Saturday, March 27, 2010

ObamaMama it's Health Care Reform!


In case you haven't heard, we've got ourselves health care reform.
What do you think?
Will this be a good thing for psychiatric patients?
Will this be a good thing for psychiatric docs (the shrinks among us?)

Personally, it's been so much commotion and so many pages, it's been way too much to follow (and no one asked my opinion anyway). I think I'm happy for movement, we've been stuck for so long with a system that just doesn't make sense. I'm told most people are happy with their health insurance. Are you?

Go for it, write in our comment section!

Friday, March 26, 2010

I Like To Paint Flowers


The title of this post comes from one of the questions in the Minnesota Multiphasic Personality Inventory, which I had to take when I applied to medical school. And I do like flowers. One of the things I like about the place where I work now is the fact that it's filled with plants---I don't know enough about horticulture to say what they are---but I think they are mother-in-law's tongue, ferns, philodendrons and other bushy green things. In front of the hospital there's a bed of tiger lillies and I can't wait for them to start blooming now that it's Spring.

Our hospital has a horticulture program. Patients who have worked their way up through the privilege level system and are safe enough to leave the ward are allowed to tend the many green plants lining the hallways and windows of the hospital. They do a terrific job and the place is beautiful and warm. I appreciate this a lot because I have a black thumb. When I walk into a nursery the plants scream and run for cover.

I think the patients appreciate the program because being able to participate is a sign of progress. Being able to gain some freedom and be responsible for another living thing gives a sense of independence and responsibility. It's also quite relaxing and peaceful to be surrounded by beauty.

Psychiatric hospitals and prisons have frequently used agriculture or horticulture for therapy and rehabilitation. I know of a maximum security prison where inmates with the highest privilege level are allowed to participate in a bonsai program, growing miniature trees.

Nineteenth century psychiatric hospitals relied upon hospital farms to provide for the needs of the patients. They grew their own food and milked their own dairy cows, which for some patients I'm sure was a source of self-sufficiency and pride. One former hospital farm, the Brattleboro Retreat Farm, still exists and is open to the public. In 2008 the New York Times published Tara Parker-Pope's article Better Mental Health, Down On The Farm in which commenters talked about their own experiences caring for animals during episodes of mental illness. One commenter talked about his horses as "a reason to go on" while depressed, because he had to feed and groom them even in bad weather.

While I didn't grow up on a farm, I did live in a rural community and many of my friends were farm kids. I still get teased for commenting on the progress of the corn crops as I drive through the country. I know farm life is not for everyone. The NYT article mentioned a Norwegian study that compared psychiatric patients treated with standard pharmacotherapy versus a group given standard therapy along with a "farm intervention", where they were asked to work with cows, sheep and horses for three hours a week over a 12-week period. By the end of that time the patients with farm experience had significantly higher self-efficacy and coping skills. Coincidentally, the farm group also had a higher dropout rate. The article didn't mention why the patients dropped out, but I can imagine why----cow pies are definitely not therapeutic.

Thursday, March 25, 2010

A Picture is Worth a Thousand Words

While I was away, ClinkShrink did a Spectacular job of keeping up the blog. And the rare moments I could get computer access, for 20 shekels a shot, I got to play beat-the-clock attempting to get through my email. There were about a zillion in response to Clink's posts. Great posts (and beware the surgeon who dares to lie to Dinah)...but no pics? Why no pics, dear ClinkShrink? Ah, but it's not too late--- I will help her out here.
Dinah's back.....

Monday, March 22, 2010

My Three Shrinks Podcast 50: More About Geeks


In this show we continue with our guest Dr. Pat Barta of the Adventures in Telepsychiatry blog.

We talk about electronic health information systems and Clink continues her rant which she started in her post Rage Against The Machine. Roy mentions the Certification Commission for Health Information Technology and the American Recovery and Reinvestment Act which provides funding incentives for doctors who use health information technology. We cover developing standards for behavioral health information technology, including personal health records which allow patients to store their own information voluntarily "in the cloud", on a server. Dr. Pat Barta talks Open source health record systems and information security.

Health Data Rights is an organization that developed a proposed declaration of rights for patient data. Another organization addressing this is SpeakerFlower, of which Roy is the spokesperson.

Dinah talks about her blog postWhat's An Emergency? and wonders how flexible psychiatrists should be when a patient says they need to be seen right away. Which situations are truly emergencies? What should you do if a patient turns down multiple appointments offered for that same day? Should your office voicemail tell people to call 911?

Finally, Dinah wonders what has happened in states with medical marijuana laws. She mentions KevinMD's blog post Medical Marijuana Has Doctors Asking Questions. Should marijuana be prescribed for attention deficit disorder? How do you do clinical research on a controlled substance?
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This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening


Send your questions and comments to: mythreeshrinksATgmailDOTcom

Saturday, March 20, 2010

Psychiatry Is For The Birds (Or: Prozac For Polly)


Don't ask me how I stumbled across this story, but I thought it was fun enough to put up on the blog. It's a study done by a parrot rescue organization in Minnesota that describes a kind of trauma recovery program for birds, using human development models. See the full article: "Avian Affective Dysregulation: Psychiatric Models and Treatment for Parrots in Captivity".

The group has a clinical psychologist and trained volunteer caregiver "therapists" while the parrots are known as "clients" (not "patients"). The five cockatoos described in this study are even given pseudonyms to protect their anonymity. The team develops individualized treatment plans for each bird that are supposed to help them recover from traumatic rearing through gradual exposure and de-sensitization.

In this paper the researchers classify the birds according to one of four attachment styles: secure, insecure-avoidant, insecure-ambivalent and disorganized-disoriented. Each attachment style is thought to be the result of certain early and juvenile caregiver experiences. Birds exposed to frequent changes of caregivers, or caregivers who were abusive or unpredictable, developed insecure or unstable attachments to other birds and to human caregivers. These birds had a number of bird "symptoms" or behavior problems such as withdrawal, lack of affect (unh...how can they tell if a bird has a flat affect?), attacking or biting behavior or a "flat crest" (I think that's the bird equivalent of a dog with it's tail between it's legs).

The paper really doesn't go into detail about how the birds were treated except to say they were given opportunities to "exercise autonomy, agency, and social and physical competence". They were also gradually reintroduced (or introduced for the first time) to other birds. The cockatoo which came from a stable, secure and consistent human family was surprised by the other birds (since he had never been around them before), but he adapted quickly to the flock and didn't show any maladaptive behaviors. The bird from the violent and substance abusing family had unpredictable and sometimes violent reactions to other birds. One bird was given a "social facilitator"---another bird who supposedly modeled appropriate bird behavior and taught him how to adapt to the flock---his own emotional support animal.

They also tried giving the most unstable cockatoos psychiatric medication such amitriptyline, clomipramine and Prozac, but the results were inconsistent. (And yes, they even figured out a way to give informed consent.)

I thought people might enjoy reading about "transpecies psychiatry". You might find it interesting to read about elephant PTSD as well as EMDR therapy for traumatized horses.

Friday, March 19, 2010

101 Dalmations (And Chihuahuas…And Cats….And…)


In the New York Times this week we have a story entitled Animal Abuse as Clue to Additional Cruelties. In this article Ian Urbina discusses the problem of people who hoard animals and the connection between animal abuse and violence toward people.

The link between animal cruelty and antisocial behavior is well known and was first studied in the 1960's by a researcher at Washington University by the name of Lee Robins. Dr. Robins followed the outcomes of children referred to a local mental health center for conduct problems, and learned that about one third of them developed antisocial behavior as adults. This is where we get the current conduct disorder criteria for antisocial personality disorder found in DSM-IV: firesetting, theft, running away, truancy and animal cruelty.

States are passing laws to better identify and track people who hoard or abuse animals, with the idea that people who do this are also likely to be abusing or neglect humans in their households. The laws allow for sharing of information between people who investigate domestic violence or child abuse and people who investigate animal neglect cases. Some states are even passing laws to create registries of animal abusers.

Two parts of this story caught my attention: the registry issue and the idea that neglecting an animal becomes a predicate offense for other investigations. Here in Maryland we're big on registries. We have a sex offender registry and child abuse and neglect registry. We have a law requiring child welfare agencies to compare recent birth certificate information to the child abuse registry, to see if any known child abusers are having more kids. Now maybe we should also check to see if they're adopting pets.

The whole idea of registering and tracking people is a bit uncomfortable for me. Registries don't prevent crime but they can prevent people from getting jobs, buying homes and reintegrating into society after they've served their time. Being on a registry (or not being on one) is not truly reflective of the risk that person poses to society. A demented little old lady found with 200 cats in her basement could end up on the Internet, with the implication that she since she has neglected animals she also abuses children. Registries also don't seem to do much for preventing people from getting access to what makes people truly violent: guns and alcohol. Perhaps we should require liquor stores to check registries before any beer transaction. While we're at it, violence is associated with mental illness, untreated mood disorders and personality disorders. Maybe a registry of psychiatric patients?

Please. Enough. I doubt Dr. Robins ever expected this kind of outcome to her work. The purpose of studies like hers was to identify people at risk, for intervention and treatment, not for prosecution and public censure. I think we need to get back to that original idea.

Thursday, March 18, 2010

Movie Review: Oasis

I saw this film over the weekend after a recommendation from a friend. It's a Korean film about ostracized misfits who find one another in the midst of a harsh society. The main character, Jong-du Hong, is released from prison after serving time for killing someone in a drunk driving accident. His family are not happy to see him again. They are hard-pressed for money and have had to squeeze into a small apartment with his many siblings. His family does not hesitate to tell him that he is a burden and that they were better off when he was locked up.

He visits the family of the person he killed to make amends, only to find them in the process of moving out of their apartment. They are leaving behind the child of the accident victim, Gong-ju Han, a severely disabled woman with cerebral palsy. Jong-du confronts her brother as they are leaving and demands to know who will take care of her. He is kicked out of the apartment and she is left alone, with physical contortions that horribly distort her limbs. It was painful to watch.

Jong-du returns repeatedly to try to visit Gong-ju, to bring her flowers and to check on her. Finally, one day he is let into the apartment. He tries to rape her then flees when she passes out.

This is the point where the movie becomes inexplicable to me. Following the attempted rape Gong-ju fantasizes about Jong-du and imagines having a lover, and struggles against her cerebral palsy to put on makeup. Jong-du returns and the two become lovers. Their train-wrecked lives come together in a predictable way. One physically damaged, one psychologically damaged, both without psychological or social support. The result is inevitable and predictable.

The Rotten Tomatoes web site gave this film an 89% favorable rating, although I'm not sure why. One of the difficulties of this movie, besides the implication that rape can trigger love, is the fact that Jong-du's facial contortions made it impossible to read her emotions, and I was left wondering if she was in pain, afraid or ecstatic. When it was crucial to directly tell the audience what she was feeling the director cut to a fantasy mode, and the physically-whole actress acted out Gong-ju's feelings. We learn she is entranced by this man, that she fancies herself teasing him and playfully flirting with him, that her days are filled with wonder and fulfillment when he is around.

The most potent part of the film was the portrayal of how this disabled woman was treated by Korean society----she was refused service at a restaurant and rejected at a family gathering---overt discrimination highlighted by Jong-du's naivety. He brings her to his mother's birthday party only to be confronted by his siblings about his inappropriateness. Gong-ju's family can't even imagine that anyone could love her, and they take it for granted that he is abusing her when they finally do make love.

Jong-du ultimately goest to prison after a false rape allegation, but personally I think he should have been there quicker after the first, real, attempt.

Wednesday, March 17, 2010

Is It Malpractice To Lie?


I came across this interesting malpractice case via the HealthLaw Twitter feed which I've been following for a while now. The case is Willis v Bender, a 10th Circuit Court of Appeals case out of Wisconsin.

In this case a surgeon was sued by his patient following complications from a laparoscopic cholecystectomy (gall bladder removal). Before the procedure he explained the risks of the surgery to her, and she also asked him questions about his experience and success rate with the procedure. She asked additional questions about whether he had ever been sued for malpractice or had any action taken against his medical license. He answered no to both questions and added that he had an almost perfect success rate with the surgery. Well, bad things happened. The patient suffered a perforated intestine and an infection. She later found out that the doctor had lost a patient during this same procedure, and that he was disciplined for the board as a result of that case.

At trial the jury found in favor of the doctor because even the plaintiff's expert couldn't say that the complications were the direct result of improperly performed surgery. Even properly done surgery of this type carried the risk of perforation, bleeding and infection. The plaintiff also alleged that the doctor failed to give her informed consent because he gave false information about his personal background. The trial court wouldn't allow the informed consent issue to be raised because in Wisconsin the law only required that physicians tell patients the material risks of proposed treatment. There was no affirmative duty to disclose professional background information even when asked.

So the plaintiff appealed.

The 10th US Court of Appeals reviewed various similar informed consent cases and found that courts took different views on whether or not lying to a patient about a physician's background could be considered a breach of informed consent. Some courts held that doctors could be found liable only if they lied regarding the risks of the proposed treatment. In this case, the appellate court decided that the patient should have had a chance to make the argument, and sent the case back for retrial on that issue.

We'll see what ends up happening on retrial, but I thought this was an interesting emerging area of law. What if the issue wasn't technical incompetence? How much "personal background" should a doctor have to tell a patient before treatment can begin? Medical school grades? Failure to pay income tax? Should doctors be required to disclose to patients the fact that they've been treated for mental illness themselves?

Tuesday, March 16, 2010

Suicide and Social Learning

I found an interesting article on the Public Library of Science web site called The Cultural Dynamics of Copycat Suicide. (And thanks to the author for being willing to share his information under a Creative Commons license---this is how medical research should be!)

The author, Alex Mesoudi, used a computer model to study the effects of social learning and mass media influence on suicide clusters. He used a statistical method to see if suicides were clustered in time and space at an unexpectedly high frequency. This method is called an agent-based similiation, and is commonly used to model transmission of infectious disease. I'm not going to pretend to understand the statistics behind this! If you're curious you can read that part of the article.

He started by explaining the difference between point suicide clusters and mass clusters. Point clusters are suicides that are grouped together in time and space, while mass clusters are suicides that are grouped together in time, but are separated geographically. Suicide clusters have been thought to be due to social learning or mimicry, but it's also possible that they occur through homophiliy (the tendency for similar people to pool together in groups). Mass suicides are thought to be due to the influence of prestigious individuals (eg. celebrity suicide deaths) combined with coverage by the media. This leads to a one-to-many transmission model.

The computer model was run using three different assumptions: that suicides were totally random and unclustered, that clusters were due to social learning, and that clusters were due to homophily. He used different formulas to generate "suicides" under each model, and looked at the kind of clusters (spatiotemporal versus just temporal) that resulted.

What he found was that social learning caused spatiotemporal point clusters while homophilic clusters were more likely to be spacial rather than temporal. In order to understand this better, imagine the difference between teenage suicide epidemics versus correctional suicides. Teen suicides clusters happen among individuals who know each other, they happen in the same geographic area and within a short time frame of one another. These are the "social learning" clusters. Correctional suicides happen at a rate higher than in free society (in other words, they're geographically 'clustered' in a jail or prison), but are spread out over time. These are the homophilic suicides, in other words deaths by high risk people who happen to be grouped together. Based on this study, the correctional deaths are less likely to be due to social learning or mimicry.

Finally, the author studied the factors influencing mass suicide clusters: deaths that happen at the same time over a broad geographic area. These the kinds of suicides you see when a celebrity commits suicide. They are generally associated with a lot of media coverage. The computer model found that social learning played almost no role in these deaths.

It's a really complicated paper and I'm sure I didn't do it justice, but I thought it was pretty fascinating that someone could basically recreate the kind of suicide death patterns we see in the real world based on a theoretical mathematical framework. And I liked the term this author used for this kind of experiment: in silica. If in vivo experiments are done on animals or humans and in vitro experiments are done in test tubes or petri dishes, then "in silica" is a great term for computer model experiments.

And if none of this post made sense, hang on and I'll resurrect it in one of our podcasts.

Monday, March 15, 2010

Dinah's Away, Clink Will Play


So Dinah has gone off on vacation and left Roy and I in charge of the blog. Doesn't she know what a really really bad idea that is??


The day started off with her calling me to help with a computer problem. Dinah wanted to download a movie to watch on her iPod on the plane. No problem, except that she needed to upgrade iTunes to do this. She downloaded iTunes but for some reason it didn't install (she later asked me which password she was supposed to enter during the install process, that may have been part of the problem). So I talked her through the upgrade and told her how to open system preferences and get to the software upgrade control panel:

"Go down to the bottom of the screen until the little launch bar pops up. Then click on the little picture that looks like a gear."

"Deer??" Dinah said. "I don't have any deer!"

"No no, click on the gear," I said. "Gear with a 'g'." I'm hollering this into the dashboard of my car as I'm trying to drive on the beltway in the rain. I wonder if my other tech savvy friends (meaning Roy) end up in situations like this, trying to solve computer problems from memory while multitasking other things. I also wonder how I'm going to teach Dinah how to use GarageBand so she can edit our podcasts when she gets lost looking for deer on her laptop. O gods of computer tech support, have mercy!

Well, she got the upgrade done, went to iTunes and bought her movie then found out it was going to take two hours to download. At that point my tech support was done. I don't know if she ever got her movie or not, but I do know I'm going to schedule an entire afternoon for the GarageBand training.

Saturday, March 13, 2010

Hey, What are YOU Doing Here?



Sarebear tells us she went to see a new psychiatrist and was surprised when the evaluation was begun by an Energy Healer and the psychiatrist joined at the end of the 90 minute evaluation. See her post, Psychiatry Bait and Switch.

So what's the standard here for psychiatric evaluations? Is there one?
Actually, yes, and here it is: Practice Guidelines for the Psychiatric Evaluation of Adults.

So let me tell you what my experience is of the standards, and we'll come back to the guidelines.

Who does the evaluation, in my experience, is determined in part by the setting. In every private practice setting I've seen, a psychiatrist does the evaluation--- who you schedule with is who you see. I believe that even in private settings, if you're having neuropsychological testing, you may get a more junior person who administers some of the tests. But in terms of psychiatric evaluations--- usually the shrink. Sarebare notes that psych evals are 90 minute events. I spend 120 minutes on them (and oh, I still run over, I gotta work on that)...but for many, many docs, they are 50 minute exams--- it's just logistically much easier on the scheduling, and if you're going to be seeing someone on an on-going basis, it's not that urgent that you get every piece of information on that first day (or you can send out detailed forms to collect info---see my post Please Print Legibly....) . In the Emergency Room of community hospitals, psychiatric evaluations are done by social workers who present the information to a psychiatrist who may or may not see the patient (granted, these are emergency issues only and do not constitute full psychiatric exams for the purpose of on-going treatment). On an in-patient unit, information may be gathered by many people---the nurse, the resident, the attending, the medical student, over and over again until the poor patient is exhausted!

In clinics, it's often the case that a social worker does an intake interview and then a psychiatrist sees the patient. The evaluation team may or may not be the treatment team; at the clinic where I work, one doctor does the evaluation and dictates a long (pages) note, but the patient is then assigned to another psychiatrist for on-going treatment. This was not my idea. In one clinic where I worked, the standard was to have a psychiatrist assigned to "coverage" for each hour and the covering doc was grabbed to do any needed psychiatric evaluations or see any patient who was due for a 90 day review (or med check)-- there was no consistency to care and bless the medical director who changed this and gave every doc a caseload and every patient a doc.

So back to the standards. Regarding the gathering of information, the Practice Guidelines I linked to say:

In many settings, it has become commonplace for the care of psychiatric patients to draw on the expertise of multidisciplinary teams. In the evaluation phase of care, other members of the clinical team (e.g., nurses, psychologists, occupational therapists, social workers, case managers, peer counselors, chaplains) may gather data or perform discipline-specific assessments. The psychiatrist responsible for the patient's care reviews and integrates these assessments into the psychiatric evaluation of the patient and works with other members of the multidisciplinary team in developing and implementing a plan of care.

Nothing at all, not a single word, about Energy Healers, but I'm not sure that a peer counselor would have more training, so I don't know what to say. Here in the Mid-Atlantic, we're not much for Energy Healers, though I did recently have my home sealed and insulated and my energy bills have been remarkably lower. Does this count? Sarebear, I hope it works out.

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And now a word on Shrink Rap logistics. I am going on Vacation ! (am I happy: yes. have I begun to pack: no). Clink and Roy have not been blogging much lately, so I don't know if they will hold up the blog or not. I'm hoping Roy will take a look at proposed changes for DSM5 and write a blog post on these. Please bother him about this. And Clink has adopted podcast editing when she's not hanging off some precipice, so maybe she'll post another podcast....Dr. Barta was kind enough to stay and chat with us even when we stopped talking about telepsychiatry and brains. Finally, we had the odd realization this past week that while our book (Off the Couch, Behind the Couch, Under the Couch?) is due at the end of June, that version has to be finished with review, so the actual finished draft is due in April. Always a fun thing to learn as I'm headed off on vacation. Fortunately, we're in good shape for this, and the first 8 Chapters got a very enthusiastic review. So all good energy at Shrink Rap, but blogging may be a little slow. Please stick with us and check back often!

Thursday, March 11, 2010

Let Me Tell You About My Friend


Hypothetical situation (with a little ring of possibility)....

So a new patient shows up at my door, referred by a friend. The patient used to be in treatment with my friend, but the friend is moving to another state. The patient is sad, she will miss her old doctor who helped her so much, and while we hit it off just fine, it's clear that I can't fill my friend's shoes.

Now here is the thing I'm wondering about: the friend who used to treat the patient is my good friend, someone I talk to all the time --Are we thinking along the lines of a Camel? Perhaps, but I'll never tell. After the move, I'll still talk to her all the time, and I'll still see her socially, even if it means a bit of planning or trekking. Should I tell the patient? My initial thought is "yes" that this will be a connection, that I can relay regards and that the patient (and the doc) won't feel so cut off. But then I wonder if maybe it will be hard to know that I am seeing the old shrink when she can't, if somehow this might be frustrating?

I'd ask here, but clearly this is one where the answers may be very individual,--oh, but why not? Go for it!

Wednesday, March 10, 2010

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.

Sunday, March 07, 2010

My Three Shrinks Podcast 49: Pixelated Psychiatrists



For today's podcast we have guest psychiatrist Dr. Pat Barta talking about telepsychiatry, telemedicine and all things neuroimaging. We ponder how licensure works for telepsychiatry, whether or not you can get reimbursed for it, what the difference is between a face-to-face evaluation versus a telephone interview and why we don't yet have an iPhone app to diagnose schizophrenia. All of these topics (and more) can be found on Dr. Barta's blog Adventures in Telepsychiatry.


We talk about Pauline Chen's article in the New York Times: "Are Doctors Ready for Virtual Visits?"



Roy, Dinah, Pat and Clink discuss electronic health records and who should have the rights to our personal health information. I'm including a link to the Speak Flower web site, an organization dedicated to promoting patient-controlled health information systems.

We also hear from Dinah's new dog. Please go to iTunes and write a review.
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Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feedorFeedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file frommythreeshrinks.com.
Thank you for listening.

Saturday, March 06, 2010

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 would gladly wear a pin that says "Why Be Normal?" Like Why? What is normal? Why would anyone aspired to that. Normal is an IQ of 100, corn flakes for break fast and tuna fish for lunch (ok, I like tuna)..normal entails conforming to some exact mediocre standard. Why would you want to be Normal. Please don't call me normal (I think I don't have too worry too much here).

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?

Wednesday, March 03, 2010

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?

Tuesday, March 02, 2010

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.

Monday, March 01, 2010

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.