Category: Observations

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Homelessness Observations Public health psychiatry Systems

Psychiatry in Context.

A few reactions on topics related to psychiatry from the past week:

An example of a transitional object in baseball. The catcher for the Seattle Mariners, Cal Raleigh, did not play a few games due to injury concerns. Early in the game against the Atlanta Braves, the camera operator lingered on him in the dugout:

Cal Raleigh leaning against the dugout railing while holding a baseball (transitional object) in his right hand. A water bottle is directly in front of his face on the railing.

Notice that he’s not dressed to play. An unmarked bottle keeps him company. In his right hand is a baseball.

The Wikipedia page about transitional objects is pretty good (though psychobabbly). The best explanatory example of transitional objects is Linus and his security blanket:

Transitional objects give us comfort and a sense of security. Maybe the baseball gave Cal comfort and security during his mandatory time off. (Some players can hold six or seven baseballs in one hand. That’s probably more about showing off!)

The MAHA Action Plan to Curb Psychiatric Overprescribing. Per the HHS press release:

HHS Secretary Robert F. Kennedy, Jr. laid out a new action plan to promote appropriate psychiatric prescribing and drive deprescribing when clinically indicated.

Does “inappropriate” psychiatric prescribing happen? Yes. Does deprescribing, whether clinically indicated or not, already happen? Yes.

Back in 2015, while mulling over the value of psychiatrists, I commented:

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.

Many psychiatrists practice “deprescribing”. In 2019 I wrote about the ongoing difficulties in treating psychosis. There I commented on my own deprescribing experiences:

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There [was] also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

Psychiatry is an easy target. Psychiatric medications, especially antidepressants, are common prescriptions. Many factors contribute to this: Health care appointments are short. (There’s not enough time for deep conversations.) It’s hard to access non-medication treatments. (Most rural areas do not have experts in evidence-based therapies.) Emotion literacy is not where we all want it to be.

For several decades psychiatry has focused on biological causes of psychological symptoms. The natural corollary is medications fix biological problems. As I noted in 2019, “Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.”

To be clear, I am not anti-medication. Psychiatric medications can not only save lives, but also improve quality of life. However, medications are not the only tool psychiatrists have to help people. Most of us do prescribe appropriately. (Some people are vexed when we decline to write prescriptions.) Many of us do deprescribe when clinically indicated. (Some people express anxiety when they want to stay on their medications.)

Ongoing hypocrisy related to “ending crime and disorder on America’s streets”. The primary community psychiatry journal published this (free) article: The Executive Order on “Crime and Disorder”: An Affront to Policy, Law, and Ethics.

I agree with the authors. I previously shared my reactions to the executive order here.

It’s fresh that the federal administration cannot recognize the crime and disorder they bring to America’s streets:

… among many other federal actions that reduce stability and increase anxiety. Choose your issue.

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Nonfiction Observations

Trump and Bundy.

When I read what Donald Trump said, it immediately made me think of comments by Ted Bundy.

From today’s New York Times:

“Ownership is very important,” Mr. Trump said as he discussed, with a real estate mogul’s eye, the landmass of Greenland….

When asked why he needed to possess the territory, he said: “Because that’s what I feel is psychologically needed for success. I think that ownership gives you a thing that you can’t do, whether you’re talking about a lease or a treaty. Ownership gives you things and elements that you can’t get from just signing a document.”

From the Wikipedia page about Ted Bundy:

Possession proved to be an important motive for rape and murder as well. Sexual assault, [Bundy] said, fulfilled his need to “totally possess” his victims. At first, Bundy killed his victims “as a matter of expediency … to eliminate the possibility of [being] caught”; but later, murder became part of the “adventure”. “The ultimate possession was, in fact, the taking of the life”, he said. “And then … the physical possession of the remains.”

And further elaboration:

“[Bundy] said that after a while, murder is not just a crime of lust or violence”, [FBI Special Agent] Hagmaier related. “It becomes possession. They are part of you … [the victim] becomes a part of you, and you [two] are forever one … and the grounds where you kill them or leave them become sacred to you, and you will always be drawn back to them.”

When one covets this much, it is no longer possible to recognize the humanity of others.

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Consult-Liaison Observations

Regime Change and Labels.

Not everyone buys into the idea that people have “personalities”. Sure, you may think that your friend acts in predictable ways. But you’ve also seen your friend change their behavior in different settings. In front of their parents they become someone else.

Heck, let’s not talk about your friend. Let’s talk about you. Do you adjust your behavior when you’re at work? (Have you ever peeled off your socks at the workplace and left them bunched on the floor?) Do you use different words when you’re with your parents versus when you’re with your friends? (If you text your parents, look at the emojis you use with them versus the emojis you use with your friends. Are they the same set?)

Maybe not so consistent and predictable, huh.

But for those who do believe in the concept of a personality—”a set of distinctive traits and characteristics“—then the idea of a “personality disorder” seems reasonable. It makes sense that people with personality disorders would have a set of “abnormal” traits and characteristics.

Over the past year(s) and maybe in response to the yesterday’s news, some have wondered if people in positions of power have personality disorders. Their rhetoric, policy decisions, and implementation of regime change via kidnapping—their emotional and behavioral characteristics—all seem abnormal. Our frowns do not turn upside down. They deepen with ongoing and worsening misbehavior.

It is imprudent to diagnose public figures with physical or psychological conditions. I don’t know these people; I will never be in a position to assess them. As an academic exercise, though, let’s look at what it means to have a “personality disorder”. This is how the most recent version of the Diagnostic and Statistical Manual defines a general personality disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

  1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
  2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
  3. Interpersonal functioning.
  4. Impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

It is hard to argue that the elected leader of a nation has “impairment in social, occupational, or other important areas of functioning”. To achieve that level of power one must be able to navigate (nay, dominate!) social relationships and occupational duties. Maybe the methods they use seem “abnormal”, but “abnormal” and “impaired” don’t mean the same thing.

Consider the history of the United States. It includes ugly events—both distant and recent—of dehumanization, oppression, and exclusion. Aren’t these “expectations of the individual’s culture”? Are we witnessing any actual deviation from these expectations?

It’s true: We don’t know if these Very Important People experience “clinically significant distress”, even as they induce that in others. Maybe they have other medical, mental, or substance use disorders. We just don’t know.

“Personality disorders” are actual clinical conditions. They are not slurs. It’s okay to dislike the totality of someone’s emotional and behavioral characteristics. That doesn’t automatically mean, though, that they have a personality disorder. We can have low approval of someone with high status. They might simply be “a stupid, annoying, or detestable person“.

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Observations Public health psychiatry Seattle

How Atmospheric Rivers Affect People in Jail.

An atmospheric river is a river in the sky.

I don’t remember these from my youth, though they seem to happen most years now on the West Coast.

An atmospheric river that reaches Seattle is often called a “pineapple express” because the long band of moisture in the atmosphere originates around Hawaii. When the pineapple express arrives, the temperatures here become unseasonably warm (mid to high 50s°F / 12 to 15°C) as the rain falls.

The thing about rain in Seattle is that it usually isn’t rain. It’s more like a mist, a quiet visitor that stops by maybe for an hour or two, then slips away. Within the hour the drizzle returns again, just to make sure you didn’t forget about it. This is why most people here don’t use umbrellas. Raincoats are enough; umbrellas are a burden.

In contrast, the rain of atmospheric rivers demands your attention. The droplets are heavy and full. The water falls in sheets. It’s the mob of young people dressed up like Santa who sing Christmas carols off-key on a crowded light rail platform.

A particularly long river in the sky recently passed above Washington State. Grey clouds rushed overhead, churning past each other like currents of a river, dark water soaring through the heavens. Mud slid, highways collapsed, and lakes formed.

Walking around in it was like walking through a warm blizzard: My face stung from all the water droplets slapping against my cheeks. I had to squint to keep the water out. One afternoon, despite only walking for about 30 minutes, the hems of my pants were soon dragging on the ground. The rain had penetrated every thread and the weight of the water stretched everything down.

There is a small city in South King County that operates its own jail. It has only around 100 beds. (Compare this to the main county jail, which operates two adult facilities with around 1500 beds.)

This small city jail is near one of the rivers whose levee failed. Even as of this writing, the major roads on three sides of the jail are closed, one of which is a state highway. At the height of flooding, the state ordered people to evacuate.

What do jails do when the state orders people to evacuate because of a flood?

Reputable word on the street is that this jail took two actions:

Some people were released from jail. I don’t know what system jail officials used to determine who should be released. Presumably there was some consideration about the severity of the alleged crime. Releasing people from jail, though, results in the former inmates themselves holding the hot potatoes: If people have been ordered to evacuate and roads are closed, how do they return to their homes? (What if they don’t have homes?) People leave jail with only the belongings they came in with (and sometimes not even that), so if they didn’t come in with rain gear, oh well.

Other people were sent to a jail on the other side of the Cascade Mountains. This means inmates piled into secured vans or buses and travelled about 150 miles to Central Washington. Again, I don’t know what system jail officials used to determine who to relocate. Jails are meant to serve the local community and people can be released from jail unexpectedly. Will these people get a ride back to this small city? Will they have to figure out their own way back? With the exit of the atmospheric river, a polar vortex has taken its place. There is snow on the pass.

May our federal government stop manufacturing artificial disasters through inhumane policies. Natural disasters are distressing enough.

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Observations

A Pope’s Death.

If he views attention as a zero-sum game, then, today, he lost. To a dead man, no less—a man who did not even rule over a state. He was just a pope.

But he’s a president. What power he wields! World leaders must navigate around him. Stock markets tumble when words fall from his lips. His thumbs tap out a tweet, and the media pores over his words.

The Pope merely died — why did he get all the attention today?

Grief from the Pope’s death has led to his eternal life. When the newspapers aren’t writing about the president, why does it seem that he is no longer relevant? And if he’s not, has his power disappeared, too?

To confirm he exists, his presence must be felt. So he pulls levers. Some produce adoration; others produce anger. These emotional reactions are proof: He still exists. He still matters.

Here’s the betrayal: The absence of the Pope has cemented his presence forever. A dead man has stolen all the attention that the president believes is rightly his. What will he do now to get it back?

Today may remain quiet. But let’s see what happens tomorrow.