Wednesday, June 30, 2010


ClinkShrink wrote about her taxicab driver in New Orleans and how a psychotherapist had changed his life in a single session. Psychobabble (a medical intern, soon to be a psychiatry resident...I think), wrote and told us about her experience with a kind cab driver who listened to her problems and provided free psychotherapy during a taxi ride to an exam after her car had been towed after she'd been on call (...Talk about a bad day!) You can read more Here! And welcome to the psychiatric blogosphere, Psychobabble.

This all reminded me of the essay/personal statement I wrote when I was a fourth year medical student applying to residency. I wrote an essay about the different experiences I'd had that influenced me to want to go into psychiatry. I had a bunch of experiences-- I'd known I wanted to be a psychiatrist or psychologist fairly early on, and I'd done rotations at other hospitals and had gotten a Mellon Fellowship at the University of Pittsburgh's psychiatry department one summer. I thought I looked good on paper.

I showed the essay to my adviser, he read it, looked unimpressed, and said, "It looks like everyone's essay." Great. What else did I have to say for myself? I did what I had to do. I bought a bottle of wine and went home to the typewriter (those were the days).

The essay that emerged began by saying that if I wasn't going to become a psychiatrist, I would be a taxicab driver in New York City. I rambled a bit, talked about what the experiences I'd had, said nice things about taxicab drivers and finished it up. I don't have a copy of the essay, it was long ago filed and lost, and it probably wasn't as interesting as I thought it was. My adviser liked it better, and oh, it made for some funny looks at my interviews. Thanks for the memories, Psychobabble.

Tuesday, June 29, 2010

The Cab Driver Story: Single Session Psychotherapy

Another story came out of the APA conference that Dinah wanted me to blog about.

I was in a cab going to pick up Dinah for dinner. The cab driver found out I was a psychiatrist so he told me about his life-changing experience with therapy. At one time he was having an incredible problem with his life. He was using cocaine, couldn't keep a job and his relationships were going down the tubes. Therapy helped him quit cocaine and change all that. (Which was good, since he was the driver of my cab. I really wanted him not to be high or in distress.) This kind of turn-around story isn't unusual for me; parolees will often come back and tell me about things they've done in free society that they're proud of.

The unusual part of this story is the fact that he made all of these changes after a single one hour session.

OK, that got my attention. What was it about this therapist?? What happened in the session?? I had to ask all the questions.

The cab driver told me that it wasn't so much what the therapist said, but rather who she was. She was a kindly, older woman who was sincere and compassionate. She told him he needed to start taking care of himself, eat better, get enough sleep, etc etc.

And that worked. Geez, I was impressed. It changed his life. The last remaining habit he wanted to fix was his smoking. He wanted to go back and see his therapist again, but she had retired. He was sorry he couldn't go back, and so was I.

That's my cab driver story.


Wait, says Dinah (who added the pic and subtitle): you told it in a more dramatic fashion at the time. He was running 8 miles a day now. There was a religious/spiritual component, something profound about the experience and about the therapist. Oy...we'll never make a novelist of you, Clink.

Sunday, June 27, 2010

Lots And Lots Of Questions

One of our blog and podcast followers wrote to us with a few questions. I'm not going to mention the person's name without permission, but they're a pre-med student with an interest in psychiatry. I thought I'd take a stab at some of the answers. Dinah and Roy can chime in with their own thoughts on the subjects. Here we go:
Dinah: I'll chime in in green. Roy? Roy? Where are you Roy?

1. Firstly why did each of you choose to go into psychiatry?
Clinkshrink: There were many reasons. I loved neuroanatomy and did well in it. I was a big fan of the "popular science" brain books as a med student--Andreasen's "The Broken Brain" and anything by Michael Gazzaniga. I enjoyed mysteries and "black box" kind of puzzles, and the human mind is the biggest "black box" puzzle in medicine.

Dinah: I was intrinsically interested in why people do what they do and feel how they feel. I'd planned to get a Ph.D. in psychology and do research, and then realized that if I became a psychiatrist, I'd have the option to do both research and clinical work. So why didn't ClinkShrink become a neurologist???
Clink redux: I didn't become a neurologist because gross neurological impairment wasn't interesting but mind-brain issues were. Neurologists don't deal with hallucinations and delusions, usually. There's a big difference between psychiatry and neurology.
Roy:  Please also take a look at this 2007 post, where we also addressed this question in more detail in Who Wants to be a Psychiatrist.  I grew up watching several family members develop hallucinations and behavior changes, questioning how this could happen to someone's mind.  I started out wanting to go into neuroscience research, deciding to go to medical school only to learn more about how the brain and body work together.  I later learned how much I enjoyed helping people with these problems that I decided to go into psychiatry.

2. How do you cope with some of the stupid and strange stuff people say to you? How long does it take to learn to keep a straight face?
Clinkshrink: The "strange stuff" is what psychiatrists enjoy hearing about. Complicated delusional systems can be bizarre and fascinating and I enjoy listening to that. It's not hard to keep a straight face when you know the person actually believes what's happening to them and it's frightening or bothering them. If you put yourself in their mind set and think about what it would be like if your food really WERE being poisoned, or you really did have something implanted in your teeth that controlled your mind, well, that wouldn't be very fun.

Dinah: There were a few times as a medical student when I did want to laugh. I haven't found that anyone says anything I feel is stupid. Sometimes I have have trouble empathizing with peoples' ideas, especially if they are paranoid or are offensive to me. This is unusual, though, and mostly I enjoy listening to stories about people's lives, and nothing about their pain feels stupid or strange. Some of it feels desperately sad.
Roy:  It doesn't feel like coping, it feels like trying to learn how to speak someone else's language, and understanding how they see the world differently from how I see it.

3. Do SSRI's make non-depressed people relatively happy? Do TCAs have any mood altering affect on non-depressed people as well?
Clinkshrink: Antidepressants are mood-correcting rather than mood elevating. There is some research to suggest that SSRI's may make non-depressed introverts more outgoing, and I have direct experience with non-depressed antisocial patients who like SSRI's because it makes them more apathetic and less reactive to minor slights. Dinah and Roy may have other experiences.

Dinah: Many people take SSRI's for anxiety and find them very helpful, even if they aren't depressed. I guess what Clink said. Also, they can induce mania, so theoretically, if someone with no mood disorder takes an SSRI, they could unmask bipolar disorder.

Roy:  While antidepressants can result in a flattening of affect for some (more so for SSRIs than TCAs), at least one study found that nondepressed subjects had a more positive outlook.

3. What is the neurological basis behind the symptomatology in disorders such as depression, bipolar and schizophrenia? Does it explain all the various subcategories assigned to depression and bipolar?
Clinkshrink: This one is easy. We just don't know. In spite of all the research being done in neuroimaging with PET scans and fMRI, we still don't know for sure what goes awry in these disorders, and we can't use these technologies to diagnose or subtype psychiatric diseases.

Dinah: As per Clink: We don't know.
Roy:  I spent three years doing postmortem brain research in schizophrenia.  There are quite a few replicable findings, such as reductions in markers of synaptic connections and fewer numbers of certain kinds of brain cells.  However, we don't know what they mean or how they are associated with symptoms of the disease.  Like Dinah said, we don't know for certain, but there are many good theories.

4. Why and how do some people with depression suffer from psychotic symptoms?
Clinkshrink: See answer #3. There's still a lot we don't know. Some people are genetically predisposed, some people have vascular or traumatic brain injuries that predispose them, some people have overwhelming life events that trigger an event. For me a better question is what makes people so resilient---able to survive horrible childhoods or natural disasters and "bounce back", while others can't handle routine life events without checking in to a hospital.

Dinah: Regarding the question: Great question. We don't know.
Regarding Clink's answer: I agree that their are some amazingly resilient peeps out there. I don't, however, know of people who end up in the hospital because of inability to handle "routine life events." Seems to me that people have episodes of illness....sometimes they identify a precipitant, often they don't, and sometimes I think the search for a triggering event is just a human nature way of trying to explain what may, at this point, be the unexplainable.
Clink redux: Some of my patients with severe ASPD seek admission to hospitals for, by their own report, being "unable to handle life". In other words, having no place to live, no friends or family to help them, and not being able to keep a job. They lack the resilience and ability to maintain the basic necessities of life. Or a girlfriend breaks up with them and they end up in the hospital.

5. What are your views on prevention for psych related problems? How do you think they should fit in a model of public health?
Clinkshrink: This is the next phase of psychiatry---primary prevention. We already have national depression screening day in October, and primary care providers are starting to use simple screening instruments for various psych disorders. All of this is well and good, but it means nothing if everyone can't afford a doctor. Finding the problem is one thing, doing something to solve it is even better.

Dinah: Prevention? We're a long way from knowing how to prevent mental illness. World peace and drug prevention would go a long way towards helping some people to not develop problems.
Roy:  Prevention is the holy grail.  (Insert Monty Python quote here.)

So those are my answers to lots of questions.
And mine, too!

Thursday, June 24, 2010


Posted for ClinkShrink:

OK, so here's the rat story:

Dinah, Roy and I were walking down
Bourbon Street at midnight during the APA conference. (Three psychiatrists REALLY didn't fit in down there, even though we were wearing duck necklaces.) All of the sudden this huge rat ran out of an alley about two feet in front of us. Dinah screamed and did one of those cartoon-like "peddling in the air" jumps, then turned and ran. Roy and I were in hysterics. We all got back safely. Not sure what happened to the rat.

Monday, June 21, 2010

What Makes it Psychotherapy?

Years ago, I had a student who repeatedly asked me how psychotherapy works. "How is it different than a conversation?"

When I think of psychotherapy, I think in terms of the
talking itself as being the aspect that helps-- and yes, of course it can be used in conjunction with medications. I think of it as being structured--in terms of time and place and frequency-- and being all about the patient. And whether or not it's actually discussed, some of what works is about the relationship--most people don't get better talking to someone they despise, and the warmth, empathy, feeling listened to and cared for, well, they're all important. And I also think of it as being a process over time. These are all parts of my definition, however, and they may not be parts of yours.

So what about about a one-time event? If someone meets with a therapist once, has wonderful insights and feels better, is that psychotherapy? (--Clink, this is your cue to put up a post about the taxi driver in New Orleans). If someone meets with their priest/hairdresser/auto mechanic once or twice or 57 times and feels better, is that psychotherapy? If someone talks to a friend over coffee every morning while the dogs play, is that psychotherapy (...clearly, it is "therapy" because most things involving either chocolate or coffee have some therapeutic value)? If a patient meets with a therapist every week for an hour-long session for years on end, but never utters a single word, is that psychotherapy?

Some psychiatrists include education about illness and medication as part of their definition of psychotherapy. Others measure it by time---if it's 20 minutes it's a med check, if it's 45 minutes, it's psychotherapy....

Okay, so what makes it 'psychotherapy?' FYI: there's no "right" answer.

Happy Belated Birthday, Victor!

Dear Victor,

I'm sorry I forgot to wish you happy birthday on the actual date. I hear you were rock climbing with ClinkShrink and hurt your knee, so I hope you are okay.

I would email you, but I'm at the hospital, and the computer here does not let me access my email addressbook. I've never understood why that is. I would put up a picture for you of pretty rocks or of a birthday cake, but the computer here doesn't let me transfer images.

I would call you, but you don't have a phone. This is a psychiatry blog, not a birthday blog, so perhaps here is where we can find a psychiatric theme in your cell-phone-free state. What does it mean when someone doesn't own a cell phone? It has to mean something, right? WWFS? (What would Freud say?). Would Freud have a cell phone? I called your landline and sang, in my own tone deaf sort of way, but you didn't answer that either.

Happy Birthday, Victor. Let's eat!

Friday, June 18, 2010

Ron Artest: Shout Out To The Shrink!

Okay, so my gang wanted the Celtics to win. But then Lakers player Ron Artest thanked the people in his hood, his family, and his psychiatrist! You can watch the video above.

From Puggle:

The famous player of Lakers, Ron Artest thanked his psychiatrist. Ron Artest delivered a surreal interview after winning the seventh game of the ‘National Basketball Association’ finals. He showed his gratitude to his supporters in the interview. After thanking his neighborhood buddies, his family, his wife and his children, he surprised everyone by thanking his doctor and his psychiatrist (a daring confession). Even Dennis Rodman did not dare do such kind of act.

At the final and the most important moments of the game, Kobe Bryant passed the ball to Ron Artest and Artest displayed his career building shot.
After thanking his family, his family friends, his dear ones and his wife and children, Ron Artest stunned everyone by thanking his psychiatrist. In fact, he expressed his thanks twice. He stated that his psychiatrist had a lot to do with his success. He added that his psychiatric consultant helped him a lot in staying calm, relaxed and focused. Furthermore Ron Artest added that his psychiatric analyst cleared his mind and offered him a perspective of lucid ‘Visualization’. The scenario resembled the famous Hollywood flick “The Love Guru” in which the ice hockey player thanked his Guru for his words of wisdom.

Thursday, June 10, 2010

Beep Beep

Hmm... I recently learned that Maryland's Department of Motor Vehicles has a long list of illnesses that must be reported to the DMV ---by the driver, fortunately, not by the shrink. If a driver reports one of these illnesses, his doc needs to fill out paper work about his ability to drive.

Here is the link, and here is the list:

Customer Self-Report of a Medical Condition

Maryland law requires drivers to notify the MVA if they are diagnosed with any of the following conditions:

  1. Cerebral palsy;
  2. Diabetes requiring insulin;
  3. Epilepsy;
  4. Multiple sclerosis;
  5. Muscular dystrophy;
  6. Irregular heart rhythm or heart condition;
  7. Stroke, ministroke, or transient ischemic attack (TIA);
  8. Alcohol dependence or abuse;
  9. Drug or substance dependence or abuse;
  10. Loss of limb or limbs;
  11. Traumatic brain injury;
  12. Bipolar disorder;
  13. Schizophrenic disorders;
  14. Panic attack disorder;
  15. Impaired or loss of consciousness, fainting, blackout, or seizure;
  16. Disorder which prevents a corrected minimum visual acuity of 20/70 in each eye and a field of vision of at least 110 degrees;
  17. Parkinson's disease;
  18. Dementia, for example, Alzheimer's disease or multi-infarct dementia;
  19. Sleep disorders, for example, narcolepsy or sleep apnea; or
  20. Autism.

A driver must report the problem when it is diagnosed, or when he or she is applying for a driver’s license or renewing an existing driver’s license.

I can't imagine that everyone with these disorders reports these illnesses, because I'm never asked to fill out form for DMV. And how would I know if someone can drive? I suppose if I'm being told about 6 crashes and getting lost....but I have patients who don't have any of the above disorders, who drive, who get into lots of accidents. If everyone abided by this law (and I wasn't able to find the actual law(s), but I didn't look that hard), I think we'd see 1) a lot less traffic and 2) many more clerical positions available at DMV.

Psychiatrists aren't trained to assess driving abilities. We do know the meds we give can cause sedation, and we do warn people of this. Apparently the form that is brought to the doctor asks about conditions which "may affect" ability to drive. So there's the issue of guessing about driving ability, and the issue of predicting the future, without a working crystal ball.

Your thoughts? And this post is about driving cars, not airplanes.

Tuesday, June 08, 2010

It's Done!

The draft of the book, along with it's Table of Contents and The Suggested Reading (which you helped with!) is now officially done and off to the copy editor. Miraculously, we didn't kill each other, but there were moments....

How long did it take? Who knows any more, at least two years. Roy wrote (finally). Lots of forensic psychiatry. Lots of psychiatry psychiatry. It's done. And we're actually still friends.

Look for

Spring of 2011, Johns Hopkins University Press.