Category: Reflection

Categories
Policy Reflection Systems

Belonging in Psychiatry.

I recently finished reading The Art of Community: Seven Principles for Belonging by Charles Vogl. He starts the book with this definition of “community”:

a group of individuals who share a mutual concern for one another’s welfare.

He continues:

[A community] is distinct from a group whose members may share ideas, interests, proximity, or any number of things but lack concern for one another.

He argues that communities (as he defines it) have “shared values”, “membership identity”, “moral proscriptions”, and “insider understanding”.

The American Psychiatric Association (APA) held its annual meeting this past week in San Francisco. I did not attend.

I have never been a member of the APA. There was a time when I took some oppositional pride in this, though I was aware of how this attitude is problematic: I cannot help change an organization if I do not join it.

Why do I resist the APA, even though it is the organization that represents the work I do?

This excellent post over at Slate Star Codex captures many of my reasons: All of the pharmaceuticals! The overt and covert intersections with politics (which can lead to overmedicalization of life and underrecognition of psychiatry as an agent of social control)! And while I know that there are members of APA who care about people, families, and communities that experience severe psychiatric symptoms (e.g., schizophrenia, bipolar I disorder, co-occurring mental health and substance use disorders), I’ve never gotten the impression that these are priority populations for the APA.

If we use Vogl’s definition, the APA, to me, doesn’t feel like “a group of individuals who share a mutual concern for one another’s welfare”.

Maybe professional organizations aren’t intended to be spaces where people have mutual concern for the welfare of others.

In the past I wondered if my lack of affinity for APA had to do with how different my clinical practice is compared to other psychiatrists. There are other psychiatrists who work with people living on the streets and do housecalls for people who live at or near the poverty line… but we are few and far between. I live in the largest county in Washington State. There are hundreds of psychiatarists here. Yet I know of only two other psychiatrists who share my work experiences!

Consider emergency physicians. They all work in generally the same setting and thus have similar clinical practices. I don’t know the membership of their professional organization (American College of Emergency Physicians), though it at least seems that their specialty organization is more cohesive and united. Because their clinical practice is more uniform, perhaps it is easier to have mutual concern for the welfare of their fellow physicians.

Meanwhile, how much does my work have in common with the private practice psychiatrist who provides psychoanalysis? I’m just trying to get the guy who lives outside due to relentless paranoia to look at me long enough so I can say hello in a manner that won’t scare him off.

A few years ago a local psychiatric association contacted me. They anticipated an upcoming vacancy in a committee involved in government relations.

During the phone call, I learned that most of the members were psychiatrists in private practice. The leadership expressed a desire for the association to get more involved in government affairs (e.g., local and state legislation). Because of my role in local government, they highlighted the value I could contribute to the association.

“You’ll have a lot of influence,” they said several times.

They also commented that they were trying to increase the diversity in their organization. In addition to the “influence” I could bring, I could also bring my non-white, non-male self.

By the end of the phone call, I said that I wanted time to think about it. What I actually thought about was the responsibilities I had to myself versus those I would have to the organization. I cannot help change an organization if I do not join it. Could I bring issues related to underserved communities to the association? Would the membership find these issues compelling? Would they have interest in legislation that did not focus on their own patient populations?

A few weeks later, I told them that I wouldn’t join. This decision stemmed chiefly from the substance of the work. However, it was also a reaction to their recruitment methods: They thought I would respond favorably to an appeal to my vanity. “You’ll have so much influence!!!” Perhaps the corollary to that was that my influence would help get stuff done, but the emphasis was on the vast amounts of influence I could wield over the group. That didn’t interest me.

And while I did appreciate the blunt commentary about how my participation would help increase the diversity of the association, it made me tired just thinking about it. Increasing diversity doesn’t just mean increasing the amount of color in a photograph. There’s a lot of work in introducing and maintaining various perspectives in a group. I didn’t want to be the only person responsible for that simply because of my non-white, non-male status.

The association certainly had concern for its own welfare. I wasn’t convinced that the association members had concern for mine.

To be clear, this doesn’t mean I’m great.

At least once a week I wonder if I would be more effective in my medical director role if I were involved in more associations and groups. What if I could bring the “forces” of the local medical society and psychiatric association to my job? What if I could use my status as a medical director in government to influence the priorities of these organizations? Would my “success” in each sphere be greater?

What responsibilities am I shirking? I believe one function of government is to convene people so we can figure out how to collaborate with each other. How many opportunities am I missing to improve the community because I am not participating in these other organizations? If I really care that much about underserved populations, don’t I have some responsibility to persuade these organizations to support initiatives that will serve the the underserved? Isn’t there more strength in numbers?

What would it be like if I shared and coordinated ideas, plans, and concerns with these big organizations with large audiences instead of here on my blog?

This has been true from the very beginning: I am a reluctant psychiatrist. I was never supposed to become a psychiatrist.

But, for reasons known and unknown, people experiencing psychotic symptoms feel comfortable talking to me.

So, here I am, working as a psychiatrist.

And, perhaps because of my affinity for complex problems, this is also why I am more comfortable working at the boundaries of fields. Yes, it is possible that the APA will create and disseminate the cure schizophrenia.

I doubt it.

I don’t think a pharmaceutical product will cure schizophrenia. But, at the intersection of nutrition science and psychiatry we can maximize the likelihood that pregnant women will have access to foods that will decrease the risk of their babies developing schizophrenia. At the intersection of legal systems and psychiatry we can reduce (if not eradicate) the use of solitary confinement so that jails and prisons do not worsen psychiatric symptoms. At the intersection of education and psychiatry we can teach kids and their parents skills to better cope with the adversity that life throws at all of us.

I will continue to struggle with joining APA and other organizations. But I already know that I’m not alone. Those of us—and not just psychiatrists—who care about the welfare of people with severe psychiatric symptoms are already part of a community. Sometimes we’re just harder to find.

Categories
Consult-Liaison Education Medicine Reading Reflection Systems

The Challenge of Going Off Psychiatric Drugs for Psychiatry.

Here are my initial reactions to the New Yorker’s The Challenge of Going Off Psychiatric Drugs:

Which populations are most likely to receive large numbers of psychiatric medications?

The woman described in the article comes from a family of money and privilege. These individuals (and families) have both the time and money to seek out psychiatrists who practice “precision psychopharmacology”. These psychiatrists then order complicated medication regimens that ostensibly address and “correct” neuroreceptors. As a consequence, people end up taking multiple medications.

There are also individuals who do not have money or privilege, but are subjected to psychiatric services due to the concerns of the public. They may be behaving in ways that endanger their own lives or the lives of others. As a consequence, they receive medications—sometimes willingly, sometimes through coercion—that aim to reduce certain behaviors. If one medication doesn’t reduce the behavior, then more are added.

What these two populations have in common are (a) the lack of clarity around diagnosis, which often stems from (b) missing information about the person and the context in which s/he lives.

I completely agree with Dr. Frances’s comment from the article:

[There is a] “cruel paradox: there’s a large population on the severe end of the spectrum who really need the medicine” and either don’t have access to treatment or avoid it because it is stigmatized in their community. At the same time, many others are “being overprescribed and then stay on the medications for years.”

The meanings of diagnosis and treatment, particularly medications.

Some people feel relief upon learning that their symptoms belong to a diagnosis, that what they have is “real”. Others don’t want the “label” of a psychiatric diagnosis; they are not damaged human beings.

For various reasons (e.g., the current primacy of biological psychiatry, insurance reimbursement, psychiatry’s seeming inferiority complex within medicine), treatment in psychiatry is often focused on medications. This is not ideal. Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.

In the meantime, doctors recommend that people take pills. Some people view pills as a necessary intervention to keep them healthy and well. Some people view pills as a shameful reminder that there is something wrong with them that will never improve. The more pills someone has to take, the more potent the reminder that they are beyond hope or repair. Some people view pills as an external validator of their pain and suffering: “Someone else believes and understands my pain and these pills remind them and me that my pain is real.”

The pills may not be treating what psychiatrists think they are treating.

The problems with psychiatric diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) focuses only on the “what”, not the “why”.

It doesn’t matter why someone has a depressed mood, takes no pleasure in work or play, can’t sleep, won’t eat, and feels hopeless. The underlying reason could be the cardiologist’s realization that he should have pursued his dream of becoming an architect… or it could be the threat of eviction after losing one’s job.

This affects the way psychiatrists gather a history from people seeking care. Instead of learning the context behind one’s symptoms, psychiatrists now focus on whether certain symptoms are present or absent. What matters more is that she feels paranoid, not that the paranoia started when she learned that her father was molesting her sister.

To be clear, there are some instances in which the underlying “why” doesn’t matter. If someone is terrified of flying on a plane, there are treatments (e.g., exposure therapy) that can help people tolerate plane rides without getting into the reasons why this fear appeared in the first place.

In other instances, though, the “why” is often relevant. Since our understanding of the biology of the brain and mind are limited, we don’t know if the biological properties of Medication A are more useful in military veterans who have fought in combat or if those of Medication B are more useful in women who experience major depression after the birth of a baby. Even if evidence suggests that medications aren’t the best treatment for either population, it is often the easiest intervention to deliver. This is due to the context and underlying “whys” of the health care system.

All of the other psychiatrists.

It’s true that there is scant evidence about how to taper and stop medications. It is a shame that psychiatry, as a field, has nothing to say about deprescribing. The scientific literature has plenty to say about adding medications, but nothing that extols the virtues of taking them away. There are risks to stopping medications, yes, but why are psychiatrists unimpressed with the risks of starting them? In this way we have failed not only the people who receive care from us, but we also fail the people who step in to help in our absence: Other physicians, nurses, family members, friends.

When I consider the psychiatrists I have worked with with, many of them have helped people come off of medications. They work with their patients and go through the trial-and-error process together. While they may not work in ivory towers of acclaim, they are still doing the work of helping people make informed choices about their care so they can lead healthy and meaningful lives. These are the quiet anecdotes that will never make it into the New Yorker.

Psychiatry as an agent of social control.

This is not the first time I’ve written about psychiatry as an agent of social control.

What does it mean that “antidepressants are taken by one in five white American women”? Is this a reflection of white American women? Or a reflection of the society and systems that want to contain white American women?

What does it mean that African- and Latinx-Americans are more likely to receive diagnoses of psychotic disorders? Is this a reflection of these populations of color? Or a reflection of the society and systems that want to contain these populations?

Perhaps there needs to be a “Challenge of Going Off Psychiatric Drugs” for the field of psychiatry. To be clear, there is definitely a role for medications in the treatment of psychiatric disorders, though: first, do no harm. When The Royal We have more humility about what we do and do not know, and exercise more care in current pharmacological tools, then perhaps getting on or going off of psychiatric drugs won’t be a “challenge”.

Categories
Consult-Liaison Reading Reflection

Antisocial Behaviors.

The anxieties and discord within my tiny world and the world at large have felt heavier as of late. Thus, my words do not flow today with the relative ease that they have under different conditions. (To be clear, I’m fine. Perhaps I am just more sensitive to the energies and emotions of others.)

I recently learned about “adulthood antisocial behavioral syndrome”. If you’re familiar with the definition of antisocial personality disorder, it’s essentially that without the requirement for conduct disorder before the age of 15. (If you’re not familiar with antisocial personality disorder, allow me to refer you to my 2013 post (!) that describes the condition.)

The prevalence of these two conditions (derived from surveys of the general public) surprised me: In the United States, about 4% of the population have antisocial personality disorder, and a striking 20% apparently have adulthood antisocial behavioral syndrome. If the prevalence is 20%, should we consider that a disorder? (Is that why it’s called a “syndrome”?) That means if you invite four of your friends over to your home, one person in that group has adulthood antisocial behavioral syndrome. (Maybe it’s you!)

For many reasons (it’s exhausting, I have insufficient data, I can’t do anything to help, etc.), I avoid the intellectual exercise of considering what psychiatric conditions certain public figures may have. That being said, regardless of who is President and which political party has the majority, it is common in psychiatric education to note that there are people in power who likely have antisocial personality disorder. These individuals just haven’t gotten caught (or have the resources to avoid punishment… or there are institutional factors that protect them).

But, for “fun”, let’s run the numbers. If 4% of the US population meet criteria for antisocial personality disorder, that means

  • four Senators and
  • 17 House Representativies

demonstrate a “pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years”. (I’ll let you discuss amongst yourselves as to the identities of these individuals.) There are 15 Cabinet members and nine Supreme Court justices, so the chances are low that one person in either one of those groups has antisocial personality disorder.

If 20% of the US population meet criteria for adulthood antisocial behavioral syndrome, that means

  • 20 Senators
  • 87 House Representatives
  • one Supreme Court justice and
  • three Cabinet members

demonstrate a “pervasive pattern of disregard for and violation of the rights of others”… but did not do so before the age of 15.

The paper that describes the survey also notes that these two antisocial conditions are

highest among male, white, Native American, younger, and unmarried respondents, those with high school or less education, lower incomes, and Western residence

When we consider mass shootings (most certainly an antisocial behavior) in the US, most of them were committed by men… but also note that the vast majority of men don’t ever kill people.

The odds ratio for Native Americans struck me: What does that mean? Is this simply due to the low numbers of Native Americans in this country (i.e., small numbers inflate percentages)? What are the other confounders?

And what about the contexts? Aren’t there occasions when antisocial behaviors are adaptive? If someone threatens your life on a routine basis, is it (1) unreasonable to lie, (2) put your safety at risk when you try to escape the situation, and (3) perform poorly at work due to the stress in your life? You only need to meet three criteria to receive a diagnosis of antisocial personality disorder.

I’m also curious about the prevalences of adulthood antisocial behavioral syndrome in other countries. Does a 20% prevalence in the US mean anything? Do we demonstrate more antisocial behaviors than others on this planet? Maybe this is just human nature?

Some people say that intellectualization is a mature defense mechanism. I’ll let you decide if this post is simply a manifestation of whatever unconscious conflict roils in my psyche.

Categories
Medicine Nonfiction Reflection

Assuming Intentions from Behaviors.

The fear first appeared in his eyes, then washed over his entire face.

“Hey, how did you do that?” His voice grew louder. “You’re supposed to help me! How did you tell the voices what to say?”

I realized that this was not going to end well.

“The voices in my head are now saying that there are robots in my brain!” he shouted. “That’s illegal! You’re not allowed to do that!”

“I have no ability to put voices in your head or anyone else’s head.”

“But you did! Before you told me about what I supposedly said the other day”—he had told my colleague that there were robots in his brain—“the voices never talked about robots. YOU did this!”

“I did not.”

“You did!” He looked around, frantic. “HELP! SOMEONE HELP ME! THIS NURSE IS PUTTING VOICES INTO MY HEAD!”

My heart sank further. Many people who experience auditory hallucinations learn to avoid sharing this with others. This man did not realize how others would dismiss his suffering.

“I’m going to go.”

“NO! You can’t go! You’re doing something illegal!” He saw an officer approach. “GUARD! GUARD! This nurse is doing something illegal! She’s putting voices in my head!”

Though he has worked on the unit for years, I suspect that he had some innate skills in talking with people who were overwhelmed.

“Hey, you don’t need to yell, I’m right here. She’s trying to help you….”

He managed to shout, “HEY, COME BACK HERE, YOU NEED TO STAY!” as I slipped away, but he stopped yelling before I was out of earshot. The officer later told me the man demanded that I call his parents to tell them that I was putting voices in his head.

There’s no way this could ever happen to you, right?

But aren’t there times when we believe that someone did something to us… except they didn’t?

Like those times when we say, “She makes me so mad!”

Or, “He’s trying to make me jealous.”

We assume intention from behaviors. Sometimes our assumptions are correct, but not always. We feel whatever emotions we feel, but that does not always mean that somebody else is responsible for our emotions.

“But, Maria,” you might retort, “there’s a big difference between hearing voices and feeling emotions. We all feel emotions. Only sick people hear voices.”

… except there’s data[1. Prevalence of auditory verbal hallucinations in a general population: A group comparison study and A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals.] that suggests that anywhere between 5% and 28% of the general population hears voices. They are your coworkers, friends, members of your family, people you routinely see in your community.

And even if we don’t hear voices, our running internal dialogue—while not “voices”, per se, but “thoughts”—can transform an event into something else that never actually happened.

I felt sad as I was walking away from this man. First, do no harm. Our conversation went sideways and caused him distress. I replayed the interaction in my mind—my own internal dialogue was loud—and recognized several points where I could have taken a different approach. The outcome still may have been the same.

The truth remains, though: I did not put voices into his head. I don’t know how to do that. My hope is that he will recognize and accept that in time.

Categories
Medicine Reflection

Answers Unknown.

The chief complaint was belly pain. He described the pain as both dull and crampy. It came and went, but bothered him the most on the same night of each week.

The notes from the primary care doctor show a thoughtful search for the underlying cause. There were comments about activity logs, blood tests, and imaging studies. Months later, it remained a mystery: He still had belly pain. The investigations did not reveal any physical causes for the aches in his abdomen.

When I asked him if he had pain anywhere now in his body, he looked at me, blinked, and then looked away. He remained mute.

The first note in the medical record was a standard template for vaccinations related to overseas travel. This international adventure would be a distant memory by the time the discomfort in his gut brought him back to the clinic.

His trip to the distant land was unhampered by children. Over ten years would pass before they were born.

I didn’t ask him about his family. I knew that they now had restraining orders against him.

The next entries in the medical record describe a different person: He no longer had concerns about belly pain. The primary care doctor in the public health clinic wrote sympathetic notes about his skin infections and paranoia. The social history noted that he was no longer in contact with his family, but did not offer any reasons why.

Physicians and nurses are trained to ask questions that are inappropriate in social settings (e.g., “Have you been passing gas?” “When was your last period?”). There are also questions that we never think to ask: We don’t believe the people under our care would ever do something so inappropriate.

Did he develop belly pain because he literally could not stomach what he was doing to his children?

Maybe I only imagined that he nodded when I asked him about spiritual distress.

Could spiritual distress look like schizophrenia?

Could guilt and shame look like schizophrenia?

Could efforts to mimic schizophrenia look like actual schizophrenia?

Could a desire for a reduced punishment look like schizophrenia?

I gave him pencil and paper. “If you’d prefer to communicate through writing instead of speech, that’s okay. I’d like to know how I may best help you.”

His fingers grasped the pencil and paper for a few minutes. He looked at the floor. He then returned the pencil and paper to me before walking away.