Author: Maria Yang, MD

Categories
Consult-Liaison Education

Most People Do Okay Most of the Time.

Because May is Mental Health Month, I was asked to present information about mental health to a lay audience. This is both an exciting and daunting task. I imagine it’s like asking someone to talk about fish. There are so many kinds of fish! They live in many habitats! Some of them look more like snakes than fish! There are so many directions to go.

I have given a “psychiatry 101” talk to many non-clinical audiences in the past. While reviewing my notes, it became clear that, while this presentation offers useful introduction, the underlying message is that psychiatry focuses on pathology. (This is a common theme in medicine: Doctors are often much better at looking for and finding things that are wrong than at pointing out and supporting things that are going well.)

So, here are three things about psychiatry that don’t focus on pathology:

People are resilient. I remain amazed with the capacity people have to take care of themselves and others when everything is falling apart.

Even though the majority of people experience terrible trauma—war, rapes, natural and unnatural disasters, etc.—most of them will not develop post-traumatic stress disorder. Most people at some point will experience heartbreaking grief following the death of a loved one, but the vast majority will not develop major depression or complicated grief.

People go to work, take care of children, and support their friends despite hearing disturbing voices, thinking about suicide, and feeling unsafe in public. They find ways to help themselves that have nothing to do with formal psychiatric interventions: The man hearing disturbing voices might put on headphones and play the same song over and over again. The woman thinking about suicide might sign up for an extra volunteer shift at the animal shelter so she is around other people. The military veteran might sit in the rear corner of the movie theatre.

Most people do okay most of the time.

It’s okay to not feel good. The goal of feeling happy or serene all the time is an impossible goal. Everyone at some point thinks disturbing thoughts. Just because it seems like everyone else is happy or serene doesn’t actually mean that they are happy or serene.

While our thoughts and emotions may seem illogical at times (“why am I thinking about that?” “why do I feel this way right now?”), that doesn’t mean that something is wrong. Sometimes your thoughts and emotions are treasure troves of information: Your internal experiences give you information about the person you’re talking to, the situation you’re in, and what your next steps should be.

The definitions of psychiatric disorders are not solely limited to “not feeling good” or disliking an emotional experience. Sometimes we don’t feel good. Sometimes that lasts longer than we want. But that doesn’t mean you have a terminal emotional illness.

Most people do okay most of the time.

Behaviors serve a purpose. We all do things that other people think are weird. The spectrum of weirdness is wide, but, if we are lucky to learn more, we can find out the basis behind the behavior.

Why doesn’t she speak up more? Because she believes that no one will find her remarks helpful.

Why won’t he wear anything other than sweatpants? Because he wants to spend his money on fancy cars.

Why won’t she stop smoking methamphetamine? Because it helps her stay awake at night so the men won’t rape her.

Why does he apologize all the time? Because, as a child, he learned that if he apologized a lot, he might be able to stop his father from beating him.

Why does he say things like, “I know a lot about wind” and “I know more about drones than anybody”? I mean, who knows. Is this the only way he knows how to interact with other people? Have these sorts of boasts helped him succeed in the past in relationships and business deals?

The definitions of psychiatric disorders are not solely limited to “doing weird things”. If we do certain things that help us or get things that we want, we will continue to do those things. Sometimes we continue to do those things even when they no longer help us as they once did. But that doesn’t mean you have a terminal psychiatric illness.

Most people do okay most of the time.

Categories
Consult-Liaison Education Medicine Reading Reflection Systems

The Challenge of Going Off Psychiatric Drugs for Psychiatry.

Here are my initial reactions to the New Yorker’s The Challenge of Going Off Psychiatric Drugs:

Which populations are most likely to receive large numbers of psychiatric medications?

The woman described in the article comes from a family of money and privilege. These individuals (and families) have both the time and money to seek out psychiatrists who practice “precision psychopharmacology”. These psychiatrists then order complicated medication regimens that ostensibly address and “correct” neuroreceptors. As a consequence, people end up taking multiple medications.

There are also individuals who do not have money or privilege, but are subjected to psychiatric services due to the concerns of the public. They may be behaving in ways that endanger their own lives or the lives of others. As a consequence, they receive medications—sometimes willingly, sometimes through coercion—that aim to reduce certain behaviors. If one medication doesn’t reduce the behavior, then more are added.

What these two populations have in common are (a) the lack of clarity around diagnosis, which often stems from (b) missing information about the person and the context in which s/he lives.

I completely agree with Dr. Frances’s comment from the article:

[There is a] “cruel paradox: there’s a large population on the severe end of the spectrum who really need the medicine” and either don’t have access to treatment or avoid it because it is stigmatized in their community. At the same time, many others are “being overprescribed and then stay on the medications for years.”

The meanings of diagnosis and treatment, particularly medications.

Some people feel relief upon learning that their symptoms belong to a diagnosis, that what they have is “real”. Others don’t want the “label” of a psychiatric diagnosis; they are not damaged human beings.

For various reasons (e.g., the current primacy of biological psychiatry, insurance reimbursement, psychiatry’s seeming inferiority complex within medicine), treatment in psychiatry is often focused on medications. This is not ideal. Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.

In the meantime, doctors recommend that people take pills. Some people view pills as a necessary intervention to keep them healthy and well. Some people view pills as a shameful reminder that there is something wrong with them that will never improve. The more pills someone has to take, the more potent the reminder that they are beyond hope or repair. Some people view pills as an external validator of their pain and suffering: “Someone else believes and understands my pain and these pills remind them and me that my pain is real.”

The pills may not be treating what psychiatrists think they are treating.

The problems with psychiatric diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) focuses only on the “what”, not the “why”.

It doesn’t matter why someone has a depressed mood, takes no pleasure in work or play, can’t sleep, won’t eat, and feels hopeless. The underlying reason could be the cardiologist’s realization that he should have pursued his dream of becoming an architect… or it could be the threat of eviction after losing one’s job.

This affects the way psychiatrists gather a history from people seeking care. Instead of learning the context behind one’s symptoms, psychiatrists now focus on whether certain symptoms are present or absent. What matters more is that she feels paranoid, not that the paranoia started when she learned that her father was molesting her sister.

To be clear, there are some instances in which the underlying “why” doesn’t matter. If someone is terrified of flying on a plane, there are treatments (e.g., exposure therapy) that can help people tolerate plane rides without getting into the reasons why this fear appeared in the first place.

In other instances, though, the “why” is often relevant. Since our understanding of the biology of the brain and mind are limited, we don’t know if the biological properties of Medication A are more useful in military veterans who have fought in combat or if those of Medication B are more useful in women who experience major depression after the birth of a baby. Even if evidence suggests that medications aren’t the best treatment for either population, it is often the easiest intervention to deliver. This is due to the context and underlying “whys” of the health care system.

All of the other psychiatrists.

It’s true that there is scant evidence about how to taper and stop medications. It is a shame that psychiatry, as a field, has nothing to say about deprescribing. The scientific literature has plenty to say about adding medications, but nothing that extols the virtues of taking them away. There are risks to stopping medications, yes, but why are psychiatrists unimpressed with the risks of starting them? In this way we have failed not only the people who receive care from us, but we also fail the people who step in to help in our absence: Other physicians, nurses, family members, friends.

When I consider the psychiatrists I have worked with with, many of them have helped people come off of medications. They work with their patients and go through the trial-and-error process together. While they may not work in ivory towers of acclaim, they are still doing the work of helping people make informed choices about their care so they can lead healthy and meaningful lives. These are the quiet anecdotes that will never make it into the New Yorker.

Psychiatry as an agent of social control.

This is not the first time I’ve written about psychiatry as an agent of social control.

What does it mean that “antidepressants are taken by one in five white American women”? Is this a reflection of white American women? Or a reflection of the society and systems that want to contain white American women?

What does it mean that African- and Latinx-Americans are more likely to receive diagnoses of psychotic disorders? Is this a reflection of these populations of color? Or a reflection of the society and systems that want to contain these populations?

Perhaps there needs to be a “Challenge of Going Off Psychiatric Drugs” for the field of psychiatry. To be clear, there is definitely a role for medications in the treatment of psychiatric disorders, though: first, do no harm. When The Royal We have more humility about what we do and do not know, and exercise more care in current pharmacological tools, then perhaps getting on or going off of psychiatric drugs won’t be a “challenge”.

Categories
Medicine Nonfiction Seattle

Questions After a Suicide.

To my knowledge, three people who were under my care killed themselves.[1. Additionally, three people who were active patients of mine tried to kill themselves. Then there are the people who have killed themselves, and I am simply unaware that they have died from suicide.]

The first was a young man—late 20s, maybe?—who I met while I was a psychiatry intern. He was hospitalized in the psychiatric unit where I had just started my rotation. I did not have the opportunity to get to know him well. Our paths crossed, at most, for two days. He had a diagnosis of schizophrenia. I can conjure up his face in my mind, though I do not remember his name. He didn’t blink much. While his face did not betray fear, he often looked uncomfortable.

I don’t know how many days he had been out of the hospital before he died, though I think it was within a week of his discharge. He jumped off of the Aurora Bridge (before a suicide prevention fence was installed) into Lake Union in Seattle.

The second was a man in his late 40s who had repeated visits to a crisis center. He did well in college and earned a law degree. His career as a lawyer was cut short due to problems with depression and alcohol. From there he became homeless and destitute. He had a diagnosis of major depression. Some professionals thought he had a personality disorder.

He was smart and sarcastic. While he was often critical of everyone around him, there were moments when he was self-effacing. After we had worked together for a few months, he commented that he liked “debating” with me, though I suspected that arguing was the only way he knew how to interact with other people. On the rare occasions when he took a break from his self-loathing, he considered how his life could change. He didn’t drink as much alcohol now as he once had, but it still helped him forget his shame and regret.

When I learned that he had died from an overdose of methadone, I knew immediately that he had intentionally killed himself. He had no history of using opiates, but he knew how, with or without alcohol, they could end his life. Over a month had passed between our last conversation and his suicide. When I learned of his death, I asked him—as if he could hear me—why he didn’t come back to the crisis center. He knew that he could.

I have not forgotten his name. Earlier this week, I saw his name in a newspaper. It wasn’t him, of course; the name belonged to an author who was promoting his book. I hadn’t seen this name elsewhere before. It made me wonder if my patient was saying hello.

This past week, I learned that a third person who was under my care killed himself. He was in his 20s, smart, and funny. When his symptoms were active, he was very ill. In the minutes to hours leading up to his death, was he experiencing a resurgence of his symptoms? Or was he mulling over how his illness could impact his life in the future and decided to impact his life first?

The last time I spoke with him, we talked about how his condition did not define him. His identity wasn’t solely his illness. We talked about the things he wanted to do in the future and how he could accomplish those things.

The person who called me to tell me the news heard my breath catch in my throat.

Death, while uncomplicated in some ways—it’s a permanent cessation of all vital functions, the end of life—our attachments make it complicated in other ways. We have so many questions that will forever go unanswered. We wonder where the dead go. Does a part of them persist outside of our memories? And for those who kill themselves, what happened? What got in the way of them asking for help? What made death the best option? What made them believe that the rest of us could not or would not understand?

The end of a life never just impacts the individual who died. The ripples spread far and wide. We search for words to describe our grief, but language fails us.

Categories
Consult-Liaison Reading Reflection

Antisocial Behaviors.

The anxieties and discord within my tiny world and the world at large have felt heavier as of late. Thus, my words do not flow today with the relative ease that they have under different conditions. (To be clear, I’m fine. Perhaps I am just more sensitive to the energies and emotions of others.)

I recently learned about “adulthood antisocial behavioral syndrome”. If you’re familiar with the definition of antisocial personality disorder, it’s essentially that without the requirement for conduct disorder before the age of 15. (If you’re not familiar with antisocial personality disorder, allow me to refer you to my 2013 post (!) that describes the condition.)

The prevalence of these two conditions (derived from surveys of the general public) surprised me: In the United States, about 4% of the population have antisocial personality disorder, and a striking 20% apparently have adulthood antisocial behavioral syndrome. If the prevalence is 20%, should we consider that a disorder? (Is that why it’s called a “syndrome”?) That means if you invite four of your friends over to your home, one person in that group has adulthood antisocial behavioral syndrome. (Maybe it’s you!)

For many reasons (it’s exhausting, I have insufficient data, I can’t do anything to help, etc.), I avoid the intellectual exercise of considering what psychiatric conditions certain public figures may have. That being said, regardless of who is President and which political party has the majority, it is common in psychiatric education to note that there are people in power who likely have antisocial personality disorder. These individuals just haven’t gotten caught (or have the resources to avoid punishment… or there are institutional factors that protect them).

But, for “fun”, let’s run the numbers. If 4% of the US population meet criteria for antisocial personality disorder, that means

  • four Senators and
  • 17 House Representativies

demonstrate a “pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years”. (I’ll let you discuss amongst yourselves as to the identities of these individuals.) There are 15 Cabinet members and nine Supreme Court justices, so the chances are low that one person in either one of those groups has antisocial personality disorder.

If 20% of the US population meet criteria for adulthood antisocial behavioral syndrome, that means

  • 20 Senators
  • 87 House Representatives
  • one Supreme Court justice and
  • three Cabinet members

demonstrate a “pervasive pattern of disregard for and violation of the rights of others”… but did not do so before the age of 15.

The paper that describes the survey also notes that these two antisocial conditions are

highest among male, white, Native American, younger, and unmarried respondents, those with high school or less education, lower incomes, and Western residence

When we consider mass shootings (most certainly an antisocial behavior) in the US, most of them were committed by men… but also note that the vast majority of men don’t ever kill people.

The odds ratio for Native Americans struck me: What does that mean? Is this simply due to the low numbers of Native Americans in this country (i.e., small numbers inflate percentages)? What are the other confounders?

And what about the contexts? Aren’t there occasions when antisocial behaviors are adaptive? If someone threatens your life on a routine basis, is it (1) unreasonable to lie, (2) put your safety at risk when you try to escape the situation, and (3) perform poorly at work due to the stress in your life? You only need to meet three criteria to receive a diagnosis of antisocial personality disorder.

I’m also curious about the prevalences of adulthood antisocial behavioral syndrome in other countries. Does a 20% prevalence in the US mean anything? Do we demonstrate more antisocial behaviors than others on this planet? Maybe this is just human nature?

Some people say that intellectualization is a mature defense mechanism. I’ll let you decide if this post is simply a manifestation of whatever unconscious conflict roils in my psyche.

Categories
Medicine Nonfiction

Follow Up.

To my surprise, he called my name and asked to talk with me.

I didn’t bring up the incident that had occurred the last time we spoke: He got upset because he believed that I had put voices into his head. I wanted him to associate me with attributes other than hallucinations. There was no way I could help him if he believed that I was doing things against his wishes.

“So, hey,” he volunteered after we had spoken for a few minutes, “I’m sorry for yelling at you the other day. I was already thinking about robots and when you asked me about them, I freaked out. I’m sorry.” A sheepish smile bloomed on his face, but his eye contact did not waver. He looked and sounded sincere.

“It’s okay,” I replied. “This is a stressful situation and sometimes we all get upset over things that we feel like we can’t control.”

He nodded. We talked about the voices—they were still talking to him, but they were quieter now—and what other things he could do so they wouldn’t bother him as much.

Even though I’ve been doing this work for years now, there are still moments when I am astonished with the effectiveness of medications for symptoms of psychosis. I already knew they can save lives. I already knew they can transform lives. And yet!

“I am going to ask the nurses to offer you medicine,” I said the last time we met while he was yelling at me. “You don’t have to take it, but I think it will help.”

And, for whatever personal reasons he had, he took it. (The manner and skills of the nurses undoubtedly helped with this, though it appears that persuasion of any form was unnecessary.)

“Do you have any other questions for me before I go?” I asked. Last time, I simply told him that I was leaving. First, do no harm.

“No,” he said, smiling. “Thank you for talking with me. I hope you have a nice day.” He waved.

“Thank you,” I said, waving back.

Wondrous!