Saturday, April 26, 2008

Now I Remember

So in my post from yesterday I talked about the normal process of memory and forgetting. Right after I published that post I started thinking about all the weird little things that I remember.

In order to be a doctor you have to have a pretty good memory. You start out by memorizing muscles and bones and nerves and blood vessels, and work your way into the body by memorizing types of cells and cell processes and biochemical reactions. (How many of you remember how many molecules of ATP are produced in the Kreb's cycle?) The comedian who played Father Guido Sarducci on Saturday Night Live used to have this bit where he'd advertise for the Five Minute College. By sending him lots of money and taking his Five Minute College course, you could get a college degree while learning everything a college graduate remembers five minutes after leaving college.

I'm always surprised by the little factoids and trivia I remember, both in day-to-day life and from college days decades ago. I remember my friend's apartment number because it's the same as the year Jamestown was founded. I remember my childhood phone number (OK, that's an easy one---it's two digits repeated two or three times) as well as the addresses for all the apartments I've ever lived in.

Remembering things too well is rarely a problem for people. When it happens it's usually in the context of unpleasant or horrible memories, memories that intrude on day-to-day life and are upsetting or interfere with one's ability to function, as in post-traumatic stress disorder. These situations are usually managed with therapy, although now people are also experimenting with the use of medications to prevent the formation of intrusive memories after traumatic events. This is still too experimental to be practically useful, however.

Of course, we know that memory is not always a reliable thing. We remember childhood events differently than our older siblings, or not at all. In the 1980's following years of a movement for the treatment of trauma survivors we learned both that bad memories can be repressed, but also they can be created through false memory syndrome. The amazing thing is that false memories can be just as convincing to the individual as real ones.

Speaking of false memory syndrome, here's a practical example. When I started writing this post I was feeling rather pleased with myself that I remembered how many ATP's were produced by the Kreb's cycle. I was wrong. See if your memory is better than mine by checking out this link here.

Friday, April 25, 2008

I Forgot

I was driving home from work the other day and I heard a piece on National Public Radio about professional musicians who forget their instruments. I didn't hear the whole thing, but they mentioned stories about symphony musicians who leave expensive instruments somewhere (the Stradivarius left in the cab, for instance).

They asked a mental health professional who also happened to be a musician why people do these things. The mental health talking head said it happened because the musician was "hyperfocussed" or so concentrated on the upcoming performance that everything else was driven out of the mind. He also speculated that performance anxiety was expressed as an unconscious wish to lose the instrument. What he didn't mention, but the first thing that popped into my head, was sleep deprivation or just simple absent-mindedness.

We all do absent-minded things at some time in our lives. We lock our keys in the car, or ourselves out of the house, or we forget to pay a bill or to mail a bill that's already been paid. We forget birthdays and anniversaries and other important dates that we (and our loved ones) really expect us to remember. Fortunately, we also forget anniversary dates of things that are better left forgotten, although I think it will be a long time before anyone forgets dates like 9/11. (Do young people know the date 12/7? Isn't it amazing what we, as a collective national memory, forget?)

Yet we don't consult mental health professionals about why these things happen. Remembering things, and forgetting, are a natural mental process that happens continously outside our awareness. If the problem becomes too severe---if we start forgetting the names of our spouses or children or where we live, or if the memory problem becomes associated with other brain problems like writing or reading or talking, then it becomes a disease.

Age-related memory changes may concern older people, but they are not necessarily a sign of progressive disease. It can also be a sign of clinical depression, in which case memory problems are temporary and reversible.

Of course, none of this explains why I keep forgetting to take my iPod out of my my car when I get home. It must be an unconscious fear of listening to My Three Shrinks. What I want to know is, what's the unconscious wish for forgetting to pick up your kid?

Thursday, April 24, 2008

Disturbing Things

I received the following e-mail from a friend. Copied without permission:

I get some of the craziest emails but this one is short and pretty good. I mean, we're all a bit nutty…but really.

Psychopath Test

Read this question, come up with an answer and then scroll down to the bottom for the result. This is not a trick question. It is as it reads. No one I know has got it right.

A woman, while at the funeral of her own mother, met a guy whom she did not know. She thought this guy was amazing. She believed him to be her dream guy so much, that she fell in love with him right there, but never asked for his number and could not find him. A few days later she killed her sister.

Question: What is her motive for killing her sister?

[Give this some thought before you answer]


She was hoping the guy would appear at the funeral again. If you
answered this correctly, you think like a psychopath. This was a test by
a famous American Psychologist used to test if one has the same
mentality as a killer. Many arrested serial killers took part in the test and
answered the question correctly.

If you didn't answer the question correctly, good for you. If you got the answer correct, please let me know so I can take you off my email list. (ha)


So I got it right....I promise I haven't killed anyone, but apparently I'm off Harry's e-mail list. The picture, by the way, was stolen off Fat Doctor's blog. Psychopathic cows for sure. Clink, any thoughts here?

Wednesday, April 23, 2008

Fat. So?

Oh, a while ago I wrote up a review of a book by Gina Kolata, a New York Times science writer. I never did anything with it, so why not, I'll post it here.

Rethinking Thin

In the mid 1980’s, I worked as a research assistant at the University of Pennsylvania’s Obesity Research Group. It’s been a long time since I’ve had any interest in the details of obesity research, but it got my attention when I saw that Gina Kolata, a New York Times science writer, wrote Rethinking Thin. This is a book which pulls together decades of human and animal research on the causes, treatments, and repercussions of being overweight. In the book, she followed four patients enrolled in a two-year research study at Penn’s Obesity Research Group, now called the Center for Weight and Eating Disorders. The group’s name has changed, some of the researchers however, have not, and it’s always fun to read a book when I can put faces and stories to the names.

The book itself is the history of obesity research, coupled with glimpses of our views about weight in the last century or so. Is it complete? I really don’t know. What I do know is that as I read the book, I was inspired to reconsider certain beliefs I’d held about weight and weight control. I also, however, could think of many examples of people who defied the principals that the author puts forth as new truths.

Kolata begins with the discovery of Jean Anthelme Brillat-Savarin, a French lawyer, who published The Physiology of Taste in 1825. Brillat-Savarin wrote that the treatment of obesity mandates, “a more or less rigid abstinence from everything that is starchy or floury.” This was a preview of the Atkins diet, nearly 200 years ago, and perhaps the start of an endless series of diet fads. Kolata moves on to discuss the practice of “fletcherizing,” named for Horace Fletcher, also known as “The Great Masticator,” who advocated that chewing food one hundred times per minute was the key to the perfect weight and all-around good health. After years of chewing, America was introduced to calorie counting by Fisher and Fisk in their 1916 book How to Live. Around this time, Americans became consumed with being thin and young girls started to diet and exercise to lose weight. The stories continue: the first obesity surgery occurred in 1911 when a Philadelphia surgeon removed 12 pounds of adipose tissue from a patient’s abdomen. The 1920’s saw skinny flappers and the first bathroom scales and full-length mirrors. The diet club, TOPS, was started in 1948. There were diet drinks, diet pills, diet contests-- Kolata describes it all.

Almost every woman wants to be thinner, the author tells us. Miss America has gotten taller and thinner. Jennifer Anniston weighs in at 110 pounds, too light for her 5’5” height. And it’s hard to be fat: fat people make less money and are treated with shame and disgust, sometimes being subjected to public humiliation. Their medical problems are all attributed to their weight. 91 percent of formerly fat people in one survey chose having a leg amputated (hypothetically!) over being obese again.

Kolata continues with a careful look at more recent research in the field—both human studies regarding the etiology, transmission, and treatments of obesity, and animal models in search of chromosomes and hormones that contribute to or control both appetite and body weight. She reports on twin studies, diet studies, research on those who’ve been starved and those made to gain weight.

The four patients/research subjects in the Penn study are revisited throughout in short chapters. There weight loss progress is noted, their optimism waxes and wanes as the pounds drop and come back. They are here, I believe, to make the book more palatable to the lay reader; it is otherwise a recital of research studies with a fair number of pages devoted to the search for a fat mouse gene and hormones which might, but so far don’t, hold answers to the problem of obesity. The Penn patients’ stories are dealt with rather superficially. They weren’t particularly distinctive or compelling and they blended in the author’s desire to show that sustained weight loss is a nearly hopeless goal.

Dr. Albert J. Stunkard, the Director Emeritus of the center, gets his own chapter in Rethinking Thin. He is presented as intelligent, insightful, determined, and inquisitive in his nearly 50 year- long quest to understand obesity. It’s good to know he hasn’t changed since my days as his college student.

Kolata wrote this book with what appears to be clear agenda, she has a message she wants to get out there. It goes something like this, and I’ll list it as bullet points:

· Obesity is not caused by underlying psychological problems or a lack of motivation to be thin.

· Weight is genetically determined (or at least not environmentally determined) and this is supported by adoption and twin studies. Individuals have a narrow weight range, a set point per se, and it is difficult for them to vary from this by either gaining or losing weight; it is even more difficult, if not close to impossible, for them to maintain a weight either above or below the set point range.

· There is are organizations, including diet industries, academic centers, and federal agencies which are invested in propagating the belief that it is unhealthy to be overweight and imperative that Americans eat less, eat healthful foods, and exercise more. Kolata quotes Eric Oliver, a University of Chicago political scientist, “If you are on the political right, obesity is indicative of moral failure. If you are on the left, it means rampaging global capitalism.”

· People are fatter. No one knows why, and interventions aimed at changing diet and behaviors do not change weight. Kolata repeatedly mentions a $20 million, intensive 8 year study done with high-risk Native American children—the study, she says, has mostly been ignored.

· Studies that broadcast the health risks of being overweight are flawed and it seems that overweight people have decreased mortality according to more recent studies. As Americans have gotten taller and heavier, they’ve also gotten healthier with longer life spans and fewer chronic illnesses.

The Penn Study finished after two years on a low note. The dieters had long ago stopped losing weight and had regained much of what they’d lost. They were disenchanted and disappointed though perhaps transformed to a better place of acceptance.

And the book itself? It was a quick and entertaining read. I did have the sense that the author was on a mission to change our views and preconceptions about weight and all that we believe to be unquestionably true about the evils of obesity. At moments, Kolata swerves towards sensationalism, and it’s clear she’d like us to decide that fat is beautiful.

Maybe she’s right and maybe we will.

Sunday, April 20, 2008

Two Years Of Shrink Rap Tomorrow: Anniversary Post

On April 21st, Shrink Rap will be two years old.

It's no longer ruining my life. I still love having a blog with my two terrific friends, Roy & ClinkShrink. I still love that her blog name is ClinkShrink.

Ducks and chocolate and podcasts with or without prestigious guests,
readers who read and those who comment. Hummus and Cake and Pizza and Beer. And they help me with computer problems and listen to my teenager stories. And people in South Africa and Australia read my random thoughts, they get stirred up or they simply ignore me. What could be better? More chocolate of course, but I don't run like Clink, so I'll watch it (go down....).

So, for lack of anything more brilliant to say: I'm reposting my first blog post. I have to say that Shrink Rap has now become so big and bulky that it's hard for me to find and navigate it. It's not a blog you could really start from the beginning and read through. I found my first post, and two years of psychiatric progress have not outdated it.

The post is called "Plan: Continue Treatment, Return When?"

Our hypothetical patient enters the office; he's never seen a psychiatrist, and he's here because he is overwhelmed with sadness after being laid off from work. He isn't sleeping well, he's lost ten pounds, he's having trouble organizing his job search, he's irritable and arguing with his wife. He is clearly a bright guy, but tells us he's lost jobs before and feels he isn't living up to his potential. He's not psychotic, he's not dangerous. A full evaluation is done and some decisions are made about what type of treatment to begin. So here's my question: When do we have him return for the next visit? Is that a silly question? And do I really want an answer? You want to ask more questions about our patient, talk about how you would treat his depression, or his adjustment disorder, wonder why he repeatedly loses jobs and is there perhaps a personality disorder as well? And no, I don't want an answer, what I want to do is throw out the idea that there probably is no consensus among us about how often patients should be seen. If our patient is seen in a clinic, he may well be started on an antidepressant and told to return in three to four weeks. In a private office, perhaps he'll be told to return in a few days, or maybe not for week or two or three or four. And if there isn't enough disagreement on how often to see patients at the beginning of treatment, what happens if he has a good response to a medication, his symptoms are alleviated, but he still fills the sessions talking-- do we continue to see him daily/weekly/biweekly/monthly if he isn't asking to come less often and if he's paying his bill?

Okay, nostalgic rambling. Come back to Shrink Rap...oh later today or maybe tomorrow.

[Roy here...]  Nostalgia, huh? Okay, here's a link to my first post, which was sort of a Tom-Kat-Scien-tology post called Tom Knows Psychiatry.  We made a very short podcast yesterday (about Virginia Tech, which we podcasted about last year) for the 2-yr blogiversary, but the recording mysteriously disappeared so there will be none this week.  We did take a picture of the carrot cake that Clink got for the occasion, which I've put up top.

And here's Clink's first post on Recertification Exam Fees.

Friday, April 18, 2008

Good Parent Bad Parent

Last week, I wrote a post about Moms and Psychiatry; see "It's Your Mother's Fault".
People wrote in to say they had good moms, great moms, good dads, lousy dads. It got me thinking that there is an objective standard out there as to what makes a parent a good one (or even simply adequate). "I had a good mom" implies there is such a thing, but it seems to me that as with any given brand of ice cream, the issue of good versus bad is one of perception. Is there some one we all agree is a good mom? Carol Brady, perhaps? Perhaps it's more accurate to say that a person is a good mom for a particular kid, because it's hard to imagine, in my current state of teenage immersion, that there is someone our there who would be a great mom to every single kid.

I listen to a lot of parents. I listen to a lot of kids (not so just my own, but patients who are all someone's kids, though these "kids" range in age from 18 to 91). Here's what I've concluded.

There are some easy-going mild-tempered people out there who are are not terribly sensitive to exactly what is said or done to them, they are forgiving of bad days, perhaps even sympathetic to their parents' trials, and they don't tend to dwell on every grievance or imperfection their parents exhibit. These people tend to like their parents and tend to be happy people. This may be because they have perfect and wonderful parents, or it may be that they tune out their parents' mistakes.

In the absence of the super-easy going person who doesn't scrutinize their parents, I've found that kids and parents judge parenting by completely different standards.

Parents focus on what they've done for their kids, what material comforts and securities they've provided, especially if it exceeds what was provided for them. They focus on the amount of time and effort they put into forwarding their childrens' interests and education-- so getting up at 5 AM to take a kid to hockey seems like a sacrifice, and points should be earned towards the good parent award. Sitting on the side lines as a spectator to any musical/artistic/ theatrical/ or athletic event counts. Cooking special birthday meals, buying presents, allowing friends to overrun the house, these all counts. Extra points please for coaching teams, den mothers, snack parent organizers, lifeguarding at a home pool.

Children expect exemplary parents. Everyone else these days seems to have them, and they view life in a more "points off" standard. Everyone's dad coaches something, it's no big deal and effusive gratitude is not part of the deal. Children, however, know exactly what the perfect parent is : Mike and Carol Brady have set the standard--- remember that blended couple with the 6 kids from the 1970's where every problem got solved in a half-hour episode, no one talked back, and no child ever mentioned that one of their parents was a step-parent. Funny, those kids never missed their absent natural parent, and not once did a kid scream "You're not my real dad, you can't tell me what to do!" So kids dock you for losing your temper, saying things that objectively sound horrible---parents aren't allowed to call kids names no matter how extremely they are provoked. The translation goes "My mother used to tell me she hated me." Funny, the story never gets told as "My mother told me she hated me every time I cut up her good silk blouses to use for art projects." Okay, okay, even I don't think people should profess hatred for their kids, but I do think we've established a hard-to-attain standard for the Good Parent that leaves little wiggle room for the fact that parents are people too, and sometimes they react in impulsive ways: Points OFF, and no going back. Kids are kids, they're transgressions are part of the deal.

I talked to Clink about this the other night and she mentioned that good parents are Consistent. I thought about that. Children are moving targets, they come up with new antics (some of them fabulously amusing, some of them totally infuriating), and the moment you get the hang of it, they move on to the next developmental stage and the rules all fly out the window. So how do you be consistent when you're dealing with a target in perpetual motion?

Okay, so What's a Good Parent and What's a Bad Parent and why do some kids seem fine with people many of us would agree are awful parents while other kids feel tormented by parents who seem to be doing all the important things right? And should I even ask how much parenting steers how the child turns out? Maybe it's all in the chemicals, balanced or otherwise

Tuesday, April 15, 2008

Are You Chemically Unbalanced?

This will be quick; I'm actually headed off to work.

In his "In Practice" blog, Peter Kramer discusses the issue of whether the concept of a chemical imbalance is still a useful one and he looks at the evidence for and against such a theory, concluding that the concept met a premature death.
"Since 1993, other biochemical contributors to depression have claimed their roles, especially “stress hormones” and factors that influence nerve cell growth. The new overarching biological model of depression (I outline it in Against Depression) integrates all three factors—monoamines, stress, and cell growth—but serotonin dysregulation remains very much on the table as a contributor to depression."

Dr. Kramer talks about PET scans and genes and differential rates of monoamine metabolism, and the stupid little bouncing Zoloft mascot with the smiley face.

For the shrink in the field, so far it doesn't mean much. I can't order a test to find out if someone has too much of one enzyme breaking down any given neurotransmitter and thereby telling me what to prescribe. I'm waiting. In the meantime, what I do have is patients who come in wanting to know what they have. "Do I have a chemical imbalance?" Now what does that even mean? Do you have too much serotonin in some places in your brain and not enough in others? How would I know that? Too much (compared to what?) monamine oxidase breaking down your noradrenergic neurotransmitters? Should we inhibit them and this will make you better? Let me get my probe.

What I do know is that while I don't know what is meant by a "Chemical Imbalance," my patients do. For them it is a term that explains things, that writes the story, that has meaning. There's something socially acceptable about it. "I have poor coping skills" is pejorative and equally unprovable. "I have a chemical imbalance" is somehow explanatory, though still unprovable in a day-by-day psychiatric practice.

So, generally, if a patient with Major Depression asks, "Do I have a Chemical Imbalance?" I simply say "yes." It seems to work.

Monday, April 14, 2008

Fight Club

OK, so Dinah inspired me with her "You're The Psychiatrist...." post. She does do this fairly regularly. She stumbled into an Ultimate Fighting event and came out wondering, "Why do people do this?"

I'll tell you why. I have some experience with fighters, both as a psychiatrist who works with violent people and as someone who has hung around black belts for about twenty years.

It's about competition, it's about adrenaline and excitement, it's about taking risks and not being afraid of the consequences. (I'm tempted to say 'it's a guy thing', but besides being a sexist comment it would also happen to be an untrue statement. At some of the martial arts competitions I've been to I can tell you there are a substantial number of women competing nowadays. And you should see their tattoos!) So it's a sport, although I have to say there's sometimes a fine blurred line between a sport and a crime. If there are rules, if there's a professional organization sponsoring the event, if you have to pay to get in and you get some kind of formal training, then it's a sport.

Then there are crimes. People who fight---without rules and without sports equipment----sometimes do it because they enjoy it. It releases tension, gets rid of pent up emotion, and sometimes it settles problems (whether it's a good way to settle problems is obviously a whole different question). Among prisoners the challenge is to see how "good" you are at it or to establish dominance and defend your turf. It's to enforce gang rules or to punish rulebreakers. Among the younger inmates (also called "hoppers" in prison slang, after hip-hop) the idea is that fighting is protective; by being willing to 'step out' you'll be less vulnerable and it will keep people away from you. Younger inmates also will prove themselves by going up against much bigger prisoners or correctional officers. (The much bigger, more experienced correctional officers can usually see this coming and can 'talk them down' or persuade them that it's really not a good thing to do.)

So that's what my experience has been and what I can say about the motivation of fighters. Street fighters eventually grow up or burn out. They figure out they won't always be the biggest baddest person on the block and that injuries accumulate over time. Then there's the rare person who never figures it out, and they stay locked up. One prisoner I met had been in a coma for several weeks as result of a street fight. I asked him what he had learned from the experience. His response:

"Next time I bring a gun."


"You're The Psychiatrist...."

First, check out our PODCAST #45 with return guest Dr. Ray DePaulo.
Then, let me tell you about my weekend.

I went away with my husband on a quick trip to my aunt's 90th birthday party. She looks fantastic, her sister was there, her brother-in-law hasn't slowed down any and he had a few too many and was out on the dance floor with his grandchildren. It was a nice time and there were maybe 50 of us there for a nice celebration in a hotel banquet room. Across the hall, there was a wedding. In the adjacent exhibit hall there were....oh, 1600 "guests" there for Extreme Cage Fighting. I've never quite seen anything like this. I'm not sure how to begin to describe it.

Okay, so I tried to go in to check it out. I've never heard of "cage fighting" but apparently it's the ultimate in brutality...two men in a cage trying to beat each other to a pulp. What fun. I was dressed like I was going to my aunt's 90th birthday party. Security stopped me. "May I help you?" I didn't know what to say. "I guess I'm at the wrong event." He looked me over and said, "You're at the wrong event." Everyone else was in wife-beater shirts. My tattoos....well, let's not go there. He let me stand there for a few, I watched as the police dragged out a few people, it was quite the scene.

So the hotel had lost my reservation and we ended up sleeping at another hotel 10 minutes away. I heard from my cousins that this was not a bad thing--- the 1600 Extreme
Cage Fighting observers were drunk, rowdy, and raucous through a good part of the night. Someone erroneously reported a fight in my cousin's room and the police came pounding on her door at 4:30 AM, she sent them away saying that she and her 86 year-old mother were not fighting.

Down the road, my husband and I spent a quieter night, away from our teenagers. We chatted, I told him about Fat Doctor's trouble with her difficult
Day-Care provider and how she wants to adopt another child. This is what my life has come to.

So everyone I tell about the Extreme Cage Fighters says to me , "You're the psychiatrist, why do people like this?" I guess I could ramble about the baser of human instincts, a pull towards competition and violence. Something Freudian. Honestly, though, I don't get it. I won't be jumping in any cages any time soon. And Roy, count me out for the mud wrestling.

Sunday, April 13, 2008

My Three Shrinks Podcast 45: Guest Ray DePaulo on Treatment Resistant Depression

[44] . . . [45] . . . [46] . . . [All]

We are pleased AGAIN to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk this week about treatment resistant depression (TRD), bipolar disorder, favorite quotes, and words we don't like.

Dr. DePaulo joined us on the last podcast (#44) and talked about cosmetic psychopharmacology, among other things.

April 13, 2008: #45 Guest Dr. Ray DePaulo on Treatment-Resistant Depression

Topics include:
  • Treatment-Resistant Depression. How is it defined (~10:00 min into the podcast)? Is there a magic bullet? Treatment strategies (don't give up; remember lithium; use proven agents; get 2nd and 3rd opinions; do psychotherapy).

  • Nellie, the Hypothetical Patient. Let her know what we know about treatment, and what we don't.

  • "Alternative" Treatments. St. John's wort; SAMe (s-adenosylmethionine); omega-3 fatty acids; ketamine; vagal nerve stimulation (VNS); deep brain stimulation (DBS); psychosurgery (cingulotomy).

  • Cognitive Therapy. Many different types.

  • Words which are Unliked by the Podcasters. Alternative treatment. Mood stabilizer. Antidepressant. Antipsychotic. Hallucinogen. Psychosis. Neurosis. Organic. Schizophrenia. Nervous breakdown. Mood Swings.

  • Quotations We Like.
    "There's only two types of music: good music and bad music." Fran Liebowitz
    "Eighty percent of success is showing up." Woody Allen
    "Expect more of yourself and less of others; you'll be disappointed less." Unknown
    "Life is unfair; the sooner you figure that out, the happier you will be." Unknown (Lilya said it in 2003 on a recovery forum)
    "A good clinician is someone who makes prudent decisions based on insufficient information." Ray DePaulo (I think)
    "Experience is what we call it when we were looking for something else." Federico Fellini
    "Good decisions are based on experience. Experience is based on bad decisions." probably Mark Twain
    "'Experience' is simply the name we give our mistakes." Oscar Wilde
    "Science is a process of conjecturing and refuting what is thought to be universal, therefore a theory can only be considered 'scientific' if it is falsifiable," paraphrasing Karl Popper.
    "It's a short step from the penthouse to the outhouse." Unknown (many found)
    "It's a short step from Who's Who to Who's He." Unknown
    "There ain't no such thing as a free lunch," or TANSTAAFL, by Robert A. Heinlein.
    "When Momma ain't happy, no one's happy." Apparently, an old southern saying.
    "For every aphorism, there is an opposite aphorism that's equally true." Unknown
    "Children can be happy when their parents are miserable. But a parent is never happier than her unhappiest child." Laura Lippman
    "Data is not knowledge, and knowledge is certainly not wisdom." Unknown

  • Drugs in the Drinking Water. Brief mention of last month's AP story finding all sorts of pharmaceuticals in numerous municipal water supplies.

  • Books we are reading.
    -Ray: "Saint Augustine", by Garry Wills.
    -Roy: "Valis", by Philip K. Dick. (Ben was reading it on "Lost".)
    -Clink: More listening to an opera about Carmen, a famous female sociopath.
    -Dinah: "How Doctors Think", by Jerome Groopman.

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they may be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

Find show notes with links at: The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from
Thank you for listening.

Friday, April 11, 2008

Out To Get You

In Tara Parker-Pope's Wellness blog for the New York Times, in Feeling Paranoid? You're not Alone, she talks about a study in the British Journal of Psychiatry where people were placed in a "virtual" simulation of the London tube and asked to comment on their surroundings and they looked at how many people had "paranoid" thoughts. A lot did.

Parker-Pope writes: The findings are important because paranoia is generally thought to be a symptom of severe mental illness. But this virtual reality study shows that paranoid thoughts are common in the general population.

I know this will surprise you, but I had some thoughts on this and commented. So my blog post today is lifted from my comment on the Wellness blog. (I've checked, in blog-o-land, this is not cheating).

I responded with:

10:46 pm

While symptoms often exist on a spectrum where the distinction between normal human emotions and symptoms of mental illness is an arbitrary one, the issue you raised is not as fluid as you make it sound.

The experiences of those in the virtual experiment, or the feelings of real subway riders, are not “paranoia” in the sense of a symptom of severe mental illness. In the absence of any unreasonable taint–which you did not describe– your experimental subjects are exhibiting “Suspiciousness.” In a setting of strangers, in a place such as a subway noted for crime, this is far from paranoia, and a degree of hyper-awareness to the surroundings is an adaptive response and not paranoia.

Paranoia is a term used loosely— it may refer to actual paranoid delusions (a symptom of a major mental illness), or it may refer to vague suspiciousness, or people often use it as a defensive counter-response when they don’t like something they are being accused of: “Are you having an affair?” >>> “You’re paranoid!”

Paranoid delusions are fixed false beliefs that hold despite evidence that they are not true. They often take on a bizarre and unreasonable quality — for example, the FBI is monitoring me through fiberoptic cameras in my walls….(if this is true, it’s not a paranoid delusion!). “Ideas of Reference” are a type of paranoid delusion in which an individual believe he is either getting specific messages from the media (Johnny Carson told me to do it) or from unknown others– so the sense that unknown people are talking about you, when they’d have no reason to do so. So, if you’re walking around in a clown suit and believe strangers are laughing at you, well, that’s not a paranoid idea of reference: they may well be laughing at you.

Paranoid delusions are indeed symptoms of mental illness. Suspiciousness is a different phenomena and is often warranted.

Wednesday, April 09, 2008

Shrink Rap: Dr Wes Doing Grand Rounds for April 8

Just a heads up that Dr Wes has got Grand Rounds covered this week, with very professional graphics, I might add.

Monday, April 07, 2008

It's Your Mother's Fault

Moms and psychiatry have a long history.

Freudian psychoanalysts like to talk about moms. "Tell me about your mother." Oh, those Oedipal sexual longings....

Winnecott, who gave us the concepts of the "holding environment" and the "transitional object" talked of the "Good enough mother"-- an imperfect creature who could still raise normal children.

Melanie Klein
gave us the good breast, a way for the infant to internalize dear mama.

Bruno Bettleheim gave us those Refrigerator Mothers who caused their children to be autistic while Theodore Lidz gave us Schizophrenogenic Mothers. Oy.

I could go on and on, if only Roy would let me. While we've moved beyond blaming mothers for autism (now we have vaccines to blame until we name the next culprit-- please don't let it be chocolate), we still believe that mothering is a key ingredient in who a person becomes. Good mothers have good kids, bad kids must have bad mothers. No matter how you dice it, we all believe in cause and effect, and we all can write the script backwards. An entitled, self-centered criminal must have had a mother who spoiled him and didn't set limits. I remember my own mother saying, "When you see a child hitting someone, you know someone is hitting that child at home." (My mother read Dr. Spock, she wasn't a scientist).

It's really easy to write the story backwards, and in fact, as psychiatrists, that's what we do. As a mother (have I mentioned that I have two teenagers?) it's not so easy to write the story forwards. If I do "X" my child will become this type of person and if I do "Y" my child will become that type of person. It doesn't work that way, trust me. If it did, we'd all read the instruction manual and have a perfect world.

So this, I've decided, is the paradox of today's world, now that we are relieved of refrigerator mothers but not bad breasts: There are lots of things that society tells us we need to do for our children to grow them good. Mozart in the womb, and that's where it starts. No drugs, no tobacco, no caffeine, no artificial sweeteners, no alcohol: the perfect internal environment. And once they pop out, there are all sorts of do's and don'ts: what chemicals they inhale, what they watch (pg, pg-13, violence and sex and how long have you been sitting in front of that boob tube, junior?), how they behave, say please and thank you, not those violent video games and what are you watching on U-Tube? Montessori this, Rebounders that, chicken nuggets are good, chicken nuggets are bad, make sure they get enough sleep and not too much MySpace, quality time, licensed day care providers who build self-esteem, car seats and safety gates and all the right influences and none of the wrong. Talk to your kids, the TV says so, the billboards say so, talk to them about sex and drugs and God and country and the earlier the better (--see, I can go on and on).

Then they turn in to teenagers and they figure out that the word "controlling" is extremely pejorative in our culture. What's worse than a Controlling Mother? Even a bad breast doesn't sound so bad. Are you a controlling mother? What do you mean I have to eat vegetables? Or be home when? And that's the paradox.

In the world of teenagers and psychiatrists, it's hard to win as a mom.

You know you've been blogging a long time when....Roy followed me and added links in this post to past blog posts I've written-- I clicked on some of them and realized I don't even remember having written them. How does he? A man who needs a longer ToDo List!

Sidebar Poll on MAOIs

Something's slowing the loading time for Shrink Rap. One reader thought it was the latest podcast. Clink thinks it's the sidebar polls. So I'm posting the results and taking them down. I was surprised that we have so many readers who've taken MAOI's... and thanks for the comments on our post below.

Have You Ever Taken An MAOI?

26 (27%)
70 (72%)

Vote on this poll
Votes so far: 96

Did It Work?
14 (56%)
9 (36%)
Not Sure
2 (8%)

Votes so far: 25
Did You Have Any Adverse Reactions?
16 (61%)
10 (38%)

Vote on this poll
Votes so far: 26
Days left to vote: 2

Sunday, April 06, 2008

Sunday: The New York Times

A couple of things caught my attention today:

An article by Matt Richtel about 24/7 bloggers, some of whom have blogged themselves to death. I'm trying not to be one of them:
Of course, the bloggers can work elsewhere, and they profess a love of the nonstop action and perhaps the chance to create a global media outlet without a major up-front investment. At the same time, some are starting to wonder if something has gone very wrong. In the last few months, two among their ranks have died suddenly.

Also about cyberspace, Virginia Heffernan wrote an article called Soft Cell with ClinkShrink in mind:

Prison Talk, a big board with nearly 150,000 members and 2,500 regular readers a day, is a case in point. It caters to what turns out to be an underserved consumer niche: family and friends of the incarcerated.

ClinkShrink and Roy were kind enough to go computer shopping with me today and we got pizza afterwards. Is there a better way to spend a Sunday?

Saturday, April 05, 2008

Guest Blogger Dr. Gerald Klee on Martin Luther King Jr., Riots and Psychiatric Hospitalizations

Oh, I so wanted to put this up yesterday! A day late, but....

Dr. Klee writes:

Today, April 4, 2008, is the 40th anniversary of the assassination of Martin Luther King, which was immediately followed by widespread rioting in cities throughout the US . Baltimore was one of the cities most seriously affected by riots. This tragic situation provided an opportunity to study how admissions to public mental hospitals would be affected by such an emergency. The following 1998 article from The Maryland Psychiatrist summarizes a report by Klee and Gorwitz in Mental Hygiene, Vol. 54, No. 3, July, 1970. The findings, though limited are quite interesting and counterintuitive. For example, psychiatric admission fell during the days of crisis, while General hospitals reported increased admissions of patients with delirium tremens during the same period.

It occurs to me that this story may still be relevant. How well prepared is our present health care system to handle the effects of future civil emergencies.

Riots and Mental Illness

by Gerald D. Klee, M.D. Editor

The Maryland Psychiatrist [Spring/Summer 1998; Vol. 25 No. 1]

Psychiatric Hospital Admissions During The Baltimore Riots of 1968

How would a widespread civil emergency affect psychiatric hospital admissions? Would they go up or down? Would there be differences in demographic characteristics or diagnoses of those admitted? Our efforts to make predictions may be more successful if we have access to biostatistical data from previous events.

The Baltimore Riots of 1968 provided an unusual opportunity to conduct such a study in Maryland.1 Following the assassination of Dr. Martin Luther King, Jr. in April of 1968 there was rioting in more than 130 cities in the U.S. Baltimore was one of those most seriously affected, with widespread rioting, looting, and burning during the four-day period from Saturday, April 6th to Tuesday, April 9th. The National Guard was mobilized and a curfew was imposed in the city and adjacent areas. Many arrests were made. Daily life was affected in many ways for nearly all residents of the area, black, white, and others.

Events of this magnitude were bound to have many effects on mental health. Soon after the riots occurred, Klee and Gorwitz studied the effects they had on mental hospital admissions.1

Summary of Methodology and Findings

Our data were obtained from the Maryland Psychiatric Case Register, a ten year (1961-1971) joint project between the Biostatistics branch of the National Institute of Mental Health and the Maryland Department of Mental Hygiene. I was the psychiatric consultant to the project. There was an active psychiatric advisory board with representation from the Maryland Psychiatric Society (MPS). With the exception of office visits to private psychiatrists, all psychiatric admissions and discharges in the State were reported to the Case Register. In this investigation, admissions from Baltimore City to the three state hospitals serving the area were studied. In addition to the four days of the riots, periods of two weeks preceding and following the riots were examined. The number of Baltimore City admissions during the two-week period before the onset of the disorders and after their conclusion did not differ markedly from comparable figures for the prior year (1967). There were distinct differences in admission patterns during the four-day emergency, however, both as compared with the preceding and the following time periods and also with the comparable period of 1967.

At that time, Maryland ’s psychiatric hospitals had been experiencing a consistent increase in admissions of approximately 10% per year. (The revolving door was already in motion.) While this pattern continued during the pre and post riot periods, there was a sharp drop in admissions during the four days of crisis. In 1967's comparable Saturday-Tuesday period, there was a total of 65 admissions to these hospitals. Adding the noted 10% increase brought the number of expected admissions to 71, but the actual number of admissions dropped to 50. Further variations were found on the basis of race and diagnosis as well as place of residence. While there were 27 black admissions for the four-day period in 1967, this decreased to 18 in 1968. The comparable figures for white residents were 38 and 32. Thus, while a drop in admissions was noted for both races, this decline was more marked for blacks. In 1968, 31 of the 50 patient admissions were diagnosed as alcoholic as compared with only 26 of the 65 admissions in the prior year.1 Concurrently, there was a sharp decline in admissions with psychotic diagnoses (9 in 1968 versus 24 in 1967; statistically significant, using Chi-square test).

In 1967's comparable Saturday-Tuesday period, two thirds of the 65 admissions were from inner city areas where much of the rioting occurred in 1968. During the 4 days of disturbances, however, only half of the 50 admissions were from this part of the city. Some of the admissions were related to the civil disturbances. For example, some patients were picked up by the National Guard for violating curfew and were found to be mentally disturbed.

The data presented are one-dimensional and represent only a fraction of psychiatric episodes that may have occurred during this period. We have no information on the number of cases dealt with solely by the police and the jails. We did not examine short- and long-term mental health effects that did not result in treatment episodes.

While the sample in this study was small and not all of the comparisons were statistically significant, the results show interesting trends and are counterintuitive.


The study provides an interesting vignette of a major historical event in Maryland history. One would expect to observe changes in psychiatric admission rates during a widespread civil disturbance affecting nearly every aspect of life within the city. It is unlikely that anyone could have predicted a drop in admissions and the other changes that occurred. In hindsight, there are many possible explanations for the findings. For example, the rise in admissions of alcoholics was thought to be related to sudden curtailment of supplies of liquor as liquor stores and bars were closed. General hospitals reported increased admissions of patients with delirium tremens during the same period. Other civil emergencies may occur in the future. How well prepared will the psychiatric system be to deal with them?

1. Effects of the Baltimore Riots on Psychiatric Hospital Admissions; Gerald D. Klee, M.D. and Kurt Gorwitz, Sc.D.; Mental Hygiene, Vol. 54, No. 3, July, 1970

Friday, April 04, 2008

Some Plugs for New Psychiatry Blogs

Check it out:

Geared towards psychiatry residents, PsychResidentOnline
has resources for exams, and says very nice things about both Shrink Rap and the My Three Shrinks Podcast. I thought I'd give them a plug right back.

And look, they've even got a Cytochrome P450 table for Roy.

The next plug goes to Dr. Peter Kramer, author of
Listening to Prozac and Against Depression (and others). He's now writing a psychiatry blog for Psychology Today called "In Practice" (...not In Treatment). Here's a link to In Practice.
Welcome to the
blogosphere, Peter!

Thursday, April 03, 2008

A New Use For Gangs

(A BGF tattoo)

I found a new use for prison gangs today. It was completely unexpected.

The patient was a very large, somewhat scarey-looking guy with a history of bipolar disorder. When manic (and psychotic) he got violent. He was transferred back to my facility for refusing to take his meds in a lower security setting. I forget what happened there, but he just wasn't doing well. Back in my facility he was among his associates from the Black Guerilla Family, a well-known prison gang. They respected his size and definitely didn't want him getting sick. They made sure he went down from the tier to the pill line to get his medication.

You'd never guess he had a mental illness when he was well. He was still big and scarey-looking, but he was also articulate. He talked about being able to haul someone into a shower and "mess him up" without guilt or remorse. He talked about staying vigilant, knowing that being part of the BGF made him a target for other gangs. He talked about being bothered by the fact that his violence and lack of conscience didn't bother him. He talked about "wearing a mask" and passing as normal. I could have listened to him forever, and it would have made a good documentary about sociopathy.

But anyway, back to the gang. In psychiatry you hear a lot about the importance of social networks and family support and how this can prevent relapse for people with psychotic disorders. What you don't always think about is how a prison gang can serve this same function. The BGF helped keep my patient well.

He finished the appointment by asking how I was doing and if I was OK, which I thought was rather interesting. It was a bit like Tony Soprano, someone who could execute a guy without batting an eye, being concerned about the ducks in his pool. And I was the duck.

Wednesday, April 02, 2008

Latest Genetic News in Schizophrenia

Schizophrenia has been long thought to be a heterogeneous disease, with many different pathways all leading to an illness with similar symptoms among its affected ranks. It is believed to be caused by a combination of genetic and environmental triggers, as there is a 50% chance of getting it if your identical twin does and a 10-15% chance if your parent or sibling does. Various environmental triggers appear to increase the risk of getting it, such as in utero infections, being born in the winter, and growing up in a family where there is a lot of yelling and emotional expressiveness. About one percent of the population has schizophrenia.

A recent study in Science of whole genome DNA in hundreds of people with and without schizophrenia finds that rare DNA mutations may more of a role to play than previously thought. From Scientific American: "In this study, researchers combed the genomes of 150 schizophrenia sufferers and 268 healthy individuals for never-before-seen copy number variations (CNVs)—mutations that result in large swaths of DNA encompassing multiple genes either being deleted or duplicated. Some such mutations have been found to be benign, but others have been implicated in ailments such as autism and cancer. The team of scientists, from research facilities across the U.S., found novel gene alterations in 5 percent of the healthy volunteers and 15 percent of the schizophrenia patients; new CNVs showed up in 20 percent of those subjects who developed symptoms at or before the age of 18."

53 different mutations were found in these patients. As more of these studies look at whole genomes from families with a high number of affected individuals (like mine, with 7 or 8 people with schizophrenia spectrum diagnoses), we will learn more about what goes wrong in these illnesses and how to better treat them.