Categories
Informal-curriculum Nonfiction Observations

Name-calling.

Let me start by saying that it actually doesn’t happen that often.

The yelling and screaming usually comes from men who aren’t under my care. It often happens when I’m talking with my patients or when I am just walking past a cell block.

Sometimes, it is repetitive yelling that sounds like a metronome:

WHORE! WHORE! WHORE! WHORE!

Sometimes, it is a tirade:

F-CKING SLUT, you’re a F-CKING SLUT, d-mn whore, F-CKING C-NT, YOU HEAR ME? YOU’RE A F-CKING SLUT, YOU F-CKING B-TCH, yes, YOU, you’re a F-CKING BITCH…

Other men take issue with my short hair and assert that I am a lesbian:

You’re a LESBIAN, aren’t you? What the F-CK is wrong with you, LESBO? Why don’t you like dick? F-CKING LESBIAN, you and your F-CKING SHORT HAIR…

For reasons I don’t understand, it is uncommon for men to yell racial slurs at me.[1. No one in jail has yet to call me a “chink“—at least not to my face or when I am in earshot. I did have a patient who would intersperse his sentences with musical phrases: “Ching chong ding ding ting tang…”. He didn’t do this with anyone else. He also refused to believe that I am a physician. He insisted, “There’s no way you’re a doctor. Women can’t be doctors. You’re probably just a clinical assistant. Women aren’t smart enough to be doctors.” I steered the conversation elsewhere.]

I have since learned that those men who yell synonyms for commercial sex workers at me or insist that I am a lesbian become more enraged when I ask them to stop yelling. Usually it goes something like this:

Maria: “Hi. Could you please stop yelling for ten minutes so I can talk to the guy over there? It’s hard for me to hear him.”

Inmate: [spewing more hatred at a louder volume and a greater frequency]

This response differs from other men who yell for different reasons. Often the men who scream about the crimes of the government, the arrival of the aliens, the ghosts in the machines, and the coming of the Antichrist will acknowledge my request and kindly stop yelling. Some can’t stay quiet for more than three minutes, but they try.

On occasion, the men who are my patients—and sometimes these are the same men who proclaim that they are actually machines and not humans, or they can’t string together coherent sentences—will scream past me to the men yelling malicious things: “SHUT THE F-CK UP!”

Their imperatives often go unheeded.

Hearing this vitriol doesn’t bother me too much. I mean, it bothers me enough to write a blog post about it, but such behaviors make me wonder more about the suffering of these men. Perhaps these men are screaming at me because I am on the other side of their cell doors and they feel anger with their lack of freedom. Perhaps these men don’t like the inherent power differential between them and me in a setting like the jail. In an effort to assert dominance a man may shout misogynistic things at me because he is trying to close the gap between his status and my status. Maybe women in his past have done terrible things to him.

My male colleagues have mentioned that these same inmates might insist that they are gay. Otherwise, most of the commentary these men lob against my male colleagues are death threats. This is in contrast to the threats I receive; men usually threaten to rape me. (Let’s be clear: Such threats are rare.) And it is not necessarily the men who scream hateful things at me who threaten rape.

What people say and what they do aren’t always congruent, whether in the jail or elsewhere. Consider the men in jail who have been charged or convicted many times of sexual assault. They may never shout anything at female staff. Some of these men show great courtesy; they look me in the eye; they say “please”, “thank you”, and offer gracious social smiles.

One wonders what they do not say out loud.

Some people will judge you just based on how you look. To some men, women are malignant deviants; they induce fear and loathing. Some men decide that the best course of action is to hurl hatred at women.

Sometimes, they might do even worse things.

Categories
Consult-Liaison Reflection

Questions about the Throwing of Urine.

If a man throws an open container of his own urine at another person, does he have a mental illness?

  • What if he throws an open container of water at another person?
  • What if he throws a closed container of his own urine at another person?

If a man throws an open container of his own urine at a nurse in a hospital, does he have a mental illness?

  • What if he throws his urine at a nurse who is trying to inject him with a medication he doesn’t want?
  • What if he throws his urine at a nurse who is trying to give him food and drink?

If a man throws an open container of his own urine at a nurse on a surgical ward, does he have a mental illness?

  • What if he throws his urine at a nurse while on a psychiatric ward?
  • What if he throws his urine at a nurse while in jail?

If a man throws an open container of his own urine at the police when they charge into his home, does he have a mental illness?

  • What if he throws his urine at the police because he has multiple containers holding his urine and those are the closest things he can grab?
  • What if he throws his urine at the police because he hates the police?
  • What if he throws his urine at the police because he hears voices that tell him to do this to protect himself?

If a man collects his urine into a container over time for the purpose of throwing it at another person, does he have a mental illness?

  • What if he believes his urine is holy water and believes that his urine will baptize others and save their souls?
  • What if he wants to witness the anger and disgust of others when his urine splashes all over their faces?

If a man throws an open container of his own urine at himself, does he have a mental illness?

  • What if he throws his urine on himself because he is in solitary confinement and cannot throw the urine at the person he is angry with?
  • What if he throws his urine on himself because he is in solitary confinement and this is the only way he can have contact with another person?

If a man throws an open container of his own urine at another person, does he have a mental illness? or is he just a jerk?

Categories
Nonfiction Observations

Enclosed.

When the elevator doors slid open, there were twelve men inside the car. Two wore black officer uniforms; the others wore unmarked and faded tops and pants. They all looked at me in silence.

They all saw me hesitate.

“Do you want to get on?” one officer barked. It was a command phrased in the form of a question.

As I took a step forward, one officer stepped out of the elevator. The inmates, wearing not scarlet letters but, instead, red uniforms and cheerless expressions, moved towards the perimeter of the car. The second officer in the elevator took a step backwards, creating a square of space.

I took my assigned spot and the other officer stepped back onto the elevator to close the square. My eyes could only see his folded arms across his broad chest. The light breath of the other officer moved across the back of my neck. The inmates cast their glances—heavy, light, and of all shapes and sizes—at me. I heard my heart beating in my ears.

As the elevator lurched into motion, the air thickened in my chest:

  • If a fight breaks out, I can’t escape.
  • If someone touches me, I won’t know who.
  • If something happens to me right now, who will be more likely to help me…?

The elevator jiggled to a stop and the doors slid open.

“Excuse me.” My voice did not waver, though my confidence did.

Without saying a word the officer stepped out of the elevator. The inmates rearranged themselves in silence. Cool air blew past me as I walked into the elevator bay.

I exhaled.

Categories
Education Medicine Observations Systems

Everything Changes, Nothing Changes.

The Mutter Museum Instagram account recently posted this photo:

Thorazine

“Thorazine” is the trade name for chlorpromazine. It is considered the medication that ushered in the “psychopharmacological revolution”, thus allowing some patients to leave psychiatric institutions. (You can read the interesting history of chlorpromazine here. Spoiler alert: It was designed for use in surgery, not psychiatry.)

Chlorpromazine is often touted as the first medication that could reduce symptoms of schizophrenia. Other FDA-approved “psychiatric” uses of chlorpromazine[1. Other FDA-approved uses of chlorpromazine that are unrelated to psychiatry include acute intermittent porphyria; intractable hiccoughs; nausea and vomiting; and tetanus, “adjunct”.] include:

  • Apprehension, presurgical
  • Bipolar disorder, manic episode
  • Problem behavior, severe

I don’t know the context of the ad (who was the intended audience: physicians? patients? husbands?). One wonders why the ad features a woman and puts greater emphasis on “emotional stress”. A hefty dose of chlorpromazine will result in “prompt” sedation that will give someone—perhaps not the patient—”sustained relief” for several hours.

Did physicians in that era tell patients that the original use of this medication was for schizophrenia? Or did physicians focus primarily on the tranquilizing effects of chlorpromazine for those individuals who had more neurotic, not psychotic, symptoms?

Everything changes, nothing changes. Quetiapine (tradename: Seroquel) was also developed for the treatment of schizophrenia. Now, its uses include:

(1) add-on treatment to an antidepressant for patients with major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; (2) acute depressive episodes in bipolar disorder; (3) acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; (4) long-term treatment of bipolar disorder with lithium or divalproex; and (5) schizophrenia.

The header for the page (what shows up on the browser tab) doesn’t even list the drug’s name. It says only “bipolar disorder medication”.

If you search for “Abilify” (generic name: aripiprazole) on Google, the brief summary that shows up under the first link says:

Official pharmaceutical site for this antipsychotic medication indicated for the treatment of schizophrenia.

However, when you actually go to the official website, the listed uses include:

Use as an add-on treatment for adults with depression when an antidepressant alone is not enough
Treatment of manic or mixed episodes associated with bipolar I disorder in adults and in pediatric patients 10 to 17 years of age
Treatment of schizophrenia in adults and in adolescents 13 to 17 years of age
Treatment of irritability associated with autistic disorder in pediatric patients 6 to 17 years of age

Asenapine (trade name: Saphris) also has approval to treat both schizophrenia and bipolar disorder. Should we be surprised if paliperidone (trade name: Invega[2. Does it mean anything that, of the five photos on the landing page for paliperidone, only one of them features white males?]) and iloperidone (trade name: Fanapt) soon also receive FDA approval to treat conditions other than schizophrenia?

This is why skepticism is indicated—nay, essential—whenever people exclaim with confidence that “we” understand the biology of psychiatric conditions. We live in an era where cancer drugs can be designed to interact with specific receptors because scientists have located and studied those specific receptors. That specificity does not exist in psychiatry. If it did, one drug class would treat one condition, not four.

While I am probably more reluctant than the “average” psychiatrist to prescribe medications, I believe that, for some people with significant psychiatric conditions, medications can offer great benefit. First, however, do no harm.

It is frustrating when many in the field of psychiatry insist that the serotonin hypothesis is true when, in fact, it is just a hypothesis that is probably false. Also frustrating are the multiple forces that insist that medications are the primary and sole forms of treatment for psychiatric conditions. What about exercise? Therapy? Diet? Social support?

If medications alone could successfully treat these conditions, wouldn’t the pharmaceutical companies have saved us all by now?

Categories
Education Observations Reflection

A Review of Inside Out by Pixar.

Like others, I saw the Pixar film Inside Out and I, too, recommend it. Drs. Keltner and Ekman[1. Paul Ekman is the guy who studies the expressions of emotions on faces and their universality.], the psychologists who provided consultation to Pixar about the film, were incisive about the point of the story:

“Inside Out” offers a new approach to sadness. Its central insight: Embrace sadness, let it unfold, engage patiently with a preteen’s emotional struggles. Sadness will clarify what has been lost (childhood) and move the family toward what is to be gained: the foundations of new identities, for children and parents alike.

The film demonstrated in colorful and delightful ways how emotions interact with each other; how memories are created, moved, and stored (the marble imagery was both beautiful and fun); and how emotions, thoughts, and behaviors can interact with each other. Parents may wish to bring tissue; all the adults around me (and me, too) audibly cried at least once during the movie.

If you haven’t seen the film yet, please note that the rest of this post has spoilers in it. You have been warned.

Some other observations of the film:

Like others, I didn’t like how Sadness was portrayed in the film. I do not protest that she was the color blue; I do wish she wasn’t portrayed as lumpy, lazy, and lethargic. (At several points in the film, Joy literally drags Sadness around.) While sadness can make us feel listless and inert, sadness often motivates us to take action. Sadness is ultimately redeemed in the film: The family becomes and feel more connected because of the introspection and action Sadness fosters. However, I don’t think Sadness should have been thrown under the bus in the first place.

It is also noteworthy that Sadness is portrayed as female. One wonders if Sadness would have been portrayed as lumpy, lazy, and lethargic if the character were male. Is this social commentary on the perceived “moodiness” of women?[2. Just to be clear, I do not equate “moodiness” to “depression”. Others sometimes do.]

Of course, sometimes a cigar is just a cigar.

The “leader” of the emotions in the mother’s head is Sadness (looking sharp in a business suit, no less!). This choice may have been a foreshadowing device: The mother demonstrates skillful parenting in the film, which hints at the organizing power of sadness. This again suggests that sadness has value and helps us connect with others in meaningful ways, as parents or not.

The film uses the model that thoughts occur as a consequence of emotions. Emotions come “first”. Champions of cognitive therapy[3. Related: Cognitive behavioral therapy may be losing its effectiveness over time. One complaint many people have had about CBT is that the process can feel invalidating: “So… you’re just saying that I think the ‘wrong’ things. If I only thought the ‘right’ things, then I wouldn’t feel this way. So you’re saying it’s all my fault. Thanks a lot, jerk.”] would disagree with this: They would argue that thoughts always precede emotions, even when we have no idea why we feel the way we do.

This is one of many hypotheses about our internal experiences. Other models concur with the film’s assertions that emotions have primacy; our behaviors and thoughts can be consequences of what we feel. I believe that they are ultimately all related and each can have primacy, depending on the circumstances.[4. This isn’t entirely related to the primacy of thoughts, but someone, who I now can’t remember, said something pithy like, “Who are you between your thoughts?”]

There are delightful visual puns in the movie. One that I thought could use elaboration was the “train of thought”. The train in the film didn’t serve much purpose other than as a literal means of transportation for the emotions. Pursuing more meaning in the train may have derailed the film, so I understand why the train of thought was left as a train. It, however, might have been an opportunity to explicitly describe the interactions between thoughts, emotions, and behaviors.

I do recommend the film to adults and children alike. It offers a refreshing counterpoint to the messages we usually get from society about sadness (e.g., feeling sad means that there’s something wrong with you; you should try to avoid feeling sad as much as possible; etc.). When we embrace those emotions we often want to avoid, we learn more about ourselves, what steps we can take next, and the value of our internal lives. Pixar does an excellent job of teaching us these lessons in a fun and colorful way.