Tower of Brains

It may be a pure coincidence, but at the San Francisco Museum of Modern Art they're displaying a tower of brains during APA week. Meanwhile, the DSM5 is officially out:

And if that weren't enough chaos for you, we have the obligatory APA protesters. (Do urologists get protesters at their conventions?)

I'm looking forward to meeting with Roy and our longsuffering Clinical Psychiatry News editor for dinner tonight.

100 Years of Psychiatry at Johns Hopkins

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In honor of 100 years of psychiatry at Johns Hopkins, Baltimore cinematographer Richard Chisolm, along with Kindall Rende,  created this movie of members of the department talking about psychiatry at Hopkins.  Many of the people shown in the film have been guest bloggers on Shrink Rap, and they include our mentors, colleagues, and friends.  Both ClinkShrink and I are proud to be members of the department and we are both grateful for the education we've received, so we hope you'll spend a few minutes watching Richard's tribute.

Manual of Mishegas, an alternate to DSM-5

Starting 6/1, CMPS will be using an alternative diagnostic system instead of DSM-5.

This will be the only diagnostic system allowed on our new EHR system. See:

The Diagnostic Manual of Mishegas:

potchkied together and .com-piled by 

Jay Neugeboren, Michael B. Friedman, Lloyd I. Sederer M.D. 

THE DIAGNOSTIC MANUAL OF MISHEGAS (DMOM)

The authors cut through the hundreds of categories in the 1000-page D.S.M. by dividing all mental disorders into two realms: mishegas major and mishegas minor. And for each of the sub-categories it analyzes—spilkes major (and spilkes minor), yenta, kvetch, alter kocker, shnorrer, dementia-with-benefits, etc. THE DMOM will enable readers to transform ordinary tsuris and mishegas—the glooms, blues, angsts, and general chazzerie of their lives—into transcendent and easy-to-understand categories. It will turn kvetching into kvelling and guilt into gelt, so that readers will learn to live at peace with their inner mishegas and to treasure its precious and life-giving absurdities.

Comments:

" ich dorf es vi a loch in kop (it's needed like a hole in the head)...."

"A Serotonin Reuptake Inhibitor is no substitute for a good piece of herring!"

"I hate this book!"  (Herbert Luftmensch, Chair, Inner Sanctomonium Sub-Committee, APA)

Changes Keep Coming and Dinah is Grumpy

For today's blog post, I whine over on Clinical Psychiatry News, and whining it is.

See CPT, DSM, EMR, and more: growing weary of alphabet soup.

The Stolen Post, Without Permission, from 1 Boring Old Man

There's a psychiatrist who writes a blog that's older than Shrink Rap called 1boringoldman.  It's a great blog, and Mickey, the blog owner, should have more appropriately named himself 1reallysmartoldman.  I go to it sometimes, but it's more political than I like, it's often filled with graphs and numbers (more of a Roy thing), and .....I hesitate to admit this here because obviously that boring old man has better vision than I do....but the font is painfully small and the layout is hard to follow.  It's archived by month/year, not subject, and sometimes I'm not sure I've expanded what I wanted to read.  Oh, here at Shrink Rap, I change the font to large and we put the whole post, no matter how long, on the page so that no one has to search, though I am terrible about tagging topics.  I know, psycritic says we need a new look, but there is something comforting to me about the familiar, even if it's noisy, and think about all the nonsense that travels through your brain, and then multiply that by 3, because there's three of us fooling with the sidebar, sticking on links and ducks, and books and bacon.  I don't really understand why our sidebar offers "Shrink Rap with Bacon," but it does.

Rambling aside, in need of more coffee, I did love a post by Mickey the other day, so I thought I'd just steal it.  If it troubles you, sir, I will take it down.  With a link to the original post (if you're of a certain age, get your reading glasses):  http://1boringoldman.com/index.php/2013/05/12/a-thought-3/http://1boringoldman.com/index.php/2013/05/12/a-thought-3/

1boringoldman writes:

a thought…

Posted on Sunday 12 May 2013

There was a time – it was a long time ago, maybe 40 years ago – when I could think whatever I wanted to think. I could use a jillion models – be doctor medical model at 8AM, psychoanalytic at 9AM, cognitive behavioral before lunch, and throw in a little existentialism in the afternoon. It was like a toolbox filled with a lot of wonderful ways to think about the problems before me and my job was to bring whatever I could find to help until I found what really mattered – some shared way of understanding that my patient and I could use to make some headway. And in conferences we’d argue back and forth, the various different kinds of us, about what was right and wrong, which was all in fun because there wasn’t any right or wrong just different cameras on the same set, then we’d all go to the pub and be human together. It was an exciting time for me. I miss it – always have.

Then in the 1980s, that all changed. Because I was a psychiatrist, I was supposed to be a biologist. Well, I am a biologist, but that’s just a piece of what I am and what patients needed from me. And because I was a psychoanalyst, I was supposed to be … psychoanalytic, but that’s just a piece of what I am too and what patients needed from me. And so on and so on through the toolbox. And worse, I wasn’t supposed to meander from tool to tool until I found the one[s] that fit that patient on that day, I was supposed to have some consistent evidence-based position that could be validated by some third party to prove I wasn’t a charlatan or a I-don’t-know-what-but-it-was-a-bad-thing. I wasn’t up to it. I’d spent a long time refining my skills at doing it the other way which was some hard work, so I went off on my own and did what I’d learned to do until I retired. I’m so glad I did that.

Now it’s coming full circle. The psychologists are saying that the medical model psychiatrists are off the deep end. The biologists  are at war with each other over which biology is the correct biology. The humanists are after the robots. The analysts have learned to be quiet, but you can bet they’re thinking their thoughts. I’m sure all the existentialists in France and elsewhere are off being existential together. I know a lot of very talented and competent mental health types who come from a wide variety of backgrounds but they are unified by a few simple things – a deeply ingrained practice ethic, a suitable awe for the marvelous and monstrous variability in human beings, a genuine curiosity, broad training and life experience, and humility. If they can’t help you, they’ll at least be able to help you find someone who can.

When I think back on things, the most helpful piece of my training in mental health was becoming a hard science Internist first. The reason is that I knew a secret my psychiatric colleagues didn’t know. The hard science medicine I left was no more precise and assured than the loosy-goosy psychiatry I went to.  Sure there were more tests, more precise diagnoses, more drugs. But there was the wall of physical disease beyond which you couldn’t go. Once you found it, that was the end of the road. With mental illness, there’s no wall. Even with the worst cases of our most devastating illnesses, there’s still something that can be done, even if it is only a small thing. You may not find it, but it’s not because it’s not there.

So in one way, it makes me sad to read all these battles flying back and forth precipitated by the release of the DSM-5. On the other hand, it reminds me of those days long ago when we fought with each other to learn from each other. I’ve missed that more than I knew. And it makes me feel hopeful that what’s up ahead will be a toxic environment for the know-it-all psychiatric KOLs that have so contaminated our world [and detracted from the contributions of biologists with good sense], and their pharmaceutical marketing colleagues, and the opportunistic Managed Care types whose job it has been to keep us from doing ours. Right now, I hope right thinking psychiatrists of all flavors, psychologists of all flavors, social workers, counselors, etc. can brace themselves for a long-needed realignment that is consistent with our shared task. It won’t happen any time soon. We’ve been lost in the wilderness too long for that. But the wind blowing in the trees is at least encouraging to this old man…

Can Psychiatry Ever Really Get Rid of Stigma?

We all think stigma with mental illness is a bad thing.  Because mental disorders are stigmatized, people hide their psychic distress and don't get help, or they live in denial about their problems when the fact that they are mentally ill is obvious to others.  People live in pain, or they simply don't live up to their potential.  Stigma is only part of the problem, of course.  There is also the issue of access to care, access to good care, cost of care, dislike of the care that exists (mean psychiatrists, side effects from medications, lousy food or uncomfortable beds on inpatient units), and the fact that sometimes people lack the insight to be aware that they have a problem.  

Insurance companies, I believe, add to stigma, not because they want to stigmatize patients, but because this is a vulnerable group of people where they can avoid shelling out money.  Inadvertently, however, policies that exclude mental disorders or reimburse them differently, increase stigma.  Whatever the intent, the result is the same.

Some people like to compare mental illnesses to diabetes or hypertension: it's chronic, it's biological (we believe), it's an illness to treat like any other illness.  It's a lousy metaphor for a number of reasons: we don't know the biology behind the disorders, and psychiatric disorders are not predictably chronic.  Okay, actually, some people can get rid of their hypertension with weight loss, and then the disorders don't actually exist, but somehow once you're labeled with diabetes, it sticks (diet-controlled, even if you're not on a medicine, even if your blood sugar is normal).  

But aside from issues of insurance parity and certainty about the biological causes of psychiatric disorders, there is a reason I think that untreated or unresponsive mental disorders will always have  stigma.  In the world of "Reduce Stigma," this is going to be the totally politically incorrect thing to say.  Psychiatric disorders come with stigma because people in the throes of certain psychiatric illnesses sometimes behave in distasteful, frightening, unusual, and disturbing ways.  I think we've done a lot to decrease the stigma of depression and anxiety, and it's been immensely helpful that famous, brilliant, successful, beautiful, rich people have talked openly about their struggles with these disorders.  And while I think we've made progress identifying other disorders as problems/disorders/illnesses and not the 'fault' of the person, if a psychiatric problem makes it such that a person refuses to bathe, or becomes loud, irritable, and irrational in the work place, then no amount of reduce stigma campaigning will make it so that people will want to be next to someone who smells bad or whose behavior is erratic.   I, too, want to see stigma reduced.  But if someone is running down the street naked screaming about aliens, they have a bigger challenge to face than the person who quietly sits in the doctor's office and learns their blood pressure numbers are over a certain level.

The answer?  Better treatments, of course.  And more success stories from those with major mental illnesses.  I remain hopeful.

Around the Web, With the ClinkShrink Article Addendum!

Today is the last day that my novel, Double Billing, is available as a free download.  This promotion has had over 1,700 downloads in the last 4 days.  If you do read it, please write a review.
The link is HERE.

For those who follow the blog Hyperbole and a Half, you may know that blogger Allie has been silent for the last 18 months because of an awful struggle with depression. She's back, I'm glad, Jessie's glad, and the illustrated story of her depression now has 5,000 comments.  I borrowed one of her graphics for this post.  It was hard to decide which of designs was best, so do check them out.

In case you haven't noticed, everyone in every media source is bickering about the DSM-5.  At Shrink Rap, we're patiently waiting.  Here's some stuff to read:
--From the New Yorker last month.
--From the New Yorker this week.
--The NIMH says they are going to use different research criteria, not the DSM-5.
--And PsychCentral talks about what this means.
--Psych Practice is looking at the differences in the old vs the new manual.
--And Psycritic is looking out how the new manual changes autism spectrum illnesses.

Finally, in case you didn't hear the shocking news (sarcasm dripping), the APA emailed out a news alert that an infant's inconsolable crying is associated with a higher risk of post-partum depression.  Maybe I'm the only one who doesn't find this fact to be obvious.  You can read about it in Pediatrics. 

Oh, no, I almost forgot, ClinkShrink wrote a great article on what it's like to be a psychiatrist in the gang-rule Baltimore City jail.  Over on Clinical Psychiatry News, do check it out. 

Andrew Solomon talks about When Illness Becomes Identity

I loved Andrew Solomon's book Far From the Tree.  His TED talk gives a better flavor for his book than any review I could write, so let me share that with you here. 

What do we make of the rising suicide rates?

Over on our Psychology Today website, I talked about the CDC's announcement that suicide rates are on the rise, a trend that's been going on for over a decade.  For today's blog post, please see:

Rising Suicide Rates: Have We Simply Failed?

Thank you to Faye who sent me the link to the radio show.

--------------------

Double Billing, my novel about a psychiatrist who discovers she has an identical twin, remains free as a kindle download until May 11th.  Since yesterday, it's had over 750 downloads.  Keeping my day job, so I'm happy to have people read it for free.

Double Billing is Available for Free on Kindle

My novel, Double Billing, is available on Kindle for free for the next few days.  The link is Here.

The moment I have time, I have blog posts to write!

Toward a New Psychiatry... cancelled

Hmm... "Implications of Neuroscience, Neurotechnology and the DSM-5"...

This could have been interesting. Too bad it was cancelled. The thematic articles that might have been discussed are here.

In the same way that we would not have predicted 40 years ago what psychiatry (and even health care, in general) looks like today, it is even harder to predict what these fields will look like in the next few decades. Still, let the prognostication continue.

The Shrink Rappers are Relocating to Hong Kong!

Exciting news!  The Shrink Rappers -- all 3 of us -- will be moving to Hong Kong.  I haven't told Roy or Clink this yet, but apparently they have a giant rubber duck in their harbor, and it calls to me.  

DSM-V : Ready to Launch

The early editions of the DSM were chaotic.  With more recent editions, there have been attempts to cluster symptoms into disorders in a way that is more useful: that allows for meaningful research and allows clinicians to have some diagnostic reliability.  It gives us a language, though anyone who tries to talk about disorders that occur on a spectrum, disorders that are suddenly omnipresent, and so-called waste-basket diagnoses, knows we still have a long way to go. 

 The "science" of it aside, the new DSM has been fraught with years of  political derision.    Let me talk just a little about the dilemma of creating diagnostic categories.

On one side, there are those who don't like the idea of labeling people with diagnoses that may stigmatize them, limit their opportunities in the future, send negative and potentially damning messages that the prognosis as a mentally ill person is bleak, or that categorize normal human reactions as psychiatric disorders.  To these individuals, it would be best if there were fewer diagnoses that captured few people.  The question gets raised as to whether certain conditions -- including issues involving sexual orientation and gender identity-- should be classified as 'illnesses' or embraced for their diversity.  Sometimes these issues are dependent on our culture, and as our culture evolves, our definitions of what constitute illness must also bend.  If you have a few minutes, by all means, read Andrew Solomon's Far From the Tree.  He doesn't limit the question of disease versus diversity to psychiatric illnesses, but he includes a few.

On the other side, there are those who want to be captured by a diagnosis.  The politics of it includes the fact that diagnosis is no longer simply about agreement for the sake of research, best treatment, and prognosis.  It now is about money (isn't everything?).  If you don't have a diagnosis, you can't submit a claim to an insurance company.  So a person who wants to talk to a shrink about rough things going on in their life and have that covered by insurance or permitted in a clinic can only do that if there is a diagnosis, even if that diagnosis is Adjustment Disorder. Without a diagnosis you can't access certain services like psychosocial rehabilitation programs,  case management services, a wide variety of educational provisions for children which may include smaller classrooms, personal aides, and the extension of educational services until age 21.  A diagnosis may even get someone a free fishing license. And diagnosis justifies treatment with medications, which are sometimes quite helpful.  If you're shy, it's who you are.  If you have social anxiety disorder, you can take a pill, and that's good for the pharmaceutical company that makes that pill.  I don't like to pass judgement on these things: I don't believe that one person should stand over another raging "You have Social Anxiety, you need medicine!" but to the patient who feels he's suffering and his suffering is alleviated by the pill, I'd like him to have the choice. (Though maybe we don't need direct-to-consumer advertisers telling people they have illnesses?)  Finally, diagnoses may explain the inability to work and the provision for governmental support.  So while there are people who  want the DSM to go away, to have less diagnoses, to be spared having their stories captured as mental disorders, there are those who hope to be captured by these categories, who hope for more of them, so they can access treatment, services, medicines, provisions & allowances.  And the APA is not immune, they will be selling the DSM-V, charging for courses, bending some money their way.  They've put a tremendous amount into hashing out these categories, and what organization doesn't do things to make money?

We haven't said much about the DSM-V here on Shrink Rap.  There's not much to say at this point.  Personally, I'd be a bit more interested if a major change to my paperwork life -- which suddenly seems to take hours more a day than it once did-- was not coming on the heals of the CPT Code changes (I'll spare you the links). Over on PsychPractice there is a survey and discussion about concerns about the new DSMV and Massachusetts General Hospital has done a survey on clinician concerns and has a white paper on the topic. 

Me?  I'm hoping someone will tell me what codes to use and it won't have much impact on my life.

And how do you feel?

How Do You Know If You Have Dementia?

Stolen from the Hopkins Mental Disorders YouTube site, Dr. Peter Rabins, co-author of The 36 hour Day, talks about how to figure out if you have dementia.  Note to ClinkShrink who always teases me: losing your keys (and presumably your cell phone) is not a symptom of depression.  Clinically, what I hear most is that people have trouble retrieving words, and this is usually associated with normal aging or with medications, not as a typical early symptom of Alzheimer's Disease.

Where Do They Go? Finding Places for the Severely -- and Dangerously -- Ill Patient

In the upcoming Mother Jones article "Schizophrenic.  Killer.  My Cousin,"  Mac McClelland talks about his third cousin who suffers from schizophrenia and ultimately kills his own father. 

McClelland talks about the difficulty in getting an ill person help, changes in how resources have been allocated which make this difficult, and fears about calling the police to bring a mentally ill patient to the hospital.  McClelland writes:

"You can call the police," the deputy director of Sonoma County's National Alliance on Mental Illness (NAMI), David France, said when I asked him what options are available to a parent whose adult child appears to be having a mental breakdown. "The police can activate resources," like an emergency psych bed in a regular hospital, or transport and admission to a psychiatric hospital in a county that, unlike Sonoma, has one. But only if the police decide your child is a danger to himself or others can they arrest him with the right to hold him for three days—what in California is called a 5150, after the relevant section of state law. Otherwise you can be turned away for lack of space even if your loved one is willing to be admitted, or be left no good options if they're not. Ninety-two percent of the patients in California's state psych hospitals got there via the criminal-justice system.

But Mark didn't want to call the police. For one, he didn't think Houston was dangerous, just upset, despairing. 

McClelland goes on to write about her aunt's devastating struggle with schizophrenia and the economics of decreasing mental health care dollars and beds.  

 Ah, California. No. 1 in the amount of mental-health funding cut from 2009 to 2011, No. 7 in cuts as a percentage. Home to one of the largest jail/psych facilities in the nation, the LA County Jail. Where visitors can't believe how many bat-shit-crazy homeless we've got. Where deinstitutionalization was pioneered under Gov. Ronald Reagan with the 1967 Lanterman-Petris-Short Act, which made it vastly more difficult to commit people, and where the rate of mentally ill in the criminal-justice system doubled just one year after it took effect. Where, often, the severely mentally ill live in jail for three to six months because they're waiting for a bed to open up in a psychiatric facility. California: where, says Torrey, the psychiatrist who warns about "predictable" violence like my cousin's, "they led the way in [deinstitutionalization], and they've led the way downhill. They're certainly leading the way in consequences

One psychiatrist we know called the article 'sensationalism not journalism,' and I'll leave that judgement to you.