Archive for the ‘Shrink Rap’ Category
Things We Argue About
Sometimes, especially on the podcasts, we get heated and go at it. Oh, sometimes on the blog, too. Among ourselves, we refer to these discussions as “The Benzo Wars” –the posts where we’ve argued about what role benzodiazepines and addictive medications have in psychiatry, and “Who Deserves Care” cause Clink thinks her patients need help more than mine (..if you see me walking around with bruises, you’ll know it’s me……)
So what else do Shrinks argue about? We’ve got a colorful history here. Took us decades to decided if homosexuality was a disorder (yes, maybe, no). Is psychosurgery with knitting needles good? Should our patients get special accommodations? What if I’m allergic to your support dog?
Ah, we’re writing a chapter and I like the input you all give!
And please listen to our podcast. We’re back…probably monthly for now, but weekly once we finish the book and they teach me how to edit them.
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Posted in My Three Shrinks Podcast 49: Pixelated Psychiatrists
ave an iPhone app to diagnose schizophrenia. All of these topics (and more) can be found on Dr. Barta’s blog Adventures in Telepsychiatry.
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Am I Normal?
Paperdoll commented that ?she (?he– do paperdolls have gender?) likes posts about “normal.”
The quick answer is: No, you’re not normal! Normal people don’t call themselves “paper doll.” Normal people also don’t write blogs called “Shrink Rap” or post photos of their feet all over the internet.
I’m a psychiatrist and people ask me all the time “Is that normal?” or worse, “Am I normal?”
And we start with a semantic disconnect here: I equate “Normal” with “Booooring!” and
To my patients, however, “Am I normal?” doesn’t mean Am I normal, it means “Please tell me I’m not crazy.” You’re not crazy. Okay, Paperdoll, I don’t know you, and I don’t know what crazy means to you, but there’s probably a good shot you’re not crazy. And I am definitely not crazy. Oh, yeah, I’m a psychiatrist and I’m not supposed to use the word crazy. Okay, you’re normal.
So sometimes I’m told that I’m too normal to be a psychiatrist. Oh, all the Shrink Rappers—believe it or not— kind of “look” normal….except for ClinkShrink who has started acting like Spiderman while she repels off steep cliffs. Apparently– or so I’m told– psychiatrists don’t look normal.
Where am I going with this? And why? Is this kind of bloggy discourse normal?
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Saving Normal
Allan Frances chaired the APA task force that created DSM-IV. On Monday, he had an editorial in the Los Angeles Times called “It’s Not Too Late to Save Normal.”
Dr. Frances writes:
The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day — despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.
The manual, prepared by the American Psychiatric Assn., is psychiatry’s only official way of deciding who has a “mental disorder” and who is “normal.” The quotes are necessary because this distinction is very hard to make at the fuzzy boundary between the two. If requirements for diagnosing a mental disorder are too stringent, some who need help will be left out; but if they are too loose, normal people will receive unnecessary, expensive and sometimes quite harmful treatment.
Okay, I have a confession to make here: I don’t keep a copy of the DSM in my office. I own an edition which I’ve opened a couple of times while writing our book. I don’t care what the precise diagnostic criteria are: mostly I know them, but I’m left with the fact that if you wander into my office saying you’re tormented and suffering or having trouble functioning, I’m going to treat you. And if I prescribe medications, it’s mostly based on symptoms. Totally? No, because if there’s history of mania (I know those symptoms) or any sense that the diagnosis might be bipolar disorder, I’m going to go pretty gently with the antidepressants, just because I’ve notice that people with tendencies towards mood instability (whether or not it meets criteria for full mania) do better if the antidepressants are kept to a minimum. I hear we over-diagnose, but I’m going to comment that absolutely no one has ever come to see me for simple, uncomplicated grief or a normal reaction to a stressor– people just don’t define this (and let’s hope it stays that way) as a reason to run to a psychiatrist. And everyone’s favorite diagnostic complaint: Shyness vs. Social Anxiety Disorder. 18 years of practice and how many patients have come with a chief complaint of isolated social anxiety? Zero. And how many patients in my practice carry the diagnosis of Social Anxiety Disorder? Zero. Over-diagnosis of mood and anxiety disorders in general? Of course– maybe we’re treating people who previously would have just suffered. Or maybe we’re forced to assign a reimbursable diagnosis because V Codes (phase of life and relational disorders) can’t be reimbursed. It all gets to be circular reasoning.
So who’s placing bets on whether I purchase the DSM-V?
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I’m Still Here.
I’m talked out on the subject of whether or not psychiatric illnesses exist and whether or not psychiatric treatments work. I went to work today. I think I’ll go again.
For the sake of completion, here’s Louis Menand writing in The New Yorker, “Head Case.” Click the link and read away.
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I Might As Well Go Home Now.
Psychiatry’s getting blasted this week: we don’t know what we’re doing, our diagnoses are not valid or reliable, our treatments no better than placebo and we maxed out in the 1960’s with imipramine. Yesterday’s NYTimes Magazine article on The Upside of Depression (see my post) implies that we’re derailing evolution by treating what may be an adaptive condition, and The Wall Street Journal says Psychiatry Needs Therapy ! Edwarder Shorter writes:
Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn’t exist and treated with a medication little more effective than a placebo.
What’s a shrink to do with this? Perhaps the diagnoses we make are wrong and the meds we use are ineffective, but at the end of the day, the patients seem to get better. Maybe it’s my charm (hmmm, there’s a thought) or the concurrent psychotherapy, or some other non-specific factor…maybe the cognitive dissonance that you have to believe that anything you’re paying a small fortune for has to be working.
So do read Shorter’s article and tell us what you think.
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Why Can’t We Be Sad?
Today’s New York Times Magazine has a really interesting article by Jonah Lehrer called “Depression’s Upside.” Mr. Lehrer talks about a possible evolutionary purpose for Major Depression.
Mr. Lehrer writes:
The persistence of this affliction — and the fact that it seemed to be heritable — posed a serious challenge to Darwin’s new evolutionary theory. If depression was a disorder, then evolution had made a tragic mistake, allowing an illness that impedes reproduction — it leads people to stop having sex and consider suicide — to spread throughout the population. For some unknown reason, the modern human mind is tilted toward sadness and, as we’ve now come to think, needs drugs to rescue itself.
The alternative, of course, is that depression has a secret purpose and our medical interventions are making a bad situation even worse. Like a fever that helps the immune system fight off infection — increased body temperature sends white blood cells into overdrive — depression might be an unpleasant yet adaptive response to affliction. Maybe Darwin was right. We suffer — we suffer terribly — but we don’t suffer in vain.
So I didn’t like the article at the beginning; it relied on anecdotes–the woman who felt so much better with antidepressants that she’d grown complacent in a bad marriage, for example. It doesn’t capture all the patients I see, and any way you dice it, if you end up dead from suicide, your productivity comes to a halt. It seems to me that there are some people who suffer in ways that these anecdotes don’t explain. I suppose, however, even if we assume that depression is an unproductive, tormenting state, when it ends, is there something to be gained from having gone through it. Lehrer tells us, “Wisdom isn’t cheap, and we pay for it with pain.” I, personally, think there remains a differentiation between pain and major depression, and that perhaps one can grow through all sorts of suffering, and I’m all in favor of finding my own personal path to wisdom in ways that might not entail so much suffering. Just a thought.
But I ultimately, I liked the article because Lehrer, while clearly a proponent of the “don’t mess with evolution, less drugs, please,” school of thought, presents a balanced view. He gives Peter Kramer (Listening to Prozac) a voice, and talks about the objections to the viewpoint he puts forth. He describes a theory that depression is evolutionarily helpful because of the ruminative nature of the illness. He also cues us in that this is just one explanatory theory which remains unproven, and there are others. Lehrer continues:
Other scientists, including Randolph Nesse at the University of Michigan, say that complex psychiatric disorders like depression rarely have simple evolutionary explanations. In fact, the analytic-rumination hypothesis is merely the latest attempt to explain the prevalence of depression. There is, for example, the “plea for help” theory, which suggests that depression is a way of eliciting assistance from loved ones. There’s also the “signal of defeat” hypothesis, which argues that feelings of despair after a loss in social status help prevent unnecessary attacks; we’re too busy sulking to fight back. And then there’s “depressive realism”: several studies have found that people with depression have a more accurate view of reality and are better at predicting future outcomes. While each of these speculations has scientific support, none are sufficient to explain an illness that afflicts so many people. The moral, Nesse says, is that sadness, like happiness, has many functions.
The article finishes off with the idea that people in depressive states are better thinkers, they notice more, they work better. He talks about a study that shows that on gloomy days with dismal music playing, shoppers notice more trinkets by the cash register. Gloomy weather and oppressive music might set a low mood tone, but this seems a far cry from an episode of major depression, and not something that is generalizable to anything more than clouds and music and trinkets. There’s a second study mentioned of undergrads doing an abstract reasoning test that shows people with a “negative mood” perform or focus better; again, it falls short of being a comparison for major depression. The shrinks among us find it hard to imagine that ‘negative moods’ and Major Depression are all that linked. Everyone has negative moods. Not everyone has major depression.
What about the studies that link mood disorders and creative tendencies? This does seem likely, and we’re left to wonder (my own thoughts, not the article) if the intense experience of an episode of mood disturbance either fuels creativity by feeding it material or requiring a release, or if the genetics are wired such that mood disorders and artistic talents might be coded near one another.
You thoughts?
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Let The Sun Shine!!!
We’ve had 80 (?) inches of snow here this year. Unheard of! Who moved that Mason-Dixon line? It was enchanting at first, and I felt like I was on vacation: fires, hot cocoa, no where to go, watch a movie, eat good food, for a day or two here and there I couldn’t get to work and no one wanted to see me. Snow Day!
Ah, but the enchantment ended. The bushes are flattened. The gutter are draped across my house leaving rotted beams exposed. The snow is in ugly blackened mounds everywhere, and as it gradually melts, there are tracks of mud pretty much every where.
And today’s forecast: snow. Yesterday they were saying 5 to 10 inches. Two patients have called to cancel (Shrink response: Call me in the morning after you look out the window). So far, so good. Hoping the gutter guys can come today.
Enough hot cocoa. Enough days off. Enough trying to reschedule everyone. Enough shoveling, Enough salt tracked onto the wooden floors. Enough. Enough. (I know, it could be much worse).
Here’s to 75 and sunny, somewhere?
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A Movie For ClinkShrink
Perhaps the most disturbing movie I’ve ever seen.
So we start with the ferry ride to Shutter Island where two federal agents are headed to a a particularly creepy hospital for the criminally insane to search for an escapee— a mother who drowned her three children and who has now “evaporated” from her locked cell. The story revolves around the haunted character of Teddy Daniels (Leonardo DiCaprio) whose flashbacks and dreams pave the story: his role in the liberation of a Nazi death camp & the horrifying death of his young wife in a fire. The movie is dark, it is set on an island during a hurricane, in a hospital built during the Civil War, with Ben Kingsley in a bow tie playing the polite but devious head psychiatrist. In every scene, things are falling: rain, snow, papers swirling, ashes, unknown particles. It’s compelling and confusing, all at the same time. The plot twists and weaves, and by the end the reality was a bit of a jumble. What really happened? We didn’t agree, and when we caught dinner after, the couples at the next table were having the same discussion.
Not exactly a positive view of psychiatry, but this one was so much about the twists of the plot, that it hardly seems worth worrying about the portrayal of our profession. And “disturbing” : the storyline itself was not terribly disturbing, but the images of dead children left me very unsettled. I’ll leave the full analysis to ClinkShrink….and no plot spoilers here.
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Medical Marijuana on KevinMD
Lockup doc gave us the head’s up that KevinMD is also talking about the legalization of marijuana for medical uses. He has good discussion of the issues up, do check it out: Medical Marijuana has Doctors Asking Questions. How’d he know I was asking about this?
The summary comes from HCPLive:
In January, New Jersey became the 14th state in the nation to legalize marijuana use for certain chronic illnesses. Other states where the use of medical marijuana is permitted include Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington; around a dozen more states are weighing pending bills.
The New Jersey law is the most restrictive in the nation and authorizes prescribed marijuana for only a handful of chronic illnesses, such as multiple sclerosis, cancer, glaucoma, epilepsy, Crohn’s disease, AIDS, muscular dystrophy and Lou Gehrig’s disease. Unlike other states, physicians in New Jersey will not be able to prescribe medical marijuana for anxiety, headaches, or chronic pain.
It goes on to discuss the lack of evidence to support uses for medical marijuana, and the obstacles to research:
Despite the Obama administration’s relaxation on prosecutions, many researchers are still having difficulty getting approval to conduct studies that involve smoking marijuana. Requests to conduct the studies must go through the National Institute on Drug Abuse (NIDA), which controls supply from a plantation at the University of Mississippi, the only federally approved source of marijuana. NIDA routinely turns down study requests unless they are designed to evaluate the potential harm from smoking marijuana. The Drug Enforcement Agency has also declined petitions from researchers requesting permission to grow their own marijuana for use in studies.
The article notes that there are some continued issues:
Most states with medical marijuana laws allow employers to refuse employment to individuals who use medical marijuana. In some states, like Colorado, the laws are ambiguous and employers are unclear as to whether they can forbid employees to use medical marijuana outside of work. Schools are also grappling with the issue, as well, with more high school students—particularly in areas with less restrictive medical marijuana laws—receiving prescriptions for marijuana, increasingly to treat ADHD. In addition, some facilities that perform organ transplants acknowledge denying transplants to patients who use medical marijuana.
In the absence of any proven benefits from smoking marijuana, physicians in the 14 states where it is legal may want to discuss some of the pros and cons with their patients prior to issuing a prescription. Patients need to be aware of the potential impact of medical marijuana on all facets of life and should be wary of letting the anecdotal hype surrounding medical marijuana use dissuade them from first trying a proven treatment option.
View the discussion on HCPLive.com.
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On another note, Rach asked us to post the following:
Stan Kutcher at Dalhousie University (Halifax, NS) is asking Canadians for feedback on how to improve infant, child and youth mental health services via an anonymous survey.
https://surveys.dal.ca/opinio/s?s=7808
Listen to our latest podcast at mythreeshrinks.com or subscribe to our rss feed. Email us at mythreeshrinks at gmail.
