Category: Observations

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Consult-Liaison Informal-curriculum Medicine Observations Reading

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.

Categories
Observations Reflection Systems

Us and Them and Homicide.

If an event doesn’t happen often, it’s difficult to predict when it will happen next. We can only talk about “risk factors”.

For example, no one can predict when an earthquake will occur. We can, however, talk about the risk of an earthquake. We know that the risk of an earthquake is much higher in Seattle than in Houston: Seattle is on a fault line while Houston is not. Because earthquakes are rare, though, we don’t know when Seattle will have an earthquake. We just know that it’s more likely to happen there than in Houston.

Homicide is also a rare event. In 2013, about five out of 100,000 people died from homicide. That means 99,995 out of 100,000 people did not die from homicide that year.[1. A reader told me that these numbers are confusing. More than 100,000 people died in the US in 2013. My point is that the vast majority of people don’t die from homicide. Communication is hard.] Compare that with suicide: In the same year about 13 out of 100,000 people died from suicide. That’s right: In the US, people are over twice as likely to kill themselves than other people.

Because homicide is such a rare event, it is difficult to predict when, where, and how it will occur. We can discuss risk factors (e.g., alcohol and other substance use; access to firearms; gang involvement; exposure to domestic violence and child abuse; previous history of fighting of violence), but none of those risk factors will help us predict when it will happen. There are adults who were beaten as children, drink alcohol now, and own a firearm… but they will never kill anyone.

The data is mixed about the association between mental illness and homicide.[2. Here are three papers that discuss mental illness and suicide:

] Based on numbers alone, though, it is both inaccurate and unfair to state that homicide is due to psychiatric conditions alone:

Compare that to the rate of homicide: 5 out of 100,000 people.

With increasing news reports of people killing others, my colleagues and I have wondered how we can intervene. Many people who have committed homicide have never encountered the mental health system. Even if they did, they may not have endorsed or demonstrated symptoms that would warrant any intervention, including a follow-up visit. We agree that individuals who kill others are disturbed, but they may not have a “mental illness” that is described in our field. (We then wonder: So what is going on with them?)

The book The Spirit Level describes the correlation between greater interpersonal violence in societies with greater inequality. The authors also show evidence of higher prevalences of psychiatric disorders, obesity, and teen pregnancies in societies that are more unequal.

While it is easier to attribute these acts of heartbreaking violence to individuals—They are the problem; this happens because They are “mentally ill”; Their religion dictates that They should kill people; We would never do that—perhaps we should attribute this violence to our society and our communities (or lack thereof).

How would our society function if everyone had food, clothing, and a home? What would happen if everyone had steady employment and income? How would relationships change if everyone in school and at work learned how to recognize their emotions and practiced coping skills? What would happen if people didn’t drink, use drugs, or resort to violence when feeling distressed? What would shift if everyone had the chance to go to school and learn about different people, places, and ideas? How would things be different if people didn’t feel hopeless and helpless? What if people believed their communities could create something better? What if people didn’t believe that the only solution involves destruction?

It is easy to blame Them: They have mental illness; They believe in a religion that is false; there is something wrong with Them.

They and We, however, are part of the same community. Until we realize that we must work together to reduce risk factors and help each other, we cannot expect that these tragic events will stop.

Categories
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.]

  1. Stanford University
  2. 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.]

  1. University of California, Los Angeles (I cried)
  2. University of California, San Diego
  3. University of California, Irvine
  4. University of California, San Francisco
  5. Loma Linda University
  6. Stanford University
  7. Johns Hopkins
  8. Vanderbilt University
  9. Northwestern University
  10. Georgetown University
  11. New York Medical College
  12. Baylor University
  13. Tufts University
  14. Albert Einstein College of Medicine
  15. Case Western Reserve University
  16. Wake Forest University
  17. Mayo Medical School
  18. 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.

  1. New York University
  2. University of California, San Francisco
  3. 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.]

  1. Bellevue Literary Review
  2. New York Times
  3. Salon
  4. Slate
  5. 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.

Categories
Observations Reflection

On Trigger Warnings.

A reader I respect asked me for my thoughts on trigger warnings.

Per Wikipedia, trigger warnings are “warnings that the ensuing content contains strong writing or images which could unsettle those with mental health difficulties”.

Let’s put aside the last part of that definition, “those with mental health difficulties”, as some articles suggest that trigger warnings are not limited to those with mental health difficulties. Part of me wonders why that fragment is in there.

First, some relevant clinical information, as trigger warnings as described in popular press are commonly paired with post-traumatic stress disorder (PTSD):

DSM 5 has loosened the definition for trauma. Affected individuals do not have to directly experience the trauma (“exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways”). Parameters to describe reactions to the trauma, however, still exist. In a previous post I reviewed the other DSM 5 criteria for PTSD.

The vast majority of people who experience trauma as described in DSM 5 do not go on to develop PTSD. Yes, people may experience symptoms in the days to weeks following the event. Most people, though, incorporate the events into their lives and move on. This is a testament to human resilience.

One of the most effective treatments for PTSD and other conditions related to anxiety and fear is “exposure“, delivered in a gradual process called “systemic desensitization“. For example, if a woman was a victim of rape and has symptoms of PTSD, the therapist and woman build a hierarchy of anxiety-inducing experiences related to the rape. The least anxiety-inducing experience may be her thinking about the facts of trauma. The most anxiety-inducing experience may be her wearing the exact same clothes she wore that day, going to the location where the rape occurred, and describing, out loud, what happened. Something in the middle may be her walking past the location where the rape occurred.

The therapist helps the patient learn coping skills to recognize, acknowledge, and manage anxiety and other uncomfortable reactions. They then work through the hierarchy, from least anxiety-provoking to most anxiety-provoking, until the patient is able to meet and overcome the anxiety associated with the traumatic event.

Do note that avoiding cues associated with the trauma is not included in the descriptions above.

So, back to trigger warnings:

Different people respond to cues in different ways. Some victims of rape don’t have any visceral reactions when they hear or talk about rape. Some do. Some people only have visceral reactions if they smell something from or see certain objects associated with the traumatic event.

Who decides which triggers are worth mentioning and which are not? Does anyone have the right to tell someone else what is a trigger and what isn’t?

People have different capabilities to cope with stress. I mean no disrespect in the following sentence: Some people have never learned how to deal with themselves. They don’t know what to do when they feel angry or sad or frustrated. No one ever taught them what to do with those emotional energies. They have a skills deficit.

Thus, for some people, the best way they’ve learned to take care of themselves is to ask for trigger warnings. That strategy has worked for them and, as a consequence, they continue to use it. The feeling of empowerment is much preferable to feelings of discomfort.

For all of us: You feel the way you feel. It’s neither right nor wrong. People may tell you that you’re overreacting or “too sensitive”, but that’s about them, not about you. You feel the way that you feel.

Emotions aren’t simply reactions. Emotions give us information about the situations we’re in. They help us decide on next steps. We certainly prefer some emotions to others. All emotions, though, serve a function. Avoiding them often causes more problems.

The request for trigger warnings may not represent a need for coddling. It may reflect a need for greater validation. When we feel like no one understands where we’re coming from or what we’ve experienced, sometimes we try harder to make others listen to us with hopes that they will then understand us.

As social creatures we build our identities in relation to others. Context matters. Perhaps the request for trigger warnings is a reaction to the limited support and acknowledgment we received when we experienced trauma. This is an opportunity to not only advocate for ourselves, but also to advocate for others who may still feel uncomfortable expressing their own distress. Feeling empowered is much preferable to feeling uncomfortable.

Do people want trigger warnings because we, as a society, are unwilling or unable to talk about the horror, helplessness, and terror that accompanies trauma?

If people can ask for trigger warnings, that means that they have voices that others can acknowledge, hear, and respond to. What about all the people in the world who don’t have a voice? And are yet unable to escape trauma? The request for trigger warnings can be noble, but does little for others who are currently experiencing and recovering from their own traumas. Not talking about something doesn’t mean it will go away.

Furthermore, the underlying assumption of trigger warnings is that people who have experienced trauma can’t handle life. Not only is this assumption wrong, it is also dangerous.

As I noted above, most people who experience trauma do not develop PTSD. For those who do develop PTSD, they can and do recover. That doesn’t mean that recovery is easy, quick, or painless. Like anything important, it takes time and energy.

Because we build our identities in relation to others, requests for trigger warnings could send the message that people who have experienced trauma will never recover. It can also suggest that people who have experienced trauma are “defective” or, as in the Wikipedia definition, have “mental health difficulties”.

To be clear, there is a role in alerting people to potentially disturbing experiences. Movie ratings do this: That “R” rated movie has violence, nudity, and drug use. This information serves a purpose for parents and viewers of films. If you find the film disturbing, you can use the energy from your own emotional reaction to write a letter of umbrage to the filmmaker, avoid similar films in the future, or tell your friends not to see the movie. However, how you react to the film doesn’t mean that everyone else will react in the same way. It also does not mean that film makers must heed your requests to provide warnings about its content.

Given that people respond to cues and deal with stress in different ways, people have unique emotional reactions to events, and avoidance is not an effective treatment for anxiety and trauma-related disorders, requests for trigger warnings are ultimately short-sighted and will not help people learn about themselves, grow, and recover.

Categories
Nonfiction Observations Seattle

Bridges, Frustration, and Coping.

The longest floating bridge in the world is in Seattle. It is 7,710 feet (2,350 meters) long and spans beautiful Lake Washington. Locals call it the “520 bridge” and, in its current incarnation, only cars may use the bridge.

Yesterday, the Washington State Department of Transportation hosted the grand opening of the new 520 bridge. On the bridge were several food trucks, booths with information related to the engineering and construction of the bridge, and equipment and heavy machinery used in its creation.

To get to the event from Seattle, people had to take shuttle buses that originated at the University of Washington campus. The buses drove about three miles on the old bridge and delivered the crowds to the start of the new bridge.

Tens of thousands of people took the opportunity to walk across the bridge and enjoy the surrounding views that, prior to then, one could only enjoy by car.

In the early afternoon hundreds of people got in line to get back to Seattle. A young man wearing an orange vest carried a sign that read “End of the Line Here”. He folded the line back and forth to compress hundreds of people into a narrow area while we awaited the shuttle buses.

Behind us were two women who appeared to be in their 60s. One wore a visor that pushed her short white hair out of her face. The other had a greying bob.

“This is ridiculous!” Visor exclaimed. “This isn’t organized at all! We’ve been waiting in line for over 30 minutes and I don’t see any buses coming!”

“I know!” Grey Bob agreed. “We haven’t moved at all. This is terrible. This is ruining the entire event!”

Thin white clouds were streaked across the bright blue sky. A refreshing breeze swept around us. Mt. Rainier stood in the distance, a lenticular cloud atop its peak like a floating hat.

“OH MY GOD we’re actually moving!” Grey Bob squealed as the line shuffled forward. “We might actually get off this bridge!”

“I’m not going to be that optimistic,” Visor replied. “I’m going to wait until we actually get to UW before I say that.”

Shimmering white light danced on the dark blue ripples of Lake Washington. As the clouds dissolved under the sunlight the snow-capped peaks of the Cascade Mountains revealed themselves. A media helicopter, less than 100 feet above us, drifted past.

“HELP US!” Visor screamed at the helicopter.

When we could no longer hear the helicopter, Grey Bob sighed, “It’s been over 45 minutes. This is unacceptable.”

“If I have to wait in line any longer, I’m going to jump over the side of the bridge and kill myself,” Visor squawked.

Grey Bob laughed before commenting, “The barriers aren’t that high. Someone could really jump over. It wouldn’t be that hard.”

“Oh yeah, you’re right,” Visor said, her voice non-plussed. “That’s not good.”

At around 55 minutes the line was no longer still. We walked in quick strides towards five buses. Two of them faced West to go to UW. Three of them faced East.

“All the buses are gonna go to Seattle,” the event planner shouted at us. “Get on any bus on the other side of the barrier. All the buses will go West.”

I smiled as I watched my father scramble over the barrier—while not a spring chicken, he is still spry—and my husband and I made a point of scurrying away from Grey Bob and Visor. The three of us got on a bus facing East.

Nearly 100 of us packed into the bus. My father sat to my right. A woman in her 50s wearing a bicycle jersey sat to my left. My husband gave up his seat in an act of chivalry for her. He stood near the rear exit of the bus.

The bus headed East towards the fancy-pants neighborhoods of Medina and Hunts Point. Once the bus was off the bridge, it passed an exit. Then another.

“WHAT?” Bicycle Jersey exclaimed. She leaned forward and barked at her friend, an older woman with glasses reading a newspaper, “Why is the bus driver not turning around? Doesn’t the driver know that we’re supposed to go to SEATTLE?”

Someone pulled the wire to signal the bus to stop. People snickered.

The bus slowed to a halt at an intersection with several other shuttle buses. It did not move for nearly 15 minutes.

“This is so disorganized,” Bicycle Jersey said. “This is not worth it. This has ruined the entire day for me.” Her right thumb scrolled through an article by Nick Kristof: “When Whites Just Don’t Get It”.

The bus then crept north towards Kirkland.

“WHAT?!” Bicycle Jersey shouted. “Why are we going to Kirkland? We’ve been on this bus for over half an hour! We should’ve gotten on a bus that was going the other way. They’re already back home.”

“I never take the bus,” a woman standing over my dad said to no one in particular. “I’m never doing this ever again. Unless it’s a shuttle bus at a really nice wedding. And I mean a REALLY nice wedding.”

A young man with facial stubble near my husband hugged a pole. “We’re almost out of water. We’re going to die on this bus.”

“It’s like we’re hostages on this bus,” Bicycle Jersey spat.

The bus stopped at the Kirkland Park and Ride, but not at the curb.

“He better not make us get off this bus,” Bicycle Jersey said.

One man got off the bus.

“Did we come all the way here just for that one guy?” Bicycle Jersey continued. “What about the rest of us?”

The bus rolled back down the hill and stopped at an intersection.

“WHY WON’T THE DRIVER GET BACK ON 520?” Bicycle Jersey shouted. “TURN RIGHT HERE.”

“We’ve been on this bus for almost an hour,” Facial Stubble announced.

When the light turned green, the bus turned right and we were back on 520.

“We’ve been on this bus for almost an hour,” Facial Stubble announced again.

The bus rolled past the line of people waiting for buses. It was nearly a mile long now.

“DON’T GET ON A BUS HEADING EAST,” Bicycle Jersey shouted at them. None of the windows of the bus were open. The bus was going over 40 miles an hour.

“We’ve been on this bus for an hour now,” Facial Stubble said. “This is the worst mistake of my life.”

Some people have to wait over an hour every day just to get food and water.

I’m going to guess that you ate breakfast this morning. I’m also going to guess that you’re going home. Because you didn’t have to work today.

You’re not showing any overt signs of dehydration. Shut up. You’re not going to die.

The only person holding you hostage right now is you. Your bitterness isn’t going to make us get back to Seattle faster.

If you are joking about suicide because you’ve been waiting in line outside on a beautiful day for 45 minutes, how do you deal with actual stress?

Maybe you sustained a brain injury in your frontal lobe and that’s why you have low frustration tolerance.

Maybe your prefrontal cortex hasn’t fully developed yet. That process isn’t complete until your mid-20s, at which point you’ll hopefully have better impulse control.

Maybe no one ever taught you emotion regulation and distress tolerance skills. So maybe this is a skills deficit.

Maybe you’re having a rough time in life right now. Maybe a relationship you value is ending. Maybe someone you care about is sick and dying. Maybe, under different circumstances, you’d exercise more patience.

Maybe you’re a victim of specific operant conditioning: Maybe you’ve learned that people only pay attention to you and value what you say when you’re expressing snark or distress. And that people will only take you seriously the louder you talk.

My dad shrugged.

“We just had bad luck today.”