What is she on?--a rant

I'm sticking my neck out again, something I try not to do but I can't resist this one. Be aware, I can and will delete any comments that I don't like. I reserve the right to be arbitrary and biased on this one.
First of all the juxtaposition of the article with the ad for Concerta is just too choice to miss (Concerta is an extended release form of ritalin).
Second of all, I'm sorry but since when do medical marijuana advocates recommend marijuana for school children and as a treatment for ADHD? In my mind giving pot to your kid is tantamount to child abuse. I know it is a free country but really. So your 5 year old has trouble sitting still and concentrating--what give him a little "medical marijuana"? Are we insane? This makes me so glad I don't live in California.
I am trying very hard to picture a classroom of stoned first graders. I might just have to write to the Comedy Network about this one. According to this writer, Jennifer L., there are 20 clinics in Oakland California dispensing marijuana to teens with ADHD. My brain hurts--hey, I forgot, weed helps with that too. I will not dignify Ms. L. with a link or even the use of her last name. I have no wish to engage her in a dialogue or promote her brand of insanity. You can see it on the screen shot if you use a magnifying glass and if you are really desperate for a laugh I will personally e-mail you the link. Ms. L. finishes her blog post with the following words:
"If I had a child with ADD, I think I would prefer they were on cannabis rather than Ritalin because it is a natural remedy." To which I reply, arsenic is natural too. As are ricin and tetrodotoxin. But I don't give them to my kids. What is the world coming to?

Sunday Scribbling--Curves

Curves

A thing of beauty is a joy for ever:
Its loveliness increases; it will never
Pass into nothingness; but still will keep
A bower quiet for us, and a sleep
Full of sweet dreams, and health, and quiet breathing.

John Keats

I couldn’t think of what to write on this topic. I thought of telling you about the infamous “S Curve” in Chicago, a dangerous bit of Lake Shore Drive, now smoothed out. But that seemed a bit trivial and boring to one who has never driven it. Then it hit me. Curves, as in women’s curves.
This week I flagged an article in Time magazine (June 9, 2008 issue, link is http://www.time.com/time/specials/2007/article/0,28804,1703763_1703764,00.html) relating to eating disorders. It references a study of an intervention in classrooms to make girls and women less fixated on the American ideal of thinness. I consult to a high school in my area and I thought that this intervention might be worth reading up on as of possible utility in this school.
I frequently deal with women, girls, and, more rarely, boys and men, with eating disorders. At their most severe form, these disorders scare me. At the less severe end of the spectrum, they make me angry. How many times have I told women that curves are normal, that a flat stomach is neither necessary nor ideal? I tell them that we would be hard pressed to find a girl or woman in this country who doesn’t feel critical of at least one part of her body, whether it is thighs, abdomen, breasts, skin, nose or neck. Ask yourself: what part of your body do you hate the most? I think most of us can answer that one in around 10 seconds or less because the answer has been well-rehearsed in hours of self-consciousness or self-hatred.
Around 13 years ago, I burned myself by spilling hot coffee on my hip. I realized that I would likely get a scar as a result. Being in my mid 30’s it occurred to me that I had found one advantage of aging. I didn’t care if a scar marred my look in a bikini. What a liberating feeling! Now, I’m not saying that I would be indifferent to putting on 30 pounds. I’m as much a product of our society as the next person. But I aspire to make it to a ripe old age without a face lift, liposuction or Botox. I will admit that I have been tempted by a good chemical peel although I haven’t tried one yet. I’m not dyeing my hair either although I only have a handful of gray hairs (which I wear with a degree of pride).
Obesity is a serious problem in this country so I am not arguing against diet and exercise for those that need it, even gastric bypass as a worst case scenario. What I am fighting against is the legions of young people I meet nearly daily who hate their bodies, who measure self esteem by how tight their jeans fit that week, who value five pounds more or less as more important than their many meaningful accomplishments.
A thing of beauty is a joy forever. The important thing is to stick to meaningful definitions of beauty.

For more reading and viewing check out Lauren Greenfield’s website, http://www.laurengreenfield.com/index.php?p=VQTME4W6, about her documentary, Thin.

Preparing this article has added a couple new books to my wish list.

Depressing Movie Night

My kids have created a new tradition which is they go out playing Magic (see earlier posts for details) on Friday nights. This is great for me because driving them there and back is one household duty that I am exempt from. Some nights I go hang out at a bookstore, some nights I take pictures (which is more pleasant in the summer) and others I read or watch TV.
I don't usually watch much television. This is in part because I prefer to read most of the time and because I don't like fighting with my three boys over control of the remote. Fridays I like to collapse. I avoid Friday night dates and parties and have done so for years. So tonight, I have the house to myself and since I have put around 100 miles on my car in the past two days for work, I have little interest in spending more time in it. I also have a rented movie to watch.
I need to preface this with an explanation of my latest movie rentals. Today and this coming Monday, by coincidence, I had/have talks to give on depression. Today's was relatively informal and was about adolescent depression and bipolar disorder. Monday's will be as part of a course entitled Neurobiology of Disease. This will be more formal which is why, of course, I haven't even started preparing it yet. The course instructor wanted some video footage of a depressed person. When I heard about this a few months ago I commented that I didn't have any videos and the instructor told me that he could get me something. Last week when the subject came up he told me he didn't have a video. I mentioned I might use a film clip from a movie (just in case he was worried about copyright issues) and he proposed that I take a look on You Tube. I was taken aback but he was right. I found a pretty good video on You Tube.
Even so I came up with three movies that might have suitable portrayals of depressed people. The first I viewed last Friday. I watched Girl, Interrupted which was pretty well done, a bit dated, and a bit distressing but provided no useful film clips. I enjoyed watching Angelina Jolie as a blonde bitchy girl, most likely with bipolar disorder. She had just the requisite evilness that some people (but not all) have during a manic episode.
I remember one bipolar guy from my inpatient days who refused medication, was incredibly unpleasant to the staff and constantly threatened to call (then Secretary of Health and Human Services) Donna Shalayla to complain of our treatment of him. It took weeks for him to improve enough to be discharged and for us to breathe a big sigh of relief. Lest you think I generally hate my patients, let me say that he was an exception. I usually can find something to like and relate to in my patients but he was notably unlikable.
Tonight's movie is Prozac Nation. I'm guessing I won't find what I am looking for for my talk but hope I like the flick anyway. If neither of those work, I will review Little Miss Sunshine--there is a character in it that I remember as being quite the image of a depressed person. Or I'll use You Tube or simply quote some written material. Maybe tomorrow's post will be composed of some depressing quotes. I have something about Abraham Lincoln that is quite remarkable.
After this post it is ironic to close with "Cheers" but I will do so anyway.
Cheers and happy viewing.

Full Moon

I feel like Chicken Little--the sky is falling! Is something wrong with the world this month? Is it bad karma, bad weather, the eclipse, the near-total lack of sunshine this month, or as they say on multiple choice tests, A & D, B & C, none of the above or all of the above?
My friends, colleagues and I have all decided that February should have been banned this year. There are those creepy, shivery events like the shootings at a university not far from here, or the therapist who was sliced to death in New York City. Then there is the more close to home feeling that this February is a lousy month to be a psychiatrist. Finally, let's face it, I and millions of other people just want this winter to be over!



People the world over have superstitions about the full moon and its effects on behavior. None are more superstitious than doctors. I once nearly got beaten up when I told a medical resident that our call was quiet that night. Saying that your call is quiet is considered tantamount to inviting 20 major disasters on the ward and in the ER. I never used the word quiet professionally again.



The most superstition is regarding the moon. ER doctors insist that there are more and stranger patients in the ER on full moon nights. Psychiatry residents dread those nights too. There is a reason someone who probably spoke Latin coined the term lunatics.
Of course true scientists know better. Take the following study cited as a letter to the editor in Psychiatric Services: Kung and Mrazek analyzed records from a psychiatric emergency room from 1997 to 2001 and found no increase in visits during full moon nights. They weren't the first (nor probably the last) to try to debunk the myth but it is still widely believed. Another tale for Mythbusters perhaps?
Personally I would have rather skipped call on Saturday nights or on the day after welfare checks came out when all the crack addicts had spent their allotment and crashed and turned up in the ER for consolation. But then, I guess I never was too superstitions, knock on wood.

Hospital

I remember my first experience of a psychiatric hospital. It was long before I ever considered being a psychiatrist. Some one I know was admitted after a suicide attempt and I went to visit. I cannot tell that person’s story because it would be a privacy violation. But I can tell you how I felt.
I didn’t really know what to expect on a psych ward. I felt scared and bad enough about what had happened to my friend and didn’t really understand what was going on. It was a creepy place. For one thing, you have to be buzzed in through a locked door. When the door closes behind you it has a feeling of finality as if you too are being admitted for an indefinite stay and not just as a visitor. You realize that someone has to let you out. You cannot just go. At the door they ask your name and business and check to make sure no one is loitering near the exit before letting you in. If you bring something for a patient, they screen it for “sharps”—knives, razors, scissors—and other contraband, including electronic devices. Gameboys, walkmen, radios and so forth are not allowed. Don’t try baking a nail file in a cake!
The ward is full of strangers who carry that frightening label “mentally ill.” At my first visit, I’m just little more than a kid myself and full of all the strange and unfair stereotypes of the mentally ill. Will there be dangerous people there? I guess I must have been picturing my experiences of mentally ill homeless people—strange, eccentric, bad-smelling, talking to themselves or cursing madly.
I remember in actuality there was one person restrained in a chair in the hallway. I had never seen anyone in leather restraints (they really are made of leather). It is very disturbing to see someone tied down like that. One woman sat in one of those institutional chairs common to hospital waiting rooms, rocking and shuffling her feet. Now I know that she had akithisia, a kind of inner restlessness that is a side effect of certain psychiatric medications.
The ward must have been smoky although I don’t remember that. Back then, smoking was still allowed on hospital wards. A few years later I “rotated” which means did a 4-6 week educational period on that self-same ward. Patients would line up at the nursing station during a set time period to pick up their cigarettes from a nurse. Matches and lighters were not allowed to protect the patients from themselves and their fellow inmates so the cigarettes were lit by staff. During cigarette breaks the smoke made it hard for me to breathe. Cigarettes often became an occasion for power struggles between staff and patients. Someone would want their smoke at a non-approved time or would be denied a cigarette for reasons unknown. Now smoking is banned and smokers ask for a nicotine patch if they are concerned about withdrawal.
As my experience with psychiatry grew, I learned that there were times when the distinction between patient and staff become uncertain except for who had control of the keys. Sometimes the staff seemed more unreasonable and erratic than those they were supposed to help. Access to the door was used in a passive-aggressive manner. When I was a junior resident and did not yet have a ward key (this was at another hospital), staff would delight in making you wait to exit the ward. It was an insecure feeling looking at the wire mesh over the small window in the door and hoping that someone would buzz you out. If you complained about the wait too vociferously, a nasty staff person might take it out on you in some other way.
Psychiatrists refer to the entire ecosystem of a psychiatric ward as the “milieu”. There are books and journal articles written about the milieu and trainees should read about the “dynamics” of the milieu. The milieu truly is an ecosystem. At times it is in balance with caring, compassionate, well-rested staff and patients who get better and behave. At other times it feels like a prison just before a riot. The staff is burned out and vindictive. The patients are burned out, angry, manic or psychotic or in full drug withdrawal. At the worst of times, mercifully rare, there is danger on a psych ward. On occasion the stress is so extreme that we experience a bit of PTSD (Post Traumatic Stress Disorder), the modern term for “shell shock.” Even typing this has elevated my adrenaline levels.
Just as general hospital wards have a nursing station, so too do psychiatric wards. The nursing station is psych wards is generally locked away from the patients. Charts and medication are stored there. There are phones, computers, a textbook or two, and cameras to monitor the “quiet room”—a modern version of the padded cell—and the front door. Strange though the place is, after a few months of working there it starts to feel like a safe haven in a storm of wounded emotions.
Lest you think that psychiatric wards are evil, terrible places, let me reassure you. They are not fun, pretty or nice, but generally they exist to help people out of their emotional “bottoms.” There are no more straight jackets and there are strict laws and regulations to protect the rights of patients. The use of restraints is ever more “restrained” by law, custom and the emphasis on patients’-rights. Inpatient psychiatric stays are usually short, on average less than 7 days. This is dictated both by standards of patient care and by standards of “managed care.” In short, just as there have been accusations of managed care demanding “drive by deliveries”, so too are psychiatric stays shortened to save insurance companies money.
I’ve lost touch with my friend who I hope is doing well. My first experience did not frighten me away from psychiatry but it wasn’t the determining factor either. I now avoid inpatient work in my own practice. The memories, both good and bad remain. So too does my sympathy for those who spent time at the other side of the locked ward.

The Power of Song

“Not by might and not by power
but by spirit a-lone, ("ruach")
shall we all live in peace”

(Debbie Friedman)

The Power of Song

The prompt for this week is “Power” which brings to mind a song. It is a song based on a biblical phrase but I am not going to be making a religious statement in this Sunday Scribble. In fact, what comes to my mind at present is the power of music. How many blog posts have I titled with the lyrics of a song because one popped into my head? Songs package words and memories in a way that the words alone cannot do. The biologist in me understands that song will be stored in different parts of the brain than words heard or read. Even in a foreign language, it is easier to learn words that are encoded as a song. Do you know the words to Frere Jacques? Most of us probably learned it as school children and retain at least some of the words whether or not we later learned to speak French. There may be a Spanish song or two you learned that way as well.
Songs attach to memories like smells did in Proust’s Swan’s Way. (I must admit here that I never did manage to wade through even one volume of Proust). While I write this, I think of the lyric (not inspiring by itself): “All right now, baby it’s all right now.” It immediately takes me back to four years of Stanford football games. The band played this every time a goal was scored. Even thinking of it makes me feel “all right now.”
I’m sure we all wish the songs we remember are the ones we especially admire and want to remember. Sometimes the ones that stick are pretty annoying in fact. “I’d like to teach the world to sing. . . . “ Yada yada. “You, you’re the one, you are the only reason. . . .” “Hold the pickles, hold the lettuce. . . .” Commercial jingles seem to have the most, and worst, staying power. There’s that power word again.
How about annoying songs from your teen years, the top 10 that played in the car while you commuted to school? At the risk of dating myself, do you remember the Paul McCartney song, “Silly Love Songs?” The one with the lyric, “I love you” repeated four times? Or that delightful tune, “Voulez-vous coucher avec moi ce soir?”
Then there’s the Carly Simon song that made me want to cry: “That’s the way I always heard it should be.”

Their children hate them for the things they're not;
They hate themselves for what they are-
And yet they drink, they laugh,
Close the wound, hide the scar.

Not exactly an advertisement for getting married.

Go back further into my childhood and songs of despair. Think of the Stones’:

“And if you take more of those / you will get an overdose / No more running for the shelter / of a mother's little helper”

Wikipedia tells me that the drug of abuse in this song is Nembutal. Makes me glad barbiturates are not a commonly prescribed drug nowadays.

Other sad songs I remember from my youth include: The Beatles’ “All the lonely people.” Check out the lyrics here
and see if they have the power to make you sad; also listen to Simon and Garfunkel’s Sound of Silence:

"People talking without speaking
People hearing without listening
People writing songs that voices never share"

Or their version of Scarborough Fair:

"Tell her to reap it in a sickle of leather
(War bellows, blazing in scarlet battalions)
Parsley, sage, rosemary, and thyme
(Generals order their soldiers to kill)
And to gather it all in a bunch of heather
(And to fight for a cause they've long ago forgotten)
Then she'll be a true love of mine."

Songs of love, loss, wounds, war and betrayal. All the powerful themes of the 60’s and 70’s as well as those of the new millennium. The other day I heard some young people listening to a new song I didn’t recognize. What caught my attention was the use of the word “suicide” repeatedly in the lyrics.
As a mental health professional, I periodically am asked by parents if they should be concerned about their teen’s listening preferences. The songs are too dark, they say, or too violent. Do we really believe that music has the power to enslave the adolescent mind? To turn the thoughts to death, murder, hate or despair? Did Marilyn Manson’s music provide a spark for Columbine?
Read some music lyrics yourself and tell me what you think. Check out the lyrics of Hood Figga by rap artist Gorilla Zoe here. I can’t print them here, too nasty.
Lest you think I believe all rap is bad, here are a few lines from another rapper, Eminem:

“You got some issues Stan, I think you need some counseling
to help your ass from bouncing off the walls when you get down some.”

This is a sad, scary song but can be read as having a positive message. At least, that is how I chose to hear it.
So what do I tell the parents? To take away their kid’s I-Pod? To censor their listening? Generally not. Some music is inappropriate for young children just as some movies, TV and video games are. Music with overt references to drugs, sex and violence is not appropriate for an eight year old. Use some judgment, guys. I have to confess that I heard the soundtrack to “Hair” many a time when I was a preteen; it was one of my mother’s favorite albums. These are the cleanest lyrics from one song:

"Join the holy orgy
Kama Sutra
Everyone!"

I had no clue what I was singing (honest, officer). Did Hair change my life or moral outlook? Highly doubtful.
No, I tell the parents to listen to the music their kids prefer. Go on-line and read the lyrics. Discuss them with the kids. Tell them you don’t like how this song demeans women, glorifies drugs, or speaks about self destruction. Ask them why they like it. Parents miss an opportunity if they simply ban music.
Music does have power, good, bad or indifferent. To sell a product, to disseminate an idea, to change a mood. But its powers are not magical. Obviously we are more than the sum of what we listen to. Otherwise I would be a sex-addicted, Burger-King-loving, love-stricken-yet-unmarried, drug-abuser. What songs had power over you as a youth? Which ones stuck in your head, for better or for worse? Tell me a few of your musical memories.

Writers Read Here

Check out this new writing site, Writer's Island, it replaces in part Poetry Thursday which appears to be defunct. The prompt for tomorrow is: The Gift. Since my writing brain seems to have turned on, at least for today, I have posted my offering below.

The Gift

“She often saw things which other people missed—a fact which rather bemused her; that is why I have found my calling, she said to herself; I am called to help other people because I am lucky enough to be able to notice things.” (From The Good Husband of Zebra Drive, by Alexander McCall Smith).

I just finished reading the above book, the latest in a mystery series set in Botswana. It is an unusual series in that the mysteries themselves are largely irrelevant. What is important in each book is character and culture. What strikes one about the heroine, Mma Ramotswe, a detective, and the author, McCall Smith, is that both have an exceptional ability to notice the small things.
I think that I too have a gift like this. Although there are plenty of times I can be cheerfully oblivious to matters around me, there are other times when I can focus on the small details in a way that is very useful. Of course, I am not a detective, unless you consider me a detective of the small details that may move a person from sickness to health, from distrust to trust, or from aloneness to feeling understood.
My grandfather used to say I had “eagle eyes”. He didn’t so much refer to the quality of my vision but to my ability to find coins and other small treasures on the sidewalk or road as we walked together. Grandpa had a heart attack when he was in early 50’s and his physician told him to walk a mile a day. When I visited with him, I would often walk with him and he took great pride in occasionally finding money or an item of jewelry on the ground. He encouraged this ability in me and I suspect I have done him proud. The most likely reason I often walk with my eyes to the ground is that then I don’t have to make eye contact with strangers but whatever the cause I am still good at finding things on the ground.
This is not the same focus that lets me read people. Superstitions about psychiatrists to the contrary, I do not read minds. I do read body language. I try to read the things that are not said but are felt. I guess I am good at that but I imagine I will spend the rest of my life refining my ability to respond appropriately to what I see. Because, in fact, it is not so much what you notice that matters but what you do with the information and this distinction is very important in a healer.
Unfortunately, this “gift” is not always helpful. I noted in a post a few days ago, that I have been known to watch and judge other people when it is none of my business. I find that the capacity to observe is hard to turn off. It is a kind of hypervigilance to the human environment that is not always healthy for me. I might see that someone around me looks like they are up to no good and wonder what I should do about it. I might misread someone’s reaction to me and think they are bored or dislike me. I enjoy being alone, especially outside in nature where I don’t have to try to tune out all that unwanted information.
It is interesting that blessing and curse, gift or unfortunate trait are determined by circumstance and the use I put it to. Perhaps like in the fairy tale, the good fairies gifted me with their best wishes but one wicked and jealous fairy placed a curse as well. In the metaphoric sense, isn’t that true for us all?

Loss of identity

I just knew this photo would come in handy.

Two weeks ago, the Department of Veteran's Affairs saw fit to inform me via a form letter that a database with my identity as a physician, including social security number, physician license number and who knows what else, was stolen in January. They helpfully suggest I access my free credit report to check for any illicit activity. Apparently 1.3 million other doctors are involved and many who have billed Medicare who are not physicians (which the news reports omit).
Why did the VA wait so long? Why are they not taking more action to help protect my identity? Why did Veterans whose information was also compromised (199,000 of them) receive their letters in March and doctors only in late May? Why was the VA doing research on my billing practices, given that I do not work for the VA? What was the government thinking? Apparently it wasn't thinking much at all given that this is not the first, very large, data breach at the VA in the past year.
Last of all, for how long is my data at risk? The rest of my life? Too bad I can't change my identity to avoid it being misused this time.
Skip the government site. It is worthless.
For more, read this link.

Small town excitement

Even though Chicago is a big city, my neighborhood is a very small town. If I look in the neighborhood phone book I can easily pick out names of people I know. Today was our neighborhood garden fair and there were any number of familiar faces.
Yesterday younger son and I were leaving his school when we noticed fire trucks and large amounts of smoke. We all know that fire trucks in an urban area can mean anything from a heart attack to a false alarm in a public building. But the smoke made it clear this was for real. It had the smell that burning rubber makes.
We immediately decided to park and check it out. Fortunately we could park before we got in the way of the fire trucks. Another less lucky driver had pulled into a driveway to clear the road but then could not get back out. I was a bit surprised that he actually asked the fireman to move his truck to let him out. I mean, really. There's only a burning building and who knows, people at risk. The fireman was up to the task. He told the guy to drive on the sidewalk.
I forgot to mention that as I had been out at a meeting in the far south suburbs yesterday, I actually had my camera with me. So here was my big chance for a little photo journalism.



My first shot of the action was of the firemen unreeling the hose and running toward the back of the building. I could see a man and boy who appeared to be helping with the hose. That struck me as surprising, kind of like the paramedics letting someone help with the CPR. Then I saw the family walking toward me; I couldn't see there faces but they looked shaken up and teary. I guessed that it was their house on fire. I couldn't take pictures of their pain. It just isn't in me. So there goes my career as a photo journalist.
Funny since I talk to people about their pain all the time. I see them cry, see them scared, embarrassed, panicky. When someone apologizes to me about crying in my office, I tell them that's why I keep the Kleenexes and joke that I have stock in Procter Gamble or whoever it is that makes the tissues. In real life I don't own stocks. I once meant a psychiatrist who was chatting with a drug rep about her investments in pharmaceutical companies. This troubled me ethically. I don't want stock in something I prescribe. It seems like a conflict of interest.
Anyway, even though my job in a way gives me a license to pry, I didn't want to pry into the business and pain of someone I didn't have a professional or personal relationship with. Don't you always cringe when there are journalists interviewing the families of a murder victim and so forth? How ghoulish. Not that I'm better than anyone else. I gape at car accidents too.
And here we were going to gape at a fire. There was quite a crowd gathered. This was a real neighborhood event. A number of police, a bunch of local people and the local electric company men who stopped working to gape too. There wasn't much of a show fire-wise. From the front of the building there was little smoke and no flames to be seen. The ladder trucks had their ladders extended into a second floor window and you could hear but not see the firemen breaking out the windows of one apartment. Most of the action was hidden by a tree.
In many ways it was more interesting to people watch. A woman walked by with her two pedigree dogs, one of whom had his leg in a cast. Several people had their cell phones out, probably to call and tell someone about the fire. Some parents were showing their kids what was going on.



My son asked why the people we saw were so upset. I told him I'd be upset if our house were on fire. He replied, why, it's just things? I wisely didn't mention our cats because that would have scared him. He's right, if no one comes to harm, it is just things. But losing one's home to a fire would be devastating nonetheless. Fortunately, judging by idle ambulances and how quickly the fire department was able to start pulling out, it appeared that no one was hurt. With fire hoses and men with axes and picks at the scene, there probably was a fair bit of property damage.
I let my son take some photos too. I figured he'd enjoy it (he has the makings of a fair little photographer) and people would mind him taking pictures less. Although it is a big camera for a little kid. He was a bit too excited to keep the camera still and take the time to focus. Some of his pictures looked more like modern art than photos.



So that's the highlight of my Thursday. How was yours?

Sunday Scribblings--Second Chances

What an interesting prompt. At first all I could think of is the trite second chances that are so often offered as solutions in our culture. You know what I mean, if at first you don’t succeed . . . etc., etc., etc. There’s It’s a Beautiful Life, Groundhog Day, even Click (which at the behest of my son, I watched recently—how many four letter words can one use in one movie? A lot apparently).
You can change careers, marriages, get forgiven after a fight, go back to school, get a sex change operation. Aren’t these all second chances? In my book, not really.
I’d say the reverse. You only get one life; make the best of it. This may seem unempathic and a bit cynical. Or maybe I’m just frolicking in my current, relatively functional existence.
But I don’t mean it that way. I’ve had my share of hard knocks (really, but you’ll have to read about it in my memoirs). But there was no room for sitting around waiting for a new life to come along. At some point I needed to get off my duff and keep moving forward. There wasn’t any alternative.
I see nearly daily those who deserve a second chance but aren’t going to get it: the single parent raising a mentally ill child, the psychotic young adult, the bereaved parent, the terminally ill middle aged woman. Life seems to say to them, tough luck, this is as good as it gets. (Great movie by the way). You don’t get to change your genes, delete all your bad choices (why did you marry and have kids with that piece of scum?), or turn back the clock.
So what to do? Isn’t part of my job to help people figure that out? To tell them that we will do our best to help them out of their chronic depression or chronic pain. But no false promises. You may have your disorder for the rest of your life. Your pain may be incurable. Your autistic child may never live independently.
If I can, I will try to “cure” with medication or psychotherapy. But sometimes I just try to help people cope. One step at a time, I say repeatedly. Let’s focus on what you’re going to do today. Let’s congratulate you for the progress made over a year’s hard work and look ahead to perhaps fewer days of disability than last year. Did you make one friend or pass your first college course after three years of trying? Don’t mind that it isn’t even for credit. Your mentally retarded child is lucky to have a mom like you; now let’s see what we can do about the tantrums.
I guess I don’t feel that life is about second chances. You can hope for change, to better your existence, to decrease your pain and suffering but this is all there is. (I’m not talking theology here.) Fight like the dickens to feel better. Fight like the dickens to have a life worth living. Never quit. There are solutions. There is progress. Change can happen. But, as I jokingly tell people sometimes, we don’t do personality transplants in my office. No brain transplants or time travel either.
Good luck to you all and Happy Mother’s Day.

Blogging against Disablism Day--BADD?

What happened recently in Virginia has been hashed over so many times that I have little original to say about the tragedy but I will tell one story to heighten awareness regarding those who silently suffer from a mental illness. It is clear the young man who killed those people and then himself was mentally ill. This doesn't bring back the dead or get him posthumous help.
But I will reflect to you all what a patient of mine once commented when another mentally ill individual made the headlines years ago. She felt that every time an outrageous act is attributed to mental illness, it becomes all that much harder to focus on the fact that most mentally ill individuals never harm a soul, don't do scary things and don't act "crazy." There are no news headlines about how someone with a mental illness holds a job, raises a family and donates money to the charity of his/her choice. Occasionally a celebrity "comes out" about his or her Bipolar Disorder, Depression or OCD, or Oprah parades a few folks on her show, but it is never enough to make my patient feel that she doesn't have to apologize to the world for her illness.
Enough said.

See Diary of a Goldfish for more.

And now for something completely serious

Sunday Scribblings' prompt for today is In the news. I chose a magazine article I wanted to read anyway. Here is my post.

In the news

April 9th’s New Yorker caught my eye recently. One of the cover articles is Jerome Groopman’s, “Is your child really bipolar?” I like to keep up with what the public is reading about the illnesses I treat so I put this article on my reading list.
Dr. Groopman is the prolific author of several books (that I have not read) and a number of articles for publications including the New Yorker, New York Times and Lancet. I admire his accomplishments as an author and he seems to be a notable scientist. However, his areas of scientific expertise are in the domains of cancer and AIDS research, not psychiatry.
Mr. Groopman’s article is well-written and informative. It gives some interesting historical background about the diagnosis and treatment of Bipolar Disorder (formerly known as Manic Depression). He provides an adequate introduction to some of the controversies regarding the diagnosis of Bipolar Disorder in children and adolescents.
His article reads like a Who’s Who of Child Bipolar research. Groopman begins the article with reference to Steven Hyman, former director of the National Institute of Mental Health. He mentions respected Child Psychiatric researchers such as Barbara Geller, Joseph Biederman, Janet Wozniak and Eileen Leibenluft and discusses their relevant research.
These psychiatrists along with a few others not mentioned here provide the core of the research-based analysis of what is and is not Pediatric Bipolar Disorder. To give you an example of these researchers stature, a search on the name Barbara Geller on PubMed lists 24 articles in major journals on Bipolar Disorder. Search on Joseph Biederman and you find 220 articles, 45 of which relate to Bipolar Disorder.
These and other scientists do not agree on the exact definition of Bipolar Disorder in children. This is a caution to us all. If the definition is not clear and (as in this case) there are no laboratory exams or body scans to identify an illness, there will be instances of both under and over diagnosis. The diagnosis is even harder in preschool and young-school aged children. As Groopman correctly points out, the medications used to treat Bipolar Disorder are often potentially toxic and should be used with great care. For some people, they may be life-saving as well.
Let us compare treatments for Bipolar Disorder to treatments for Dr. Groopman’s specialties, AIDS and cancer. It is well known that chemotherapy, radiation and AIDS medications can be extremely toxic; however, they are used because they also clearly can save lives. We probably wouldn’t give these treatments to someone if we weren’t sure they had cancer or AIDs, however. What would we do if we believed they had a 50-75% probability of having cancer or AIDS? This is what we are dealing with when we treat presumed Bipolar children.
Some of these children are so severely afflicted that they are at risk of being institutionalized, expelled from school, jailed or placed for adoption (or re-adoption) by their families. Under these circumstances can you afford not to treat? Even if the diagnosis is uncertain, the medication may help, sometimes remarkably so. What do you do when the child is suicidal, violent or so impulsive as to be placing their physical health at risk on a nearly daily basis? I treat these children.
Dr. Groopman is correct. The basis for a bipolar diagnosis, especially in a prepubertal child is difficult and controversial. I tell this to parents I work with. I also discuss medication risks and before I suggest mood stabilizer medications I need to feel confident that the child experiences a serious level of impairment from their mood disorder and that a safer form of treatment is not a viable option. I have indeed seen children that were incorrectly diagnosed with Bipolar Disorder. I have also seen the illness evolve in children I or another health professional had previously diagnosed with ADHD, depression or anxiety disorders.
Like Dr. Groopman, I feel that childhood onset Bipolar Disorder is a bit of a disease du jour and that too many challenging, irritable children are diagnosed with it.
Where I argue with Dr. Groopman is that he trivializes the argument against the diagnosing of children with this illness. He interviews two psychotherapists to make his point. One is April Prewitt, a child psychologist, who apparently spends a good deal of time “undiagnosing” children with were told they had the disorder. What are her qualifications besides a Ph.D.? Hard to tell. She is not cited in PubMed. The only April Prewitt, psychologist, I could find on the internet, works at a health center specializing in women’s health issues. Dr. Prewitt has seen 30 children diagnosed with Bipolar Disorder in three years, according to the article. I doubt this qualifies her as an expert on the illness.
The other therapist interviewed is Phillip Blumberg, “a psychotherapist in Manhattan.” I have no idea what his credentials are. He apparently does not publish in the scientific journals as his name is not mentioned on PubMed. His previous employment as a vice president at ABC Motion Pictures seems irrelevant at best. I cannot even find out what therapy degree he has. In fact, Mr. Blumberg cannot be found at all on a casual internet search. Blumberg seems to blame the drug companies and academic pressure on children for the increase in diagnosis of Bipolar Disorder in children. However, his arguments are vague and not well substantiated.
If Dr. Groopman wants to make a case for the overdiagnosis of Bipolar Disorder in children, more power to him. But let’s have some substantive facts or at least meaningful opinions. Edit out the paragraphs regarding Dr. Prewitt and Mr. or Dr. Blumberg and the argument against the pediatric Bipolar diagnosis is weaker but the article is sounder. We owe it to our kids to accurately portray all sides of the controversy.

Addendum: After writing this article, I decided to edit it and send it to the New Yorker as a letter to the editor. I truly doubt they’ll publish it but why not send it anyway?

Now for the Words--Deepest, Darkest, Part 1

Deep, dark

Does this mean I have to tell you a secret?
In my professional life, I get told secrets all the time. I regard it as an honor to be the repository of people’s secrets and for some it is an important part of the treatment. I believe that many, or even all of us, feel that we carry these terrible skeletons in our closets that will drive away anyone who knows of them. These skeletons rarely are actual skeletons. To date, no one has confessed a murder to me, thank heaven.
Some people tell me of things they actually did that they find shameful; others are more ashamed of a thought, feeling or fantasy. The common theme is the shame.
The whole issue of secrets is a tricky one in therapy. I think that secrets are a necessary and often healthy part of life. But some people feel that they are obligated to tell me their secrets and it puts them in a bind. I will explain to them that they never need to rush something like this. A forced revelation is often too traumatizing. I also tell people that if anything is truly important we will get to it in the future, so there is no hurry.
What is so important about these secrets? Secrets are part of a question that people carry inside them which is whether they are truly likeable and loveable. As long as they hold back a secret or two or three, they can continue to believe that no one truly knows them for who they really are. It is a Catch 22—the secret holds them hostage to their belief that they are unacceptably ugly inside, but the secret is too shameful to be told. Amazingly, most of the secrets I am told are pretty easy to accept. There have been a few exceptions but I have never stopped respecting and liking someone because they told me a “deep, dark secret.”
In a way, I think this is because the capacity for guilt means the person has qualities that I can empathize with. Once many years ago, I treated a man for a medical condition who had been imprisoned for two murders. I found I couldn’t feel a genuine physician-patient relationship with him. He scared me and he was a thief and manipulator while in the hospital. We would diagnose such a person with anti-social personality disorder. People with this diagnosis rarely seek out therapy.
Even the few kids I see with severe behavior problems, what psychiatrists call Conduct Disorder, have the potential to improve. So I try my best to give them a fair chance, although on occasion I have had to call it a day if the lack of honesty and cooperation is too extreme. I don't think I'd ever want to treat antisocial adults. It is just not in my ability to invest enough of myself in this personality type.
I’m not sure if this essay isn’t too frank to post on my blog so I am going to save it for another day. Maybe one day it will lead somewhere.

Addendum: Obviously I decided to post it after all. The comments on my previous post suggested that I should go ahead and stick my neck out a little. We'll have to see how it goes.

Beware--gross-out story!

Too gross for words?
This story is inspired by Debo Blu’s last Thursday Thirteen. She gave a very funny list and one point was describing how a woman having a gynecologic exam is not in the mood to discuss the weather with her physician. Please go to her site if you need a laugh.
I am only going to tell you my second most gross medical story. The grossest is much worse. Don’t read any further if you have a weak stomach or heart.
To orient you first I have to explain how the emergency room rotation at a teaching hospital works. There is the usual hierarchy of attending (senior) physician, senior resident, junior resident (intern), and medical student. As everywhere the med student gets the scut (medical jargon for undesirable duties). In an ER frequented by low income individuals who don’t have regular health care, many people come to the ER for minor problems—the pediatric ER may be full of head-colds and ear-aches; the adult ER is full of minor gynecologic complaints.
The only time in my career to date (and hopefully never to happen again) that I was stuck with a bloody needle was while attempting to sew up a minor knife wound on the hand of a very drunk man. His hand was bloody and therefore slippery and he was too drunk to sit still. I was too green to be a good seamstress. Hence, the needle wound up in my hand. Fortunately I didn’t get AIDS or Hepatitis. Since I was pregnant when I got the stick, I was quite scared until the results came back.
But this isn’t the gross story. Take a deep breath, here goes. So as the bottom of the totem pole, we med students didn’t get to do any fancy stitching (incompetent stitches leave scars), intubations, or last ditch life-saving efforts. We got to do the gynecologic exams on the women who came in with mysterious discharges from “down there”. I learned to live with this job. After all, I wasn’t likely to kill anyone and could test for yeast with the best of them. It was at this part of my medical career that I learned that it is hard to get Chlamydia off a toilet seat (aren’t you relieved?).
Well, one day I was the med student (AKA scut monkey) of the hour and was assigned the pelvic exam on a woman being screened for a sexually transmitted disease. Apparently she wasn’t all too happy with my technique because at one point she tightened up certain muscles and managed to squeeze out the speculum. Sadly for me, it landed, plop, right in my lap. I can’t tell you how fast I changed scrubs.
Maybe that is what scared me away from gynecology (not really). I simply felt like I had an affinity for psychiatry when I chose it. I did at various points consider Neurology, Cardiology and Pediatrics. When you go into psychiatry, everyone, including one’s closest relatives tells you that you are crazy. My mother-in-law took up telling stupid psychiatry jokes. The chairman of Internal Medicine told me I was wasting my talents. My grandmother’s response was: “Why don’t you go into some real useful specialty like, say, gynecology?” Being a polite young woman, I didn’t say to her “What are you nuts?” But I thought it. Loudly.
Actually my grossest story is about a psychiatric patient in a different ER. But I won’t tell you that one. It isn’t printable.

Dream a little dream

“Dream no small dreams for they have no power to move the hearts of men."—Goethe

It amazes me how much we make of dreams and dreaming. There are feeble attempts to understand dreaming in the scientific sense. Then there are the people who interpret dreams a la Freud or Jung.
I don’t really do dream analysis in my work. Occasionally a dream is discussed. Sometimes these dreams are traumatic dreams, literal or metaphoric reenactments of a trauma. Sometimes they are garden-variety nightmares. From time to time, a patient complains to me of “vivid dreams” which can be a side effect of antidepressants. These latter dreams aren’t necessarily frightening, but they are rather more Technicolor than the ordinary dream.
If someone asks me what a dream means, I ask them what it means to him or her. After all, it is not my dream. I don’t believe that there are fixed symbols that mean the same thing for everyone. A dream of water could be a childhood memory returning or a wish for a beach vacation. It could be the result of an overfull bladder. I doubt it is a memory of the womb. And baseball bats, carrots, bananas and cigars are just, well, baseball bats, carrots, bananas and cigars.
I have a recurring dream that I have forgotten some crucial school work. On some days it is a test I slept through or forgot to study for. On other days it is a paper I didn’t write. Since it has been less than 10 years since my last medical board exam (and now we are mandated to take a refresher test every 10 years), I shouldn’t be surprised I haven’t gotten test anxiety out of my system.
I have another recurring dream that takes me to a certain place. I haven’t dreamt of this place lately and do not remember much about it. I just know that I go there at times and that when I am there it is familiar and well-known. I think this place is quite detailed but when I am awake I cannot access it.
Fortunately, I only rarely have nightmares. You know, the kind that wake you up crying or scared and make you unwilling to go back to sleep. I think they were more common when I was younger. Does this mean I am more balanced or just that my nervous system is older?
Daydreams are much more fun than the nighttime kind. After all, I get to set the content and theme. There are no frightening moments allowed. No twists from mundane to fantastical. There are the dream vacations, dreams of learning a new craft, skill or language, the dreams of finding myself on a mountain-top somewhere and the dreams of writing my memoirs or the great American novel. For these dream journeys, all one needs is a few interruption-free moments and a good imagination. I could use a few more of the former but the latter has not yet died of old age.
To close, here is my wish for you all. Sweet dreams.

Long Days

I realized that I don't have it in me to produce much of anything for this day's posting. Last night I worked late. My day started at 7:30 AM with getting the kids out to school. I left for my office at 9:30 AM, saw my first patient at 10:15 and ushered my last out the door at 9:30 PM. I didn't make it home until 10:30 at which point I said good-night to older son, younger was asleep, husband, read half an hour and went to bed. I had an hour off for lunch, 1/2 hour to take care of business thanks to a now-show and that was it. Dinner didn't happen.
This is self-inflicted. I could set limits but it is hard to stop trying to save the world. It is a character strength and weakness all at the same time. I have another nine hour stint ahead of me today, so I guess I should grab some food and head on out.
See you tomorrow.

Blog Alert

Professionally I have had a fair bit of experience with 12 step groups--you know the type--Alcoholics Anonymous, Narcotics Anonymous and so on. For the classic substance abuse model, these groups are quite helpful to many people. However, thanks to a fellow blogger, Liza at Liza's Eyeview I have discovered BA--Bloggers Anonymous. Catch this blog before it gets deleted--the last entry was posted in July of 2006. I guess someone out there overcame his blog addiction. His post The "Mock 10" Signs of Blog Addiction is a hoot in a "isn't denial a river in Egypt" kind of way. How many signs do you admit to? I'll confess to at least 2.
Remember the first step is to remember you are powerless over your addiction to _____ (fill in the blank).

Medication Management--Poetry Thursday

Prozac, Luvox, Symbyax,

Lizzie Borden took an axe
Gave her mother forty whacks.

Ambien, Valium, Geodon,

When she saw what she had done.
Gave her father forty-one.

I have always wondered why psychiatric medicines had such nasty sounding names. All the x's, z's, k's. Most of them don't manage to sound like "happy pills". Somehow it turned into how to write a poem featuring drug names and then trying to rhyme them and Lizzie Borden popped into my head. This is how free association works, I guess. Especially when trying to write poems while driving. I was taught the Lizzie Borden ditty by my mother--Freudian? I never did jump rope to it.
As an historical aside, Lizzie Borden lived from 1860-1927 and was accused of the murder of her father and step-mother. She was acquitted but the murders were never solved. I am not trying to imply that Lizzie Borden was mentally ill or that the mentally ill are axe murderers. I am not totally responsible for my twisted mind, but mine is not responsible for these bizarre medication names.
For more on Lizzie go to Wikipedia.

Out of words

I find myself not having much to say for myself. Perhaps I posted too much in December or perhaps I just have jet lag. Yesterday, we traveled for 10 hours from Seattle to Chicago (one layover in Minneapolis). I managed to read a bit but didn't arrive home in the mood to blog much.
Tomorrow I have a long work day and I'm dreading the transition back to the routine. My work involves some subtle and some not so subtle stresses that do wear on me. I was reading an article in a medical journal which stated that around 1/3 of all doctors would not encourage their children to pick medicine. Although I love what I do, the joy of the practice of medicine has been eroded by the advent of managed care, increasing costs of malpractice insurance, increasing work loads and pointless paperwork. Someday maybe I'll post a rant about dealing with insurance companies. So much of what they do is intended to waste physician, patient and hospital's time. And every now and then there is just one of those bad days when I doubt myself and what I do.
But see, now you made me depressed. So I am going to change the subject and post a happy photo or two. I'll look for something summery.

This is a fortress in the Tuscan town of Castiglioni di Garfagnana. The light from the setting sun was just beautiful that evening.

And the answers are--response to comments on Zero Tolerance post

Pepper: it sounds like you have been through the mill as a parent and I am glad things are better for you and your daughter. Your experiences with medication and (mis)diagnosis are reflective of the sad state of our knowledge base about psychiatric illness in children and about the lack of adequate care available. As we all know, taking care of the mentally ill is not a priority in this country (probably not anywhere). And there is a distinct national shortage of Child and Adolescent Psychiatrists. This will guarantee me a job forevermore but I could do with losing this particular popularity contest. What an amazing story.
Ren.kat--You do ask the tough questions. Child Psych journals and conferences do daily battles over what is Bipolar Disorder in Children. I am convinced it exists as are most Child Psychiatrists but it is also diagnosed in some kids (and adults) who do not really have it. One tactic scientists have used is to study the children of Bipolar parents. It is clear that some of the kids have classical bipolar symptoms but others do not. There are also kids who look a bit Bipolar but may not have the full illness. We do not know what they will grow up to have (if anything). In my profession, there is a split between the narrow definition of bipolarity in children (essentially same symptoms as in adults) and the broad (basically kids who are explosive and impulsive but do not have clear cut mania or mood cycles). One issue brought on by managed care is: no diagnosis, no treatment. So at times, people get labels because "I don't know what you have" won't get you health care.
I haven't heard anything to suggest that most of the kids who were involved in school shootings were or are Bipolar. Much was made in the press of the discovery that a few had received psychiatric treatment and/or medication. I wholeheartedly agree with the concern about stigma and do not want to add to any perception that the mentally ill are necessarily more violent than other people. But some Bipolar kids can be quite mouthy and I do have to defend their right to get back into school after they say something inflammatory.
Regarding racial issues, I was going to make the point that most of the shooters were white but deleted it after realizing that the one teen was American Indian, so as to not make broad racial comments myself. I'm not really all that knowledgeable about the details of violence within inner city schools. Of course, these spectacularly violent episodes in schools would never have happened if the kids were unable to readily get their hands on guns. But that is a topic for another post.
I did a (little) research on this theme before posting and discovered that they are having troubles with school shootings in Germany, as well. I guess the U.S.A. does not have the monopoly on this brand of human ugliness.
m.m.crow: I'll look for the book you mention. My motto in life is "so many books, so little time."
Thanks to you all for your interest and comments. This is what makes blogging fun.