Author: Maria Yang, MD

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!

Categories
Medicine Nonfiction Reflection

Assuming Intentions from Behaviors.

The fear first appeared in his eyes, then washed over his entire face.

“Hey, how did you do that?” His voice grew louder. “You’re supposed to help me! How did you tell the voices what to say?”

I realized that this was not going to end well.

“The voices in my head are now saying that there are robots in my brain!” he shouted. “That’s illegal! You’re not allowed to do that!”

“I have no ability to put voices in your head or anyone else’s head.”

“But you did! Before you told me about what I supposedly said the other day”—he had told my colleague that there were robots in his brain—“the voices never talked about robots. YOU did this!”

“I did not.”

“You did!” He looked around, frantic. “HELP! SOMEONE HELP ME! THIS NURSE IS PUTTING VOICES INTO MY HEAD!”

My heart sank further. Many people who experience auditory hallucinations learn to avoid sharing this with others. This man did not realize how others would dismiss his suffering.

“I’m going to go.”

“NO! You can’t go! You’re doing something illegal!” He saw an officer approach. “GUARD! GUARD! This nurse is doing something illegal! She’s putting voices in my head!”

Though he has worked on the unit for years, I suspect that he had some innate skills in talking with people who were overwhelmed.

“Hey, you don’t need to yell, I’m right here. She’s trying to help you….”

He managed to shout, “HEY, COME BACK HERE, YOU NEED TO STAY!” as I slipped away, but he stopped yelling before I was out of earshot. The officer later told me the man demanded that I call his parents to tell them that I was putting voices in his head.

There’s no way this could ever happen to you, right?

But aren’t there times when we believe that someone did something to us… except they didn’t?

Like those times when we say, “She makes me so mad!”

Or, “He’s trying to make me jealous.”

We assume intention from behaviors. Sometimes our assumptions are correct, but not always. We feel whatever emotions we feel, but that does not always mean that somebody else is responsible for our emotions.

“But, Maria,” you might retort, “there’s a big difference between hearing voices and feeling emotions. We all feel emotions. Only sick people hear voices.”

… except there’s data[1. Prevalence of auditory verbal hallucinations in a general population: A group comparison study and A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals.] that suggests that anywhere between 5% and 28% of the general population hears voices. They are your coworkers, friends, members of your family, people you routinely see in your community.

And even if we don’t hear voices, our running internal dialogue—while not “voices”, per se, but “thoughts”—can transform an event into something else that never actually happened.

I felt sad as I was walking away from this man. First, do no harm. Our conversation went sideways and caused him distress. I replayed the interaction in my mind—my own internal dialogue was loud—and recognized several points where I could have taken a different approach. The outcome still may have been the same.

The truth remains, though: I did not put voices into his head. I don’t know how to do that. My hope is that he will recognize and accept that in time.

Categories
Medicine Policy Reading Systems

The Word is Not the Thing, And…

This past week I finished reading McCloud’s Understanding Comics: The Invisible Art.[1. I purchased Understanding Comics to learn a different perspective about storytelling. I am not a routine reader of comics. Regardless, I do recommend this book. It is a thoughtful and fun read, and it’s a comic book.] The second chapter, “The Vocabulary of Comics”, reiterates a major point in Hayakawa’s Language in Thought and Action:

The first of the principles governing symbols is this: The symbol is NOT the thing symbolized; the word is NOT the thing; the map is NOT the territory it stands for.

McCloud uses René Magritte’s “The Treachery of Images” to welcome the reader to “the strange and wonderful world of the icon”:

I’m using the word “icon” to mean any image used to represent a person, place, thing or idea.”

This idea that “the word (or icon) is not the thing” is relevant to a recent opinion piece, “Beware the Word Police“, in the academic journal Psychiatric Services:

Frequent calls for changing diagnostic labels to decrease stigma may result in unintended consequences. Condemning incorrect language by policing word choice oversimplifies the depth of work involved to increase opportunities for people with mental illness. This Open Forum reviews three unintended consequences of using scolding language.

The author of that opinion piece, Patrick Corrigan, lists these three unintended consequences:

  1. the word police’s focus on “just changing terms” misrepresents the depth and persistence of bias and bigotry
  2. word police are a major barrier to the essential goals of stigma change
  3. word police may undermine stigma change at the policy level

I’m One of Those People who avoids using the words “addict”, “schizophrenic”, or “diabetic”. I instead say “individual with a substance use disorder”, “person with a diagnosis of schizophrenia”, or “someone with diabetes”.

While I agree with all the authors above—words and icons aren’t the thing, they only represent the thing; the use of different words does not equate to actual reduction in discriminatory behaviors—I also believe that, as a society, The Royal We have come to agree that certain words have certain meanings.

For example, if I describe a person as a “diabetic”, what comes to mind? Perhaps you think of a family member who has diabetes and has excellent management of her blood sugars. Maybe you think of the person who goes to the emergency department multiple times a month due to high blood sugars and non-healing wounds. Or maybe you’re thinking about the growing number of people who struggle to pay for insulin to treat their diabetes. The range of ideas that come to mind with the word “diabetic” is broad.

But if I say someone is an “addict”, what comes to mind? Maybe you think of a senior vice president of a major business who wears tailored suits, but most people don’t. When I teach and ask audiences—comprised of health care professionals or otherwise—to list what comes to mind when I say “addict”, the list always includes things like

  • dirty
  • mean
  • desperate
  • selfish
  • etc.

(When the audience is comprised of health care professionals, I remind them that, right now, they are likely working with someone with a substance use disorder… and that person won’t disclose how much s/he is suffering because they feel shame about the presumed characteristics of “addicts”.)

It is true that the word “addict” is NOT the person with a substance use disorder. However, we, as a society, have somehow arrived at the agreement that the word “addict” describes someone who is dirty, has no self-control, etc.

Even though a different word doesn’t change the actual thing, the different word can change the idea about the thing. A different word can have a different definition, different associations.

Again, if I describe someone as “schizophrenic”, what characteristics comes to mind?

But what if that person with schizophrenia is your neighbor? works as a barber? works at Microsoft? is raising two kids? just earned her graduate degree? volunteers at the animal shelter? is the owner of that plot in the community garden that is overflowing with flowers and vegetables?

If different words can change the idea about the thing, then different words can help people change their behaviors about the thing.[2. To be clear, insight does not always result in behavior change. Even if the psychoanalysts argue otherwise.] In regards to the “word police” piece above, shifts in ideas and behaviors can drive improvements in health and social policy. This can lead to a reduction in stigma. The Royal We can develop new agreements for these different words. And using different words is sometimes easier than changing definitions for the same word (e.g., consider racial slurs).

Maybe I am falling into the “word police” camp. However, I do agree that behavior change is the ultimate goal, since what we do matters more than what we say. As with many things, the solution is somewhere in-between: Let’s work on word choice to help shift ideas and behaviors, but also remind ourselves that the word is not the thing.

Categories
Reading

Interesting Reads.

Here are some things I’ve read recently that you may also find interesting:

1. When Going to Jail Means Giving Up The Meds That Saved Your Life. “Pesce worried that while he went through withdrawal from methadone in jail, someone would offer him drugs, and he wouldn’t be able to refuse. He turned to the courts for a solution: Pesce sued the Essex County sheriff on the grounds that his addiction was a disability and that denying him treatment was a violation of the Americans with Disabilities Act, as well as cruel and unusual punishment.”

2. Though I do not follow sports, I enjoy sports writing. Here is a pair of articles related to baseball and economics: Why Isn’t Anyone Bidding for Bryce Harper and Manny Machado? (“… and now owners are squeezing players on either end like so many papayas in a juicer”) and Baseball Doesn’t Need Collusion To Turn Off The Hot Stove.

3. I recently saw the play M. Butterfly (and was one of the few apparent Asians in the audience…) and wanted to learn more about the curious events that inspired this work: The True Story of M. Butterfly; The Spy Who Fell in Love With a Shadow. “… Bernard Boursicot, as he has always wanted to be, becomes a man of extraordinary distinction: the man who made love to another man for 18 years and did not know.”

4. I much prefer prose to poetry, though occasionally a poem will catch my attention. Here’s David Whyte’s Everything Is Waiting For You.

5. I only learned of Donella Meadows after her death. Here’s one of her columns where she discusses “What Makes a Great Leader?” One wonders what she would say about the current President.

6. The first book I finished reading in 2019 is Language in Thought and Action. This is one of the best books I have read in my life. Many of the ideas are familiar to me from my clinical training, but Mr. Hayakawa discusses the impacts of language and word choice from a non-clinical perspective that is more accessible. The first edition was published in 1941; it still has potent relevance today.