Category: Medicine

Psychiatrists and Demonic Possession.

Post author By Maria Yang, MD
Post date July 3, 2016
1 Comment on Psychiatrists and Demonic Possession.

A colleague sent me a Washington Post article, “As a psychiatrist, I diagnose mental illness. Also, I help spot demonic possession.”

After the author lists his credentials as a psychiatrist, Dr. Gallagher explains why he believes that some people who demonstrate unusual behaviors do not have psychiatric conditions, but are actually possessed by demons.

The sheer number of comments (over 2300 as of this writing) tells me that many people had strong reactions to this piece. (Or perhaps the bulk of comments are vitriolic arguments, name calling, and other unfortunate aspects of communication on the internet.)

It appears that Dr. Gallagher and I share some general principles when it comes to psychiatric diagnosis. For example, he notes:

I technically do not make my own “diagnosis” of possession but inform the clergy that the symptoms in question have no conceivable medical cause.

Indeed, one of the most important services psychiatrists can provide is giving an opinion about whether someone has a psychiatric condition or not. A common saw in medicine is that diagnosis guides treatment. Incorrect diagnosis can lead to incorrect treatment which, at best, will do nothing or, at worst, will harm someone.

Say a man is thrashing around the room, shouting nonsense, and looks confused and angry. The cause of his behavior is low blood sugar. If, however, all the physicians in the room assume that this man has schizophrenia, then instead of giving this man some form of sugar, they may instead give him a variety of tranquilizers.[1. In practice, people with low blood sugars who are behaving this way often receive both tranquilizers and sugar.]

Sometimes people may not recognize that a psychiatric condition is present, which can delay useful treatment. Sometimes people assume that a psychiatric condition is present, when in fact it is a medical condition. Sometimes people assume that a psychiatric condition is present, when in fact it is a variant of human behavior.

As I’ve written many times in the past, though, context matters. Where I believe Dr. Gallagher has taken a misstep is his assured belief that, if these individuals don’t have a psychiatric condition, then they must have demonic possession.

All of his referrals come from clergy who believe in demonic possession. To his credit, Dr. Gallagher does comment

I’ve helped clergy from multiple denominations and faiths to filter episodes of mental illness —– which represent the overwhelming majority of cases —– from, literally, the devil’s work. (emphasis mine)

In medical parlance, then, the chief complaint for his referrals is always “does this person have a psychiatric condition?”. It appears that the answer is often “yes”.

I must comment, though, that I cringed when I read some of his descriptions of people with psychiatric conditions. For example, he describes some of these people as

histrionic or highly suggestible individuals, such as those suffering from dissociative identity syndromes

I will assume that he has no ill will towards “histrionic or highly suggestible individuals”, though no one wants to be described as either. It’s not clear to me if he believes in the construct of “dissociative identity syndromes”. I am skeptical.

He also describes some of these people as

patients with personality disorders who are prone to misinterpret destructive feelings, in what exorcists sometimes call a “pseudo-possession,” via the defense mechanism of an externalizing projection.

Perhaps I underestimate the fund of knowledge the general public has about psychoanalysis. I had to read this sentence twice at a slow pace to understand what he was trying to say. If you believe in psychoanalytic theory, then, yes, that sentence makes sense. If you don’t believe in psychoanalytic theory, then that sentence might make as much sense as demonic possession.

If the answer to the question of “does this person have a psychiatric condition?” is “no”, though, then it appears that the only other option Dr. Gallagher considers is demonic possession:

This was not psychosis; it was what I can only describe as paranormal ability. I concluded that she was possessed.

This is dangerous, whether we’re talking about medicine or any other field. The moment you limit your options, you overlook evidence that supports other ideas and focus only on evidence that supports your theory. This is also called confirmation bias.

The following list may be absurd, but for the sake of illustration, is the only possibility that the “self-styled Satanic high priestess” is possessed by a demon? What if:

she is an alien?
her previous devotion to the Catholic faith has turned into contempt, so she is using her abilities to combat the faith?
she has excellent skills in “reading” other people and senses that Dr. Gallagher may be “histrionic or highly suggestible” to the ideas of demonic possession?

In medicine we often speak of the importance of “having a wide differential diagnosis”. Yes, the man described above who was thrashing around the room, shouting nonsense, and looked confused and angry could have schizophrenia. He could also have low blood sugar. Or he might:

have dangerously high blood pressure
have an infection in or around his brain
not be getting enough oxygen
be bleeding in his brain
be intoxicated with illicit drugs
be experiencing toxic effects from a poison

If we’re only thinking about a few of those things on that list, we might miss everything else. And all the things on that list can lead to the man’s death.

Do I think it is possible that people are possessed by demons?[2. My initial experience with Catholicism was spending hours in debates with my college roommate about transubstantiation. She, raised in the Catholic faith and able to recite Catholic prayers while falling asleep, insisted that the Communion wafer was literally the body of Christ and the wine was literally his blood. I insisted that this was physically impossible. These debates then wandered into other differences in Catholicism compared to other Christian faiths (faith versus good works, etc.—to be clear, I’m a big fan of good works).] Maybe. Is “demonic possession” high on my list of possibilities? No. Do I think that people experience spiritual distress? Yes. Do I think Dr. Gallagher has done an excellent job of promoting his forthcoming book about demonic possession? Absolutely.

Medicine Observations Reflection

My CV of Failures.

Several people on Twitter and Vox recently discussed “CVs of failure“.

We don’t like to share our failures, though we often don’t realize how our failures resulted in opportunities. (Or maybe that’s the narrative we tell ourselves so our failures don’t sting as much.)

Someone who provides wise counsel to me commented that sharing a CV of Failures is much easier to do when you’ve achieved success. I can see his point, though would argue that sharing a CV of Failures more reflects self-acceptance than success. Some people don’t ever think they’ve achieved success even though everyone else thinks they have.

So, in case it does provide inspiration for others, here’s my informal and abridged[1. This is most certainly an abridged version of my failures because (1) this includes only the professional failures I can remember, and (2) it includes strictly “professional” failures.] CV of Failures:

Universities I Did Not Get Into[2. Patients rarely ask me where I went to college or what I studied.]

Stanford University
Harvard University

Medical Schools I Did Not Get Into[3. Patients are even less likely to ask me where I went to medical school. The people who most frequently ask this question are physicians who work in academic settings.]

University of California, Los Angeles (I cried)
University of California, San Diego
University of California, Irvine
University of California, San Francisco
Loma Linda University
Stanford University
Johns Hopkins
Vanderbilt University
Northwestern University
Georgetown University
New York Medical College
Baylor University
Tufts University
Albert Einstein College of Medicine
Case Western Reserve University
Wake Forest University
Mayo Medical School
MCP Hahnemann University (now Drexel University)

I can’t remember the other schools I applied to. All told, I applied to 28 schools. Two offered letters of acceptance.

Residencies I Did Not Get Into[4. I don’t think any patient has ever asked me where I did my residency.]

Applicants “match” into a residency. Medical students apply and interview at residency programs. They then make a rank list of where they want to go. Programs also generate a rank list of medical students they want. A computer then “matches” the lists.

The lore is that “good” students will match into one of their top three choices.[5. Somebody who interviewed me at one of those programs actually asked me during the interview: “Were you abused as a child?”] I did not.

New York University
University of California, San Francisco
Mount Sinai School of Medicine

Places That Rejected My Essays[5. I compare this list to the list of medical schools I applied to and realize that I should submit more essays. More attempts may lead to more failures, but increases the likelihood of actual success.]

Bellevue Literary Review
New York Times
Salon
Slate
Vox

As a total aside, there was a time when I did not list my blog on my actual CV. About five years ago I did. I wish I had sooner.

Lessons Medicine Nonfiction Reflection

Repost: Control.

Post author By Maria Yang, MD
Post date December 13, 2015

I wrote the post below over ten years ago during my last year of medical school. I was on an elective hospice rotation. This came to mind this weekend after I visited a mentor who is dying from cancer. Someone from a hospice service also visited him while I was there.

I will miss him.

We all die.

Really. We all die.

And people know this. Sort of. Kind of. Maybe.

Some people accept this fact that yes, we all die, with calm grace. Some, indeed, genuinely welcome death and look forward to shedding this mortal coil. Some don’t necessarily want to die, but they recognize the inevitable fact and actively choose to spend the rest of their days living, not dying.

And then there are people who fight death. Or maybe it’s not death itself that they fight; they fight their mortality. They struggle with the fact that life will end. They don’t want to relinquish control over their existences. They want to know how much time they have left, what exactly will happen, and how things will progress between this moment and that last breath.

Family members of dying people (but really, aren’t we all dying?) seem to feel more—sadness? anger? frustration?—whatever; they often seem to feel more than the patients. The Type A’s get super Type A, jumping all over the place, asking How? When? Why? What? How much? How often? How quickly? How slowly? Can I do this? What about this? And that? The angry people get angrier, but I don’t think the core emotion is anger. The sad people try not to feel more sad, but their cheery smiles are obviously superficial. And the crazy people just get crazier.[1. I wince at what words I used to describe people in the past. I hope the wincing means that I’ve gained some wisdom over the years.]

It’s not fair to say that this grief is entirely selfish, but in a way, it is: If the loved one dies, it is a theft from the person in question. There will no longer be any shared moments, quiet glances, bursts of laughter, or shouting matches. And if the loved one dies, it only reminds us of our own mortality.

Because we all die. We just don’t believe it.

A hospice nurse and I sat in a family’s house for nearly an hour this afternoon. The patient, an aging woman, lay on the gurney in the living room. She’s had multiple strokes and doesn’t interact with the world. Her eyes fix upon yours, but she’s not looking at you. Her pale lips, smeared with Vaseline, are parted. Her left foot writhes in the bed, as if forming cursive letters on the white sheets. Her skin is cool and she doesn’t really react to the touch of another human hand.

Her daughters keep extensive notes about her: How much did she pee? poop? sleep? Has her skin changed color? Is she throwing up? How much morphine has she gotten? (They won”t say “morphine” in the room; they call it “M”.)

They don’t want to give her too much morphine because they fear that they will kill her. And yet they want her to be comfortable—and the grimaces on her face suggest that she is not. The daughter who is administering the morphine will not—cannot—give her any more.

“It’s about HER comfort, not YOURS,” her sister said, trying not to shout at her.

“Well, you don’t want to give it to her, so I am, and this is what I’m comfortable with,” the sister replied.

“I know she’s declining… I know she is…” and yet she cannot accept this fact completely and buries herself in her dying mother’s urine and fecal output, her blood pressure and pulse measurements, the dosages of her medicines.

It’s about control. Lack thereof, really. And to sit there, actively listen, and be present with these patients is exhausting. You literally feel what they feel, and yet you also feel what you feel in response to their feelings, and your brain is running through the algorithms of disease. So you monitor yourself while you monitor them, staying in the moment, completely unsure of how the next moment will unfold. Part of you wants to comfort them and part of you wants to scream in frustration. Part of you wants to run away and enjoy the gorgeous world outside and part of you wants to give everyone in the room a big hug. Part of you wants to give up completely and part of you wants to fight for the life that remains.

God, it is so beautiful to be alive.

Consult-Liaison Education Informal-curriculum Lessons Medicine Reflection

What is the Question?

I can think of only two times in my life where I received formal instruction on how to ask questions.[1. Without a doubt there have been more than two occasions when someone taught me how to ask questions, but it appears that I either was not paying attention or the lesson was not memorable.]

The first instance was when my parents taught me how to order food in a restaurant. They told me to make a single choice and have my order ready before the wait staff appeared. (“Don’t waste their time.”) They told me to phrase my order in the form of a question:

RIGHT: “Can I have the grilled cheese sandwich, please?”

WRONG: “I want the grilled cheese sandwich.”

My parents also told me to look at the faces of the wait staff and to speak loud enough so they could hear me. They also told me to thank them after they took my order.

(When I became more finicky about sentence construction, I changed the beginning of my orders to “May I…?”. This is mostly due to my 6th grade English teacher who, in his booming voice, would challenge any student who said, “Can I…?” “I don’t know, CAN you? CAN you go to the bathroom? If you CANNOT, perhaps you should see a DOCTOR. MAY you go to the bathroom? Yes, you MAY.”)

In sum, I was supposed to know what I wanted and exercise good manners.

The second time I received formal instruction on how to ask questions was during my third year of medical school.[2. Of course I received formal instruction on how to ask questions throughout my training as a medical student and as a psychiatry resident. However, that was over the course of years and done with varying quality. There were also all the people who taught me how to ask questions and I didn’t understand at the time that they were teaching me how to do that. Communication is difficult. This also explains why my efforts to ask boys out on dates in my youth often resulted in said boys looking at me askance and running away.] Interns and residents often asked medical students (e.g., me) to call consults.

Here’s the thing: When you’re a medical student, you don’t know how to do things like call consults because you don’t entirely know what you’re doing. Mastery comes with practice. Mastery also results from direct feedback, which often comes from exasperated and impatient residents.

When you call a consult you’re asking another service to help you with your patient. For example, if I’m a surgeon and I have a patient who stabbed himself multiple times in the abdomen in an attempt to kill himself, I’ll do the surgery to look around inside and make sure there aren’t injuries to internal organs. However, as a surgeon, I don’t know what to do about my patient’s urges to stab himself, so I’m going to call the psychiatrist to ask her for help.

WHAT IS THE QUESTION?

A surgical intern named Tom[3. Tom had cropped blonde hair. He wore leather pants sometimes. He often went dancing when he wasn’t working. He was smart and, perhaps more importantly, he was kind.] taught me how to call a consult while we were speeding around the hospital one day.

“Before you call a consult, you have to know what you want. What is the question you want answered? The patient is your patient, so you have to provide most of the care. But if you need help, what do you need help with? Don’t just say that the patient has diabetes and high blood pressure. That’s not a question and it’s not clear what you want. Make your question very clear:

‘My patient has diabetes and high blood pressure. He took insulin regularly before he came to the hospital, but now his blood sugars are high. They haven’t been below 300 since he’s been here. Can you help us bring his blood sugars back down?’

See how that’s a clear question? If you ask a clear question, you’ll get answers that will actually help you.

And be nice. Some of the residents you talk to won’t be nice, but that’s just because they’re tired and stressed out. Don’t take it personally.”

In sum, I was supposed to know what I wanted and exercise good manners.

To be clear, it’s not like I had this one conversation with Tom and I thereafter called in stellar consults. I still went on for too long and didn’t share pertinent pieces of information. Residents interrupted me before I had spoken for five seconds and they often made no effort to mask their annoyance.

But! It set me on the path of continually clarifying for myself what I wanted and how to craft better questions. Focusing on “WHAT IS THE QUESTION” has helped me as a psychiatrist (much of the work is often helping other people clarify for themselves what they want), a teacher (if people don’t understand something and get stuck, it’s often because they don’t know what they want to know), and as a human being (when meeting someone new, the question might be as simple as, “How can I make this person feel comfortable so maybe we can become friends?”).

Sometimes asking questions is more complicated than just knowing what you want and exercising good manners (e.g., “Will you marry me?”). Doing both, though, is an excellent place to start.

Consult-Liaison Education Funding Medicine Policy Systems

The Value of Psychiatrists.

Post author By Maria Yang, MD
Post date November 15, 2015
1 Comment on The Value of Psychiatrists.

While slogging through a crappy first draft of a document about the value of psychiatrists in mental health and substance use disorder services, I did a literature search for supporting evidence.

I found nothing.[1. Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.]

“So how exactly are we helpful?” I mused out loud. Maybe we aren’t: There are groups out there who do not believe that psychiatrists can or do help anyone.

I am an N of 1. Therefore, this post is an anecdote, not evidence. Nonetheless:

Psychiatrists provide psychiatric services. These are increasingly limited to only medication management, which is unfortunate. Psychiatrists need psychotherapy skills—or, abilities to connect with people to build trusting and respectful relationships—to do effective medication management. I can write dozens of prescriptions and change doses as much as I want, but if the person I am working with doesn’t trust me, none of my tinkering matters.

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications. This “deprescribing” also requires the use of psychotherapy skills: Some people feel great discomfort when coming off of medications. Sometimes the reasons are physiological; sometimes they’re psychological. Psychotherapeutic interventions and education are necessary in helping people cope with and overcome these discomforts.[2. For any psychiatrists out there: You could build an entire practice around “deprescribing”. This is one of the most common clinical requests I receive through my blog. I don’t have a private practice, so I turn all these people away. To be clear, deprescribing isn’t limited to private practices; I deprescribe in my clinical work in the jail.]

Psychiatrists often have the most clinical expertise. Most have had exposure to the spectrum of psychiatric services (in residency training) and thus have perspective about how systems work (or fail). Thus, psychiatrists can provide clinical consultation about specific patients and program design, implementation, and improvement. One example is the use of medication assisted treatment for substance use disorders. Certain programs or agencies may believe in abstinence only and will view medications as another misused substance. That perspective is not invalid, though giving people more options may help someone reach the goal of abstinence.

Psychiatrists can provide education to other staff to improve their clinical skills, which can elevate the quality of care clients receive across the agency. Psychiatrists can also provide leadership and influence the direction and ethos of a clinical service. For example, you can imagine how a psychiatrist might influence a service if he believes that the only way to help patients is to convince them to take psychotropic medications forever. A different psychiatrist who believes that employment or housing may be more effective than medication for some patients would provide a different influence.

Psychiatrists can triage patients who are in crisis. A roving psychiatrist on the streets or visiting people in their homes often can’t do things like draw blood, but they can assess people and circumstances to determine whether a visit to the emergency department can be avoided. Psychiatrists can also provide strong advocacy: Psychiatrists can work with law enforcement so that people who would be better served in a hospital actually go to the hospital, and not to jail. Similarly, if someone who has a significant psychiatric condition requires medical attention, psychiatrists can talk with hospital staff to advocate for this. Too many of us have stories about our patients who needed medical interventions, but others thought their symptoms were entirely due to psychiatric conditions.

Psychiatrists go through medical training and often have ongoing contact with other medical specialties. They are thus familiar with the practical realities of communication about and coordination of care for patients across systems. While overcoming the financial and policy hurdles to integrate care are important, the reason why integration matters (or, at least why I hope it matters) is to improve the experience for the patient. Administrators should consider the interaction and experience between the physician and the patient as paramount. The system should not sacrifice that relationship to make administration easier.

This is the message that all physicians, psychiatrists or otherwise, need to communicate to administrators. We don’t do ourselves any favors by assuming that people know what value we bring to patients or to the system. Sometimes it also helps to remind ourselves, too, so we can improve our work for the people we serve.