteristic dry wit, Insel concludes that biology never read the DSM. If this was supposed to be the biological underpinning of psychiatry, the firm foundation was more shifting sand than any might wish.
The really troubling thing that I learned from Harrington is not that drug companies have become less an “engine of innovation” than a “vast marketing machine.” That is already widely appreciated by anyone who has not been living in a cave – including most psychotherapists, psychiatrists, and front line medical doctors.
Harrington’s reasoned, documented, and compelling narrative contains the ultimate smack down: “many psychiatrists, having tethered so much of their identity to drugs and prescribing rights, sold their services to the drug companies” (p. xviii). This remains the blind spot of the profession, even among those who acknowledge the dilemma. If you make a deal with the devil, be sure to read the find print.
The blind spot becomes a black hole as the gravitational pull, in this case of revenue, prevents practitioners from escaping, even though they really want to talk with their patients at the length needed to figure out what is actually troubling them.
The breaking news? What is less well known is that Big Parma is now nearly flat out stopped in its quest. The quest to find the biological foundations of mental illness is on a slope of diminishing return; and Big Pharma seems to be abandoning the search. This does not mean that there will not be copycat drugs of medicines coming off patent or new variations on old themes. To my mind, this development needs to be better known and debated.
Another former NIMH director, Steven Hyman, comments on the abandonment of the field by the pharmaceutical industry: “the underlying science remains immature and . . . therapeutic development in psychiatry is simply too difficult and too risky” (p. xv).
In a separate email communication with Harrington, Hyman writes: “When [pharmaceutical] companies were told they had to compare new drugs not only to placebo but to an existing drug known to be efficacious, or have a predictive biomarker to gain approval in Europe – their response was ‘we don’t know how to do that.’ . . . In essence the EMA [European Medicines Agency] called their bluff” (p. 266).
Full disclosure: in my own training as part of the Committee on Research and Special Topics (CORST) at Rush Medical University in the 2010-2012 time frame, all my teachers, the psychiatrists, without exception, made us memorize the generic name for the medications so as not unwittingly to give publicity to the brand name of the drug companies.
While acknowledging that the medicines often helped, the teachers sensed – indeed knew – something was off the rails. Thus, they expressed their disdain for the monopoly rents of Big Pharma (though not using these exact words). Yet, for so many reasons, they continued to turn the crank as rapidly as possible in prescribing the pharmacological interventions that were the prevailing paradigm. No alternative paradigm was visible.
How could this happen? The irony is that, at a high level, the biological psychiatrists made the same mistake as the Freudians. It is a “pride that goeth before the fall” moment, and notwithstanding selected voices of moderation, both sides came to embrace a position that no one else but us (really) knows anything about anything.
Harrington’s ultimate analysis of the unraveling of the optimistic biological psychiatry paradigm of the 1980s: “I argue that this happened, not just become the gap between hype and the state of scientific understanding was too great to bridge (though it was), but also because of a critical error that the original revolutionaries had made. Instead of reflecting on the extent to which the Freudians had lost credibility by insisting that they could be experts on everything, the new generation of biological revolutionaries repeated their mistake: they declared themselves thenewexperts on everything. No one suggested that it might be prudent to decide which forms of mental suffering were best served by a medical model, and which might be better served in some other way. Revolutionaries don’t cede ground” (p. xvii).
Harrington’s narrative is a page turner, even for those who already know the details and the usual suspects, extending from Charcot’s ground breaking work and monumental self-deception, Emil Kraeplin’s distinction between thought disorder and mood disorder, Karl Jasper’s “brain mythology,” the psychoanalysts domination of psychiatry, through the fever cure of Julius Wagner-Jauregg, John Cade’s lithium salt discoveries, the dancing tuberculosis patients responding to iproniazid (complete with a photo from Life Magazine, 1952), the human rights violations, “operation icepick” of Walter Freeman (and James Watts), Ugo Cerletti’s electroshock machine, the breakthrough to the chemical lobotomy of chlorpromazine, the emptying of the asylums, the broken promises, the litigation faced by Chestnut Lodge, the appalling case of Rose Kennedy, listening to Prozac, anti-psychiatry, the accidental judgments, the good intentions gone bad, and, in the upshot, purposes mistook and fallen on the inventors’ head. All this does Harrington truly deliver.
The narrative left me wondering whether we are not living through another period of brain mythology. Granted the account of neurotransmitters, of serotonin and/or dopamine imbalance, can be traced down to neural synapses, science is at the effect of a massive correlation versus causation fallacy. The voodoo correlations in fMRI research support the colonization of vast areas of the social sciences and humanities by neurophilosophy, neuromarketing, neurolaw, neurohistory, neuroaesthetics, and so on. But enough of my cynicism and resignation.
What are the possibilities going forward? Is an alternative paradigm coming into view? Though Harrington’s recommendations are combined in a section on Afterthoughts that left me wishing for more, what she does offer are powerful and on target. Still, after having spent so much time and effort telling the tortured tale of psychiatry’s rise and looming fall, will the profession be willing to listen to her call for “an act of great professional and ethical courage” (p. 273)?
Her recommendation is to cut scope. Given the lack of underlying science, this also implies expanded modesty about psychiatry’s entitlement to power, authority, and market boundaries. Positively expressed, renew the commitment to engaging with the most severe forms of mental illness and leave the routine care of the “worried well” and support for the mentally ill to other professionals. “
Harrington: “The new psychiatry I am envisioning could also aim to overcome its persistent reductionist habits and commit to an ongoing dialogue with the scholarly world of the social sciences and even the humanities [….] [E]ven as it [psychiatry] retains its focus on biological processes and disease, it seeks to understand ways that human being functioning, disordered or not, is sensitive to culture and context (as the recent crisis over the placebo effect in psychopharmacology […] has likely shown)” (pp. 275 – 276).
Harrington calls for interdisciplinary collaboration on a “pluralistic, powering-sharing approach” (p. 274). Make it a priority to overcome the position that “the knowledge and practices of all the nonmedically trained workers are by definition subordinate to those of the medically trained ones” (p. 274). This would help to close the credibility gap suffered by the psychiatric establishment as a result of the shameful ways of deinstitutionalization in the 1960s and ‘70s led to homelessness, incarceration, and premature death (pp. 274 – 275).
I can hear psychiatrists saying, off camera, we too were blindsided, we too did not know. That may indeed be the case, but professional psychiatry has been left holding the smoking chlorpromazine gun. A major tranquilizer and a highly useful one; but nothing like insulin that a diabetic would contemplate taking for lifetime due to a specific disease that leaves the patient deficient in insulin. Begin the process of rehabilitation by acknowledging the solid social science research that shows many people with serious mental disorders benefit far more from being given their own apartment and access to support communities than a script for new or stronger antipsychotic (p. 275).
Harrington makes a powerful case that general practitioners and psychiatrists are perpetuating a fiction that the drugs they are prescribing are correcting biochemical deficiencies caused by disease, much as (say) a prescription of insulin corrects a biochemical deficiency caused by diabetes (p. 273). Such rhetoric is badly oversold. Harrington does not say that the medicines do not help the person tolerate distress, regulate emotions, or self-sooth. Often they do. If one is going to step in front of a bus, far better to take the medicine. Live to fight another day.
Given the complexity of the scientific challenges, psychiatry need not feel embarrassed. However, neither should it be zealously promoting imminent breakthroughs and revolutions as if it were an adjunct to the popular press or a corporate press release.
Harrington makes the case that the underlying science is not anywhere near the level the neurohype would have us believe. “You have a chemical imbalance” is a marketing position, not a scientifically established truth. “Schizophrenia is like diabetes and you have to take this antipsychotic drug for the rest of your life” is a rhetorical position, not a scientific fact. This is scientism, not science. This is psychiatry’s troubled search for the biological basis of mental illness.
(c) Lou Agosta, PhD and the Chicago Empathy Project