Category: Reading

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NYC Observations Reading Reflection

Three Comments about Race.

I’m currently reading Nelson Mandela’s autobiography Long Walk to Freedom. Learning about his experiences with apartheid in South Africa provide both hope and discouragement about current race relations[1. The juxtaposition of reading Mandela’s book with the protests about Ferguson and Eric Garner is… interesting.] in the United States. While there has been some progress in the past fifty years, it seems like it’s not happening fast enough. Why do Nelson Mandela’s experiences and words still apply to the world today?[2. Though I am just over halfway through it, I would recommend Mandela’s autobiography. He tells his story with clarity, humor, and dignity. Do note that it over 650 pages long.]

While in New York I visited the New York Historical Society, which had an exhibit entitled Chinese American: Exclusion/Inclusion. The banner fluttering in front of the museum for this exhibit features the “certificate of identity” of a Chinese actress. I, of course, have no idea what she was thinking when the authorities took her photo, though I see fierceness and indignation in her face.

There I learned that the Geary Act of 1892, which served as an extension of the Chinese Exclusion Act of 1882, introduced the first form of photo ID in the United States. (Which makes me wonder if the Chinese in America were the first to create fake IDs.)

Again, there has been progress in the past century, but that there exists a museum exhibit on the exclusion/inclusion of Chinese Americans tells me that, as a population, we continue to wobble across that slash. And I think it is meaningful that “exclusion” comes first.[3. Iris Chang wrote an engaging book about The Chinese in America that discusses these exclusion acts. I will note that Chang’s writing brims with anger and hostility at points throughout the book. I nonetheless still recommend it. A more modern perspective on Chinese exclusion/inclusion is Gene Yang’s lovely graphic novel American Born Chinese.]

One of my patients in the jail, a man who is not Caucasian, has significant psychiatric symptoms. Some days he tolerates our conversation better than others. He recently became overwhelmed with rage and, in the midst of some colorful epithets, shouted, “I’m gonna rape you! No! You know what? I’m gonna get a whole bunch of WHITE GUYS to rape you!”

I immediately ended the conversation (for what I hope are obvious reasons). His commentary, though, fascinated me:

The emphasis of his threat was focused on race, not on the number of men. When you look him or me, you can instantly discern that neither one of us is white. He judged that the threat of a white man raping me was more demeaning and insulting than a man of any other race raping me.

It is also noteworthy, though perhaps not surprising, that he has directed this specific threat only to me. He has told my male colleagues that he will either beat or kill them. Neither threat, of course, is desirable.

Categories
Education Funding Homelessness Medicine Nonfiction Policy Reading Reflection Systems

My Thoughts about Torrey’s “American Psychosis”.

This weekend I began and finished E. Fuller Torrey’s American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. (That’s not an inflammatory title. At all.) Though I have read a few of his articles, I have avoided reading his books. Part of this was due to all the other books I have wanted to read; most of this was due to my discomfort with how he frequently presents people with severe mental illnesses as dangerous and violent. Torrey is probably best known for his arguments to change the law so that it is easier to hospitalize people against their wills.

You can see how that is controversial. What his Treatment Advocacy Center says is advocacy, others say is coercion and social control.

In this book Torrey presents a history of the Community Mental Health Act of 1963 and presents compelling arguments that it was flawed since its inception. He also argues that patients with severe psychiatric conditions now continue to suffer consequences from the Act.

Although I do not agree with all of Torrey’s opinions, I do agree that the current “mental illness treatment system” doesn’t work. People—social workers, patients, nurses, therapists, case managers, psychiatrists—are all doing the best that they can, but the system could improve. A lot.

Fuller offers ten solutions to make the “mental illness treatment system” better:

Public psychiatric hospitals cannot be completely abolished. A minimum number of beds, perhaps 40 to 60 per 100,000 population, will be needed. This is approximately four times more beds than we have available today.

Torrey argues that a small percentage of people, due to their chronic and severe psychiatric symptoms, will need to stay in hospitals for a long period of time.

I am torn about that: On the one hand, I have my own anecdotal experiences working with patients who, with the “right”[1. “Right” is a relative term and depends on the individual. I also recognize that my anecdotal experiences are just that: anecdotal.] support, were able to stay out of hospitals despite their significant symptoms. The lack of public hospital beds forced all of us—the patients and the supporting team—to figure out creative ways to keep patients out of the hospital.

On the other hand, people get caught up in where patients with severe psychiatric symptoms are. There is an underlying assumption that being in a [state] hospital is bad, an evil to be avoided at all costs. Yes, there were and are hospitals that do not provide good care. That does not mean all psychiatric hospitals are terrible. Some people who are in jails, on the streets, or sitting in emergency rooms night after night are those who could benefit from treatment in public psychiatric hospitals.

As someone who has worked in all three systems—jails, homeless services, and emergency/crisis centers—I must say that the stability and structure of a [state] hospital is much more therapeutic and safe than the chaos often inherent in the other sites.

Lack of awareness of illness (anosognosia) must be considered when planning any mental illness treatment system and provision made for the implementation of some form of involuntary treatment, such as assisted outpatient treatment (AOT) or conditional release for approximately 1% of all individuals with severe mental illnesses who are living in our communities.

Prior to reading this book I had never considered the comparison of anosognosia in people with dementia with the anosognosia of people with psychiatric conditions. People readily commit people with dementia (who can be as violent, though perhaps without the same sense of purpose, as people with psychosis) into homes and institutions without discussions about their civil liberties. Why don’t we do the same with people who are psychotic?

The conditions are different, of course.[2. We will put aside commentary about Kraeplin’s dementia praecox for now.] Dementia is a global phenomenon; it affects nearly all spheres of a person’s existence. Psychosis is often sphere specific. There are people with psychotic conditions who pay their rent, buy food, take showers, and spend time with friends and family… and earnestly argue that cameras are monitoring them, that chips were implanted into their bodies in the past, and the FBI is trying to kill them.

The system often tries to avoid admitting people with dementia into hospitals for psychiatric reasons. Why? Because, at this time, we have no interventions or expectations that people with dementia will get better.

We admit people with psychiatric conditions into hospitals because we expect people will recover.

Community treatment of mentally ill individuals will only be successful if carried out by community mental illness centers, not in community mental health centers. The change of one word is crucial to the success of any such program. Mental illness centers may be freestanding or integrated as part of medical centers.

The italics are Torrey’s, not mine. You now see why Torrey calls it the “mental illness treatment system”.

While I agree that words matter, I don’t think using the word “illness” will endear the system to either patients or those who work in them. There is already stigma attached to psychiatric conditions. Who wants to walk into a “mental illness treatment facility”? Furthermore, when we do understand etiologies of psychiatric conditions, why not invest energy in prevention?

There are dialysis centers, children’s hospitals, and heart and vascular institutes. If a name change is indicated, why not “mental treatment system” or “mental institute”? Some people will maintain their mental health; others will receive active treatment for mental illness.

Continuity of care, especially continuity of caregivers, is essential for good psychiatric care of individuals with serious mental illnesses.

This is true for anyone for any condition (cardiologists and people who have had heart attacks; students and teachers; parents and children; etc.).

We must create a system where staff retention is a priority. So many people leave community psychiatry because they burn out and don’t receive support. Patients should leave us because they recover and become independent; we should not leave them.

In addition to medication, individuals with serious mental illnesses need access to decent housing, vocational opportunities, and opportunities for socialization. The clubhouse is the best model for meeting these needs.

Note that Torrey argues that medication is the anchor for psychiatric treatment. Others disagree. I think it depends on the person and situation.

Clubhouses don’t receive the attention they should. They’re inspiring. Fountain House in New York City is the original clubhouse. One of the primary arguments against clubhouses is that they do not foster integration with people who don’t have psychiatric conditions. We all, however, are free to choose who we want to spend our time with and people with psychiatric conditions are no different. If they want to spend time at the clubhouse, they can. If they don’t, they won’t.

To protect vulnerable mentally ill individuals living in nursing homes and board-and-care homes, there must be periodic, unannounced inspections by an independent state agency. Evaluations and corrective actions must be made public.

I agree.

My work has not brought me into nursing homes and adult family homes (what “board-and-care homes” are called here in Washington State). Torrey presents heartbreaking anecdotes and data about the treatment people did not receive and the abuses they experienced in these facilities. (They mirror reports that came out of some state hospitals in the past.)

Unfortunately, people with psychiatric conditions generally don’t pull at heartstrings the way kids with cancer do. I worry that, given the relative apathy to the number and conditions of people who are homeless, the public may not have any reaction upon learning what happens in adult family homes.

For-profit funding of public mental illness services has been tried and does not work.

I agree.

Torrey and I share the same perspective: If the organization’s goal is to make a profit, money will always trump patient care. People with significant psychiatric conditions will somehow exit the system[3. And by “exit the system”, I mean patients are actively pushed out, not let back in, or made to jump through hoops that they cannot get through in order to receive services.] because they often require resources—time, money, energy—that are antithetical to saving or earning money.

This is why I am biased against for-profit correctional systems.

In selected cases, psychiatric information on mentally ill individuals who have a history of dangerousness should be made available to law enforcement personnel, because they are now the frontline mental health workers.

This point is tied to Torrey’s arguments that people with severe mental illnesses are dangerous. To Torrey’s credit, he does state that people with psychiatric conditions are vulnerable and are often victims of violence, but he spends a lot more time discussing the murders that people with psychiatric conditions have committed.

There are obvious privacy concerns about this. Are police officers familiar with HIPAA? How else might law enforcement officers use this information?

The single biggest problem with the present anarchic system of mental illness services is that nobody is accountable. It will be necessary to assign responsibility to a single level of government, and to then hold such individuals accountable, before any improvement can occur.

Torrey makes it clear that the federal government should not be the responsible party. I agree with that.

While I understand the Torrey’s sentiment, it is much easier said than done. The “mental illness treatment system” now spans multiple domains: the legal system, emergency departments, medical clinics, homeless shelters, law enforcement, mental “health” centers, hospitals, etc. Working with all these groups and aligning efforts to a set of goals will require significant culture change.

If you made it this far in the post, let me conclude by saying that, even if you don’t agree with Torrey’s thesis, this book is still an engaging and thoughtful read. I will confess that I began to feel hopeless and overwhelmed as he laid out all the failures of the system. However, he did finish the book with compelling solutions and highlighted that we can’t give up. This is not easy work, but it is meaningful work, and there is value both to individuals and the community if we take care of the vulnerable people in our lives.

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Education Funding Homelessness Medicine Observations Policy Reading Systems

Thoughts on Stuff.

Recent things I have read that I have found interesting, curious, or vexing:

The Social Security Administration maintains a “compassionate allowances” list, which is a list of “medical conditions [that] are so serious that their conditions obviously meet disability standards”.[1. You can learn more about how diseases make it on to the “compassionate allowances” list here.] Cancers, genetic conditions, and diseases still known by eponyms make the list. (Medical types: This is your list of zebras, not horses.)

“Can you receive SSI (Supplemental Security Income)[2. The Social Security Administration mails a check of about $721 once a month to individuals who receive SSI. To receive SSI, you must have “limited income and resources” AND you must be disabled, blind, or age 65 and older. I got lost while digging through all the subsections, so I don’t know what the “limited” income is. “The limit for countable resources is $2,000 for an individual and $3,000 for a couple.”] while living in a public shelter for the homeless?” the Social Security Administration asks.

Answer: “Yes. You can receive up to the maximum SSI benefit payable in your State while living in a public shelter for up to 6 months out of any 9 month period.” (Emphasis mine.)

While it is true that most people are in the shelter system for less than three months, is it possible that some people who receive SSI will need more help over a longer period of time to get out of the system?

If someone must stay in a shelter, that usually means that he can’t pay rent. Most employers prefer to hire employees who have actual home addresses. No job means no income. No income means difficulties finding affordable housing. And it is mighty difficult to pay for housing and food with only $721 a month.

Psychiatry has little to offer in the realm of prevention.[3. Some would also argue that psychiatry has little to offer in the realm of treatment. In moments of frustration, I agree.] We have no medications to prevent schizophrenia, though omega-3 fatty acids might reduce the likelihood that a youth already showing some signs of psychosis will develop “full blown” psychosis. (Researchers are putting efforts into preventing psychosis, which is exciting.) Most people don’t go to therapy prior to experiencing uncomfortable and distressing emotions.

The WHO has a paper about social determinants of mental health that cover the entire lifespan. Frequent themes in the paper include providing education for women; attending to the mental health of mothers before, during, and after pregnancy; reducing poverty; and providing support to people in school and in work. The prevention of and reductions in psychiatric symptoms were not due to medical interventions.

Incorporating mental health into daily living helps people stay well and develop the resiliency to deal with crap. It’s not a separate thing. We know that people who have had adverse childhood experiences are more likely to have psychiatric and medical problems as adults. Exercise, spending time with friends and family, maintaining stable relationships, eating nutritious foods, learning about stuff, finding value in work and hobbies, avoiding conflict and trauma—all of these activities are useful in preventing major psychiatric conditions.

How many of us in psychiatry focus on these social determinants in our daily work? How have we let ourselves become “prescribers”? Can we change that so that we “prescribe” education and activity more often, and only prescribe medications in the most severe circumstances?[4. This is easier said than done, given that we cannot control the behavior of other people or systems. I also detest the word “prescriber”. That’ll be another post.]

Someone pointed me to this article with the polarizing title: Bad Managers Talk, Good Managers Write. The author argues:

When managers write, you create work product — white papers, product requirement documents, FAQs, presentations — that lasts and is accessible to everyone in the organization. From marketing to sales to QA to engineering, everyone has a document off which they can work and consult.

The upshot is that the manager also takes public responsibility for what happens when the rest of the team executes on the point of view taken by the documents. That ratchets up accountability through the organization.

This is also the benefit of keeping a blog. You create a body of work that people can read, refer to, and learn from. More importantly, regardless of your work (whether it is your formal profession or what you do “on the side”), it gives you the opportunity to reflect on things that matter to you, clarify your thinking, express your ideas, and connect with interesting people, including yourself.

Categories
Consult-Liaison Education Medicine Reading

DSM-5: Malingering.

My DSM-5 group has lost its previous vitality for the same reasons my blog has lost its previous verve (pending job change, ongoing family health concerns). But! The DSM-5 group has had a few updates; the most recent edition is below. If you’re interested in subscribing to the DSM-5 e-mail group, you can sign up here.

Malingering in DSM-5, like in DSM-IV, is a “V code”. “V codes” (in ICD-9) will turn into “Z codes” (in ICD-10) and these are considered “other conditions that may be a focus on clinical attention”. This means two things:

(1) Conditions listed as “V codes” are not diagnoses because

(2) Conditions listed as “V codes” are not mental disorders.

Therefore, malingering is not a mental disorder.

In crass terms, malingering means that people are faking or *really* embellishing physical or psychological symptoms. People who are malingering do this “consciously” (hat tip to the analysts) because there is an external incentive to do so. These external incentives might include:

a) avoiding military duty
b) avoiding work
c) obtaining financial compensation
d) evading criminal prosecution
e) obtaining drugs

Malingering can be hugely adaptive: If you were homeless and the temperatures outside are below freezing and a winter wind is whipping the frost off of the trees and there are no open shelter beds and you are hungry because the last time you ate was two days ago and that was a soggy, half-eaten sandwich you found in the trashcan–

–wouldn’t you consider going to the hospital and say that you want to kill yourself so you could be in a warm place for a few hours and get some non-soggy food?

DSM-5 argues that if “any combination” of the following four items is present in a patient, you should consider the condition of malingering:

(1) Medicolegal context of presentation (a lawyer sends the client for evaluation or the patient presents for care in the midst of criminal charges)

(2) There is a “marked discrepancy” between the individual’s “claimed stress or disability” and “objective findings and observations”

(3) “Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen” (some tired clinicians would summarize this as “a difficult patient”, though I much prefer DSM-5’s description)

(4) The presence of antisocial personality disorder

I applaud DSM-5’s efforts in keeping the description of malingering neutral. Some people have strong reactions towards (translation: self-righteous fury at) people who present with malingering. Keeping the focus on the behaviors helps temper the emotional reactions.

DSM-5 then clarifies the differences between malingering and factitious disorder, conversion disorder, and related conditions. Malingering is the only condition here where symptoms appear solely because there is an external incentive.

On a somewhat related note, the condition that follows malingering in DSM-5 is “wandering associated with a mental disorder”. This is apparently limited to walking (where the “desire to walk about leads to significant clinical management or safety concerns”).

The next post will hopefully show up less than one month away.

Categories
Consult-Liaison Education Medicine Reading

DSM-5: Delirium.

This post is the most recent addition to my DSM-5 e-mail list. I include it here only because I apparently have a fondness for delirium; it was one of my favorite teaching topics when working with medical students. If you’d like to read my other DSM-5 summaries, let me know.

(724 words = 5 min read)

How rarely, particularly outside of hospital settings, do we remember to think of delirium!

DSM-5 lists five criteria for delirium:

A. There is a disturbance in attention and awareness.

Because people who are delirious have problems with focus and sustaining attention, this means you might find yourself asking the same questions over and over. The delirious patient may end up providing the same answer over and over, even though you’re asking a different question.

Furthermore, if patients have severe inattention, they might not be able to have a conversation with you at all.

B. Delirium develops over a short period of time, typically hours to days. There is a change in baseline attention and awareness. It fluctuates throughout the day.

Attention and awareness often worsen at night (sometimes referred to as “sundowning“).

C. There is also another disturbance in cognition, such as in memory, orientation, language, and perception.

Delirious patients might think that a pair of socks is an opossum (illusion), the nurse is trying to sell his blood (misinterpretation/delusion), or that he can hear the conversations that are happening in the cafeteria (hallucinations/delusions).

D. The disturbances in (A.) and (C.) are not better explained by another pre-existing, established, or evolving neurocognitive disorder. (Having a neurocognitive disorder, however, increases the risk of the development of delirium.)

You also can’t diagnose delirium is someone is comatose. Essential to the diagnosis of delirium is that the patient can respond to “verbal stimulation”.

E. There must also be evidence that the delirium is due to a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

This means that delirium always has a cause. Your job is to find that cause (or work with someone who can help you find that cause).

There are many specifiers for delirium (which clarify the cause):

(1) substance intoxication delirium
(2) substance withdrawal delirium
(3) medication-induced delirium
(4) delirium due to another medical condition
(5) delirium due to multiple etiologies
(6) acute
(7) persistent (how terrible!)
(8) hyperactive (more frequently recognized, because these are the people who are shouting that they are on a boat and think that the IVs are snakes)
(9) hypoactive (this is often missed because these are the people who seem to be the most “compliant” patients ever)
(10) mixed level of activity

DSM-5 spends a fair amount of time discussing the recording procedures. If you are a consult-liaison psychiatrist, you should look those over.

DSM-5 states that, in hospital settings, delirium usually lasts about one week. Some symptoms, though, persist even after individuals are discharged from the hospital.

Delirium is considered a “great imitator” amongst psychiatrists. People who are delirious can look psychotic, depressed, manic, anxious, or a combination of all four. Delirium also messes with sleep-wake cycles and may manifest more at night because there is less environmental stimulation present.

DSM-5 provides some prevalence numbers:
(1) people in the community: 1-2% (that number ideally should be 0%)
(2) hospitalized people: 6% to 56% (this is not a comforting range)
(3) people who just had surgery: 15% to 53%
(4) people in ICUs: 70% to 87%
(5) people in nursing homes: 60% (yikes!)
(6) people who are at “end of life”: 83%

Thankfully, the majority of people with delirium experience a full recovery, though delirium is a harbinger of death: About 40% of people who are diagnosed with delirium in the hospital are dead within a year. Delirium also increases the likelihood of “institutional placement” and “functional decline”.

In addition to neurocognitive disorders, other risks for delirium include extremes of age, drug use, polypharmacy, a history of falls, and functional impairment.

Delirium is a clinical diagnosis (there is no test for it), though EEGs might show “generalized slowing”.

I have never thought about the differential for delirium, as that is what I always consider first (but that may be due to my past work as a consult-liaison psychiatrist). DSM-5 includes psychotic disorders, acute stress disorder, malingering, factitious disorder, and other neurocognitive disorders in the differential for delirium. Rarely, though, do those conditions have the “waxing and waning” in level of consciousness and attention that is seen in delirium.

I’ll resume sending [DSM-5] posts out after January 1st. May you all recall fond memories from 2013. May 2014 bring you good health, mirth, and ongoing learning.