a loud creaking noise…

Posted on Saturday 6 July 2013

This is from a transcript of Osherhoff v. Chestnut Lodge in 1985, amended after a failed arbitration. I can’t find the original from 1982. I suspect that the wording of number 6. might have been changed between the two but that’s just a guess that I can’t confirm:

4. Dr. Osherhoff volintarily admitted himself to Chestnut Lodge on January 2, 1979 complaining of depression and agitation. The clinical symptoms included: (1) progressive incapacitation which worsened during the morning; (2) anhedonia (an incapacity to find enjoyment); (3) agitation which lead the patient to engage in pacing activities, almost unable to keep still; and (4) difficulty in concentrating and working effectively.

5. There are two kinds of depression known to psychiatry. One kind of depression is an individual’s reaction to external situations and events. It is usually milder and may respond to psychotherapy alone. This type of depression usually appears following a precipitating event such as a result of "symbolic" loss. Depending on the duration and degree of symptomatology, somatic treatments (i.e., medicinal and/or electroshock therapy) may or may not be indicated. The other kind of depression results from internal physiological causes and is called "endogenous" and may appear "out of the blue"; sometimes it begins as a "reactive" depression but then develops and independent biological life of its own and is transformed into a depression having the characteristics of an endogenous depression and is sometimes referred to as "endogenomorphic". The endogenous and endogenomorphic depressions have a physiological basis. They are of a more severe profound nature and present with clinical characteristics indicating a physiological disturbance in the central nervous system, such as sleep disturbance, excessive agitation as manifested by pacing and handwringing, weight loss and disturbance of mood. "Endogenous" or "endogenomorphic" depressions should be treated by somatic means.

6. The appropriate treatment for depression depends on which type of depression in involved. Endogenous or endomorphogenic depressions, which are strongly grounded in physiological disturbances within the central nervous system, are responsive to electroconvulsive (shock treatment) or drug therapy. In current terminology, these physiologically-grounded depressions are referred to as "major depressive illness." This term replaces the earlier used terms "endogenous depression" "agitated depression," "psychotic depression" and "melancholia." This form of depression is uniquely responsive to somatic treatments as compared to other forms of depression. It is easily recognized by a trained professional because of its associated sleep disturbances, weight loss and agitation, and is the subject of a vast body of scientific and professional literature. For this reason, it is important that health care providers dealing with depression perform a complete and careful diagnosis to ascertain the type of the depression they are dealing with.
Long ago in a previous career, I was a part of a team that had found something new, and being the youthful member of the team, I was the one to do the ponderous literature review. I spent many months poring over dusty volumes and ancient articles. As tedious as it was, it was a marvelous lesson. The hints and pointers towards our finding stretched back to the dawn of time – beautifully illustrating how medicine and science creep and build towards new levels of understanding. But reading this thirty year old legal complaint, I’m having a much different reaction. These are the things I was taught as a resident. These are the things I’ve seen in my forty year psychiatric career. These are the things I still believe as they are written here, even though by credential, I might be expected to be on the other side of the fence. The essence of the specific case is in the next paragraph:
7. Dr. Osherhoff was suffering a major depressive illness (herinafter referred to as "major depression"). Nevertheless, Chestnut Lodge negligently failed to properly diagnose the kind of depression from which Dr. Osherhoff was suffering. The failure to make this proper diagnosis was a result not only of negligence but as well appears to be grounded in a doctrinaire approach that Chestnut Lodge applies to all patients in which it apparently refuses to recognize that some mental incapacities are physiological in origin.
Check and Mate! in my book [see Dr. Carroll’s comment]. But it changes the context of the Gerald Klerman v. Alan Stone debate discussed in the last post [respecting our limits…]. Although I would still recommend a trainee read the writings of the Chestnut Lodge legends [Harry Stack Sullivan, Frieda-Fromm Reichmann, Otto Will, and Harold Searles], their contributions are nowhere seen in this case of medical malpractice. Regressive intensive psychoanalysis would’ve been contraindicated for the treatment of the kind of depression Rafael Osherhoff had in 1979 just as today. I would also recommend the trainee read the writings of Osherhoff’s experts [Gerald Klerman, William Z. Potter, Frank Ayd, Bernard Carroll, Avi Kiev, Donald Klein] as I did in those days. The point of this post isn’t about the Osherhoff case. That was malpractice – duly punished. It’s that in those few paragraphs, there’s the nidus of a rather massive mistake in the process of happening right before our very eyes. And the reason I think it might have been worded differently in 1982 is that the highlighted adaptation to the then new DSM-III might not have been there yet.

In this document, I hear a loud creaking noise. I didn’t even know about this case at the time, but in those days, I must have heard that noise, because I abruptly changed the whole direction of my life for a second time in response. And I guess now I feel obligated to live up to my daughter’s naming this blog 1boringoldman, because I know I’m going to linger on this legal document longer than many can tolerate. It speaks to the fact that almost everything written is in some  way autobiographical, and this topic is certainly that for me. It also happens to address a critical node in the history of modern psychiatry, and in my opinion, also focuses our attention on something that’s happening of equal importance right this very minute. In perseverating on this topic, I hope to skip being repetitious from earlier passes [when I looked at the documents from the time of Dr. Spitzer’s framing the DSM-III or the time I ran across Dr. Mel Sabshin’s book about this same period] by referencing those posts from times past, and sticking to the current thread. I think this case and the subsequent furor adds to the understanding of the narrative [but I’ll be the first to admit that boring people rarely know when they’re being boring]…
    July 6, 2013 | 8:10 PM

    Linger on o’ wise psychiatrist, you. For personal reasons, this is exactly what I want to see you get into, right now. These words

    One kind of depression is an individual’s reaction to external situations and events. It is usually milder and may respond to psychotherapy alone. This type of depression usually appears following a precipitating event such as a result of “symbolic” loss.

    are music to my ears. The kind of “depression” I was suffering when I first was given an anti-depressant was just like that— I was mourning the setback and loss of momentum I suffered after months of the worst PTSD I had ever suffered up to that time. I might have also been suffering from a little B-12 or a mild iron deficiency (I was vegetarian); but what I needed was counseling for PTSD, the losses I suffered because of it, the identity crisis that went with it, and the fear it would start again. I was functioning— not as well as I was famous for in my circles— but I was taking care of myself.

    I’m completely open to the idea and diagnosis of endogenous depression, it’s just that I’ve never suffered from it. Now, the “pendulum” has swung and any depression or even just symptoms of depression are treated with the big guns— anti-depressants, “adjuncts” that are anti-psychotics, etc. It looks to me to often be as much of a case of malpractice as this case, only it’s systemic now.

    I don’t think I’ve had a lot of psychoanalysis, but I have overcome serious suffering, self-incrimination, and self-blame with various styles of counseling with psychiatrists and psychologists. It saddens me that it’s so difficult to get that anymore. I think the field of psychiatry has thrown away a profoundly effective tool for people who are suffering a reactive depression, or grief, or extreme doubt about themselves who could be patched up in a short time and sent on their merry way without ever having to think of themselves as having an incurable biological flaw in their brain. That’s a diagnosis that should not be made until all other possibilities are eliminated, though trying various treatments “as if” is fair enough.

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