Obama, Laureate

Those Scandinavians, as we know from Munch, Hamsun, and Sibelius, are known for their riotous humor. And this time of year, as northern Europe begins its dive into collective Seasonal Affective Disorder, the Nobel Prizes afford an irresistible opportunity for global titters. Nonetheless, President Obama must be muttering, "With friends like these..." What's next, an honorary doctorate from Harvard, or perhaps a lifetime achievement award from ACORN?

I'm a sucker for grand symbolic gestures, but I have to believe that the Peace Prize is less about Obama himself than about the ideal of the United States as inspiring and responsible superpower, which people in most parts of world appear to want to be back. Who does the world look to? Europe? With polite curiosity. China? With wariness. Russia? Please. If the 19th century lasted, politically, until 1914, it appears the the American century, while a bit dyspneic lately, hasn't yet breathed its last.

Total War (?)

"War is the continuation of politics by other means."

Clausewitz

Frank Herbert in today's New York Times both laments the dearth of public interest and support for the wars in Afghanistan and Iraq and suggests that such lack puts in question those wars' very reason for being. Wars? War is one of those words (like "love" perhaps) that is misleadingly applied to a vast spectrum of human activities.

Horrific tragedies for military families continue, but I would submit that Iraq and Afghanistan elicit little more than a yawn from most of the public these days because these conflicts have become too remote and too abstract for most to fully appreciate (in this respect they may be similar to global warming and health care). I think I am no Pandora in reminding that 9/11 was eight years ago; that's twice the duration of U. S. involvement in World War II. No further attacks have occurred on American soil. Unlike Germany or Japan seventy years ago, Al Qaeda simply does not pose a sufficiently concrete threat to American survival, whether directly or by distortion of the global order, to provoke an unequivocal response.

To be sure, the risk of further attacks has by no means been removed, but the "war on terror" is no more a true war than the "war on drugs" or the "war on poverty" were true wars; it is a failure of metaphor. The adversary is no state, but rather an enormously complex cultural system, and perhaps "police action," notoriously applied to the Korean War if memory serves, most accurately applies to Iraq and Afghanistan.

Herbert marvels that only one percent of the U. S. population is directly involved in the military effort to protect the country, at this point against Al Qaeda. But this ceases to be surprising if one views the work in Iraq and Afghanistan as analogous to police work. After all, the work of the police is really never done; there never is any end point at which the crime rate is reduced to zero. The idea is to reduce the risk to the public to an acceptable level. That is really all the military can hope to do at this point in Afghanistan. The police protect all of us, but only a tiny fraction of the public is actively involved in policing. Is this fair? Apparently so, inasmuch as police work is voluntary and rewarded with respect and honor, if also by substantial risk.

I wish "war" would be used only for serious conflict, that threatening the actual integrity of nation states. Some other term, "police action" if nothing else will serve, should be used for more measured responses. If we really thought that Al Qaeda posed an irrefutable risk to our national survival (by means of weapons of mass destruction presumably), would we post a few tens of thousands of soldiers in the wasteland of the Afghanistan/Pakistan border? No, we would institute a draft and flood the region with, I don't know, half a million or more soldiers, reduce the rocks there to smaller rocks, and flame out cave by hidden cave, as we did in Pacific islands on the road to Japan. The national will is not there because the perceived threat is not there.

To be sure, this could change tomorrow with an audacious new attack. But the risk of prevention in military matters, like prevention in, say, psychiatry or policing (Minority Report anyone?), is that one can make things worse in trying to make them better. I am not recommending pulling out of Afghanistan, as if I had expertise to do so, but I wish we could stop calling it a war, as if clear victory were possible. Deaths are parallel and appalling tragedies wherever they occur, but at this point the death of a soldier in Afghanistan has more in common with the death of a state trooper in the line of duty than it does with a death on the beach on D-Day.

Is Humor Possible in Psychiatry?

I just have a few moments before heading off to my (perpetually solemn) work, but at the risk of seeming to protest too much, I thought I'd dash off a few thoughts on humor and its hazards in psychiatry as raised by the last post.

The theory of humor is famously unfunny, but it seems to me that amusement can arise from: our common vulnerability to physical circumstance (slapstick), the humbling of the high and mighty and the pretentious (satire), and the sheer delight of ambiguity (puns).

The general humor of medicine, such as it is, owes most to satire inasmuch as doctors are viewed as (and really are) self-important. However, psychiatry is more subject to smirking precisely because of the ambiguity of its practices. Thus the myriad on-the-couch cartoons of The New Yorker are funny precisely because psychoanalysis is an ambiguous endeavor (this humor is also safe inasmuch as the patients there are viewed as well-to-do worried well). However, from the point of view of stigma, one could argue that psychoanalysis is in desperate straits as a profession; can it afford such lampooning?

There are a number of problems that are not funny because they are both serious and unequivocal: schizophrenia, dementia, mental retardation, severe depression, etc. However, when, as yesterday, when I see a new patient who has diagnosed himself with adult ADHD, I smile wryly to myself not because ADHD is not a real and serious condition, but because it has become so faddish and so ambiguous. Senility used to be faintly amusing until it became better appreciated how devastating dementia really is. Similarly, drunkenness is becoming less amusing over time as the gravity of alcoholism is better appreciated.

Arguably bipolar disorder is in a class by itself in this respect inasmuch as, in its severe forms, it is an appalling and potentially fatal disease, but it continues to defy proper understanding, as reflected in the ongoing controversies over its diagnosis and treatment. If I sometimes roll my eyes at bipolar disorder, I am doing so not due to its sufferers, but due to my and our own incomprehension of what is really going on. I will grant that, given the epistemological quagmire, humor may be best avoided, but prudence does not always prevail.

So in my humble opinion the Onion piece was funny on multiple layers. It was a kind of behavioral pun, in which Obama's roller coaster ride in politics and public opinion was suddenly cast in the absurd new light of a mood disorder. It was absurd, and therefore funny, precisely because we know that Obama doesn't have bipolar disorder (if he suddenly did, it would cease being funny). And given Obama's lofty status ("The One"), there is a pleasure in puncturing the pretension, even for one of his supporters.

So as a politically-interested psychiatrist, I was naturally amused not because the piece somehow made fun of bipolar patients, but because it showed the fallibility of our own diagnostic practices in a political context. I can well understand, of course, that someone with clear-cut bipolar disorder might view the Onion piece rather differently. After all this analysis, it ceases being funny, but that fact in itself is mildly amusing.

Bipolar Barack

Some time ago I wrote a post that questioned the practical feasibility of electing a U.S. president with openly diagnosed bipolar disorder. I caught some flak for that, but I have changed my point of view only today, thanks to this mind-blowing story by The Onion. This changes everything. Vice-President Biden is helpfully diagnosed as well at the end of the first clip. If President Obama starts to put on a lot of weight, we'll know why. (No, this is not a cheap shot at bipolar disorder; it's merely hilarious).