Sunday, October 31, 2010

Food Additives and ADHD: New Evidence of Genetic Factors involving Histamine

Just in time for Halloween, a post about candy, children, and behavior problems.  For many years, parents have noted an association between certain foods and their children's behavior.  "If he eats candy he's out of control."  "If she has anything with red dye in it, she'll be up all night."

These observations have caused many parents to have intimate knowledge of ingredient lists of food items, searching for things like sunset yellow, tartrazine, sodium benzoate, carmoisine, ponceau 4R, allura red, and quinoline yellow.  Avoiding these can be challenging -- find a processed food without sodium benzoate.

Double-blind, placebo-controlled trials have shown that artificial food colors have a significant effect in children with ADHD.  However, many have not been convinced of the association, given a lack of plausible explanations for how this range of food additives could cause behavior changes, including inattention, impulsivity, and overactivity.  Granted, any child will have these characteristics at times, but the Attention Deficit Hyperactivity Disorder (ADHD) diagnosis is reserved for those with such severe symptoms that they interfere with home and school functioning.  And, even in toddlers and 4th-graders without ADHD, food additives have been shown to have and adverse behavioral effect (McCann et al, 2007).

Most of the treatments for ADHD have direct effects on the brain chemical, dopamine.  Indeed, genes influencing the dopamine system (eg, DRD4, DAT1) have been found to be involved.  Yet, there has not been clear evidence of a connection between food additives and dopamine.  There have been some observations that certain food dyes can provoke the release of histamine, causing hives and itching but also inattention, hyperactivity, and dopamine release in prefrontal brain areas.

In the October issue of "the green journal" (American Journal of Psychiatry), McCann's group analyzed six genetic polymorphisms (I explained these here) involving genes affecting dopamine and histamine (Stevenson et al, 2010) in the same group of general population kids (not just those with ADHD) from the 2007 study.  What they found provides one possible explanation for why these additives cause behavior problems.

They found that two polymorphisms in the histamine enzyme gene, HNMT, and one in the dopamine transporter (DAT1) gene, were associated with inattentive and hyperactive symptoms when kids were given juice with the additives in it, compared with juice without the additives.

Meaning that children with these specific polymorphisms (think a genetic code swap, like the difference between "their" and "thier") will have an enhanced effect of histamine on their brain's histamine (H3) receptors and an altered effect of dopamine on the brain.

So, what's it mean?  It means those parents were right, of course.  And, for foods that are targeted for children, the food industry now should pay attention (!) to finding alternatives to these artificial chemical additives.

Happy Halloween: Send Us Your Leftovers

Dr. Deb is wishing everyone a Happy Stigma Free Halloween on her blog.

Here at Shrink Rap, we're all in favor of Halloween. Please do forward us any leftover chocolate. Clink's already been carving-- see above. I'm going to try a giraffe pumpkin this year, late start and all. We'll see if the photo is blog-worthy.

Thursday, October 28, 2010

In Treatment: Adele

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Paul goes to a new psychiatrist because he wants a prescription for Ambien. He ran out three days ago and it's 5PM on Friday and he can't wait until Monday when he's scheduled to see a neurologist. The new shrink, we learn from her diploma on the wall, has an M.D., a Ph.D. and she's a psychoanalyst. By my count, that makes her about 80, but Paul is quick to repeatedly comment on how young she is. "I'm sure whatever grade you're in, you've learned to write."

Paul wants a script, that's it. And he came to a psychoanalyst for it? He's hostile, irritable, angry, and condescending. He gets annoyed when she asks him what dose. He's kept awake by a dream, but he's been analyzed by Gina and he knows what everything is about and he won't tell her the dream, only that it relates to his patients, his frustration with his work (...being with a patient is like being two mice trapped in a glue trap), and his certainty that he has Parkinson's Disease. Oh, but when you hear how he takes extra Ambien in the middle of the night, it's kind of got me wondering if he hasn't misdiagnosed himself and isn't in withdrawal during the day, ...but I suppose we'll find that out next week. My guess is that Paul's tremor is psychogenic...but again. Oh, yes, ClinkShrink reminds me he is a TV character and not a real person.

Gina, his old analyst whom he used to fight with miserably, has written a novel and Paul has brought it with him. Got it in a book store on the way to the appointment and he wishes he'd asked for a bag. He gets defensive when Adele questions his treatment with Gina: she was your teacher, your supervisor, your analyst, and your couples therapist? He is offended, after all what does this newbie pipsqueak know? Adele apologizes. Twice. And she's extremely tolerant of Paul's patronizing and demanding demeanor regarding the Ambien prescription. He's clearly not a patient, not interested in being evaluated or getting treatment recommendations (ah, he knows it all, there's nothing anyone can offer)...he's here to purchase a prescription and he's not even going to play the game of being polite.

Paul predictably softens as the episode goes on and talks a little about himself. Adele ends the session by telling him the door is always open to him -- something Gina said she 'should' say but wouldn't. He comments on what a difficult patient he is and Adele says she hadn't notices, but alas, Adele is lying.

Wednesday, October 27, 2010

In Treatment: Jesse

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Jesse is one troubled kid. He's cutting school, hanging out at a bar (at 16, no less), sleeping around, selling his Adderall, staying out all night, cursing at his shrink, and being generally difficult. And Jesse's adopted-- he gets to mid-session before he plays a voicemail for Paul: his birth mother has contacted him and wants to speak.

Jesse and Paul relate more like angry-father to angry-son than like therapist to patient. Paul orders Jesse to stop attending to his iPhone. Put it away. Give it to me. Don't make me tell you again. Don't talk to me like that. Paul knows every parental cliche and Jesse reacts in kind, mostly with obscenities, sarcasm, and wise cracks. Paul even corrects Jesse when he mispronounces "Merriam" and he gives Jesse a mini-lecture on the history of the Merriam Webster Dictionary. This is therapy? The session builds tension-- you think the two of them might fight, and then suddenly the tension breaks and Jesse becomes submissive, or cooperative, or has a moment of genuine reflection. I'm sorry, he says, after Paul scolds him--- out of sync with all the rest of the f* bombs that keep exploding.

Before each episode, there is are snippets from past seasons to help the viewer remember what happened last year. We see Paul sparring with his own therapist, Gina, and he yells at her that he can't keep seeing her to get the mothering he'd never gotten.

So is therapy a fill-in for parenting?

Antidepressants on Kevin.MD

Dheeraj Raina is a psychiatrist who has a blog post on KevinMD called "How an Antidepressant Can Hurt Your Patient."

The post is directed at primary care docs and talks about the danger and downside of prescribing anti-depressants. Too much use as 'feel good' drugs without careful consideration of the diagnosis, appropriate treatment with adjunctive psychotherapy, and the risk of manic induction and suicide.

It's probably not likely that every patient with anxiety and depression will end up seeing a psychiatrist. Obviously, we at Shrink Rap don't think antidepressants should be doled out mindlessly--- if primary care docs are going to prescribe them, they should--

Know how to diagnose depression.
Know how to use the medications. This is not as easy as it might sound: Antidepressants take time to work and the dosing requires titration. Sometimes they need to be changed, increased, augmented. If the first try at a standard dose works, you can call it a day---but this is why the meds have the rap for being only as good as placebo. They don't work if you don't know how to use them and one size doesn't fit all.
There are risks, side effects, adverse reactions, and contraindications.
With psychotherapy, time, and support, there are people who won't need treatment with medications and those options get bypassed when a script gets written in a quick visit.

PS. I agree with Dr. Raina that this can't be done in a 15 minute office visit.

Tuesday, October 26, 2010

In Treatment: Frances

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Paul is arranging flowers to put in his waiting room. He opens the door, flowers in hand, and there is his patient, come early. "You shouldn't have," she says to the man standing at the door with a bouquet.

Debra Winger plays Frances, an actress who is having trouble remembering her lines. Oh, and Frances is the sister of a former patient. Patricia was Paul's patient 18 years ago---she spoke highly of Paul when she saw him when their mother was dying of breast cancer. But now sister Patricia is dying of breast cancer, and Frances is 2 years out from a divorce and her teenage daughter is not speaking to her. Again, a parallel to Paul's life.

Frances is an in-your-face kind of patient. She knows Paul has teenagers and quickly jumps to "you know what it's like." He is clearly uncomfortable, and she backs off, but then she asserts that Paul doesn't have a wedding ring on and he must be sleeping with a boppy 25-year-old. She makes a sideways reference to the idea that men his age may have trouble getting it up, and then wonders if her sister was a nicer patient. Hmmm.

Paul continues to be an in-your-face kind of therapist. He's always been quick to point out a patient's issues to them in a confrontational manner. I never like this, and this session/episode is no exception. And Frances comments on it--- her sister said he was supportive and easy to talk to. Funny but Paul is irritating her. Sunglasses on, and Frances asks if he always puts out flowers or if he was trying to impress her. Two people dealing with issues of aging, fading, and self-doubt.

The episode ends when Paul calls a friend to ask for a reference for a neurologist. As Frances is worried that she, like her mother and sister, might get breast cancer, Paul is worried that he may get Parkinson's Disease like his own father.

Monday, October 25, 2010

In Treatment : Sunil (It's back!)

Week 1: Sunil - Frances - Jesse - Adele
Week 2: Sunil - Frances - Jesse/Adele
Week 3: Sunil - Frances - Jesse - Adele

Week 4: Sunil - Frances - Jesse - Adele
Week 5: Sunil - Frances - Jesse - Adele

Paul is tired, irritable, and balancing a long-distance relationship with his son and a new girlfriend. Oh, and he has a tremor.

A new patient arrives with his adult son and daughter-in-law. Mr. Sunil has just arrived in New York City and he's not doing very well--he's been depressed since his wife died 6 months ago. There is obvious tension between the patient and the daughter-in-law; she finds him to be scary and he finds her to be controlling. Oh, and the son is an osteopath who is prescribing Effexor for his father. And Effexor doesn't work, especially since the patient buriess them in the dirt---but the plant in his room is flourishing.

The kids leave, the father speaks. He rolls a cigarette and smokes. He talks of the losses in his life-- he misses his wife. His son moved to America and changed his name. He doesn't approve of his daughter-in-law and there is a cultural/ethnic divide. She is empty, Sunil says, and looks to others to bow to her to let her feel important.

Mr. Sunil would like a prescription to go home to India, for his wife to be alive, to have a wonderful dinner with her, to tell her about his days, to fall asleep by her side. They set another appointment and wish each other a good day.

As always, the issues with the patients rebound off Paul's issues--we've started by hearing his own discussion with his son, and the tremor, we'll assume, is a reference to his own father's death last season from Parkinson's disease. The patient asks Paul if he has a wife--a sorrow-filled reminder that Paul's own marriage ended in divorce, and in the opening scene, we got a glimpse of the fact that his new relationship is strained. And boundaries--this show is always about boundaries! Nothing quite like having the son prescribe psychotropics for the house plant.

ClinkShrink: Run for the Hills!

In Treatment is back. Starts tonight. Stay tuned.

Saturday, October 23, 2010

What I Learned: Part 3

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 2, click here.

The first talk of the day was a discussion of SB1070, the Arizona law which required police officers to verify the citizenship status of anyone suspected of being an illegal alien. I learned that there were several parts to the law and that some parts were under injunction and were working their way through legal challenges. An immigration attorney talked about the ambiguity of the law and how it could be misapplied. For example, one provision barred anyone from picking up day laborers. In theory, it could be used against emergency medical personnel who transported illegal aliens. He also talked about the problems faced by mentally ill illegals who were deported to Mexico where they had no family support or access to mental health services.

I was planning to go the session about fMRI's in court, but I ended up getting invited on a trip to Tupac, AZ. Very cool little place with nice shops. Incidentally, Tupac is just past the Titan Missile Museum. I didn't go tour the museum because it creeped me out a bit but you can see a short video of the place on their web site.

I got back for the afternoon sessions. Dr. Ezra Griffith gave the Isaac Ray lecture entitled "Identity, Representation, and Oral Performance in Forensic Psychiary." I could never give it justice in a short summary. Fortunately you can read the full text of his talk here, because AAPL continues to be one of the few organizations that still keeps it's articles open to the public for free. Griffith talked about the role of perfomance in expert testimony. While most people would think of this solely in terms of communication skills, he put testimony in the context of the performing arts or literary narrative. The telling of the crime "story" is like drama, with behavioral elements and a physical context (the court room). The expert's purpose is to develop the facts as one would a character, so that the listener can hear the facts in a coherent way and is able to infer a line of understanding about the case. The jury then chooses between two competing narratives, the defense and the prosecution. Read the paper, Ezra explains it much better than I can.

The last session was about privacy in forensic psychiatry. I tweeted the highlights until my data coverage gave out. There was a lot of discussion about the "evils" of social media and the Internet, and how it could be used against you. There was no mention of any potential utility of Facebook, Twitter, blogs, etc. which I found highly ironic. Here I am using these same tools to (hopefully) provide a little public education while the speaker was cautioning the audience against them. The second speaker gave a great presentation about patient privacy rights in the emergency department. He presented literature that psychiatric patients get disrobed and searched in the emergency department twice as often as medical patients, although both patients are equally likely to bring weapons into the department (about 14% of all ED patients are found with weapons). Finally, there was an interesting talk about DNA privacy, legal cases challenging mandated DNA sampling (eg. sex offenders and violent offenders) and potential future misuse of current DNA samples. There have been two recent lawsuits challenging how hospitals store and use newborn blood samples drawn for routine disease screening. Read the details here.

So that's the end of day three. There is one more morning session tomorrow, but I may or may not have time to blog afterward. Hope you enjoyed this.

PS The support duck did not go to Tupac.

Friday, October 22, 2010

What I Learned: Part 2

Continued coverage of the American Academy of Psychiatry and Law (AAPL) conference. For Part 1, click here.

Day Two began with a section on PTSD as a criminal defense in military criminal cases. There was a presentation of a murder case committed by several military personnel in Iraq, followed by a discussion of the uniform code of military justice (UCMJ) rules of criminal procedure. The limitations of PTSD as a diagnosis was discussed, specifically the fact that many symptoms of PTSD overlap with other psychiatric diagnoses and that some people meet symptom criteria for PTSD without ever being exposed to a traumatic event. In 2008, 2.9 million veterans were receiving compensation for PTSD.

In criminal cases, defendants can claim self-defense if they have a reasonable belief that they are in imminent danger of serious bodily injury or death, if the force used in self-defense was reasonable, if the defendant was not the aggressor and if the defendant had no opportunity to retreat. Problems happen when the defendant reasonably believes he is in danger, but there is no objective evidence of imminence. (Eg. battered spouse syndrome and "burning bed" cases: a woman believes she is in danger and pre-meditates violence in self defense.) Soldiers with exposure to traumatic events may base a PTSD defense on a reasonable belief of danger, in the absence of imminence. Although the term "battered soldier syndrome" is not actually used in these military cases, they are clearly drawing an analogy.

As an aside, the UCMJ is interesting in that in courts martial, the military panel (analagous to a jury) decides guilt and also passes sentence. Judges have no role in sentencing. Also, there is no option for bail at the pretrial stage. Defendants have a right to a trial within 120 days, which is not much time to prepare a case for a felony offense.

In a presentation about zolpidem (Ambien) I learned that there were 22 criminal cases at the appellate level in which this medication was used as a defense. Ten were driving cases, seven were violent offenses. Zolpidem has been associated with sleep disordered behavior when combined with an SSRI. There have been 16 cases reports of zolpidem causing improvement in a chronic vegetative state.

There was a fascinating talk about tasers given by a guy from Utah. Apparently tasers have a USB data port that is used to gather stored information about when the taser was used and how many tasing cycles were triggered on a defendant. The presenter collected data from many police departments around the country regarding taser use and the nature of the defendant. He found out that in two-thirds of the cases the taser is never actually fired---merely pointing the taser at a defendant is enough to cause the defendant to surrender. When a taser is used, 82.2% of people required a single cycle. The majority of the cases in which a taser was used was on a defendant who was mentally ill and/or intoxicated. According to 1999 Justice Department data, only 2.1% of arrests actually require the use of a police weapon.

I went to the forensic sciences lecture, which is usually my favorite presentation. The American Academy of Forensic Sciences is a companion organization to AAPL and some of our members are shared between the two organizations. Anyway, this year's presentation was about computer crime. Sadly, it was bad. While the investigator was a good speaker, he didn't say much of anything about the techniques of how computer crime is actually investigated. There was no case presentation. The only crime discussed was online child pornography. The mental health professional talked about child porn users, but made at least three pretty outrageous anti-feminist statements. (Eg. women who made late accusations of child sexual abuse had been 'brainwashed by the feminist movement.') A female forensic psychiatrist audibly blurted out "that's bullshit!" and I could hear the silent dropping of jaws. The most enjoyable part of this talk was when the computer investigator had trouble getting the audience survey system to work.

Lastly, I went to a talk about a survey given to 492 members of the South Carolina bar. 83% of the lawyers said they felt their law school training about mental health law was inadequate. Two-thirds had personal or close experience with mental illness. Judges were the least knowledgable about mental health law compared to public defenders, private attorneys and prosecutors.

Tidbits from the poster session:
  • 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.
  • One poster studied inpatient threats in a state hospital over one year. Only one-quarter of the threats were deemed credible by the treatment team, and only one-half of these threats were thought to meet criteria to carry out a Tarasoff warning.
  • There was an interesting review of the Maurice Clemmons case in which public information was used to assess his risk of violence. I blogged about the case here, and provided links to the published clemency materials. Using two violence risk assessment instruments, the poster found Clemmons to be a high risk offender. Easy to say based on his history, but of course the limitation of static risk assessment instruments is that your base risk never lowers. You can get worse, but never better.
  • A national household survey of substance abuse, done annually with tens of thousands of people, showed that 3.8% off all women had used methamphetamine at least twice in the past year. Female meth users were more likely than users of other substances to be involved with the law, but not necessarily for violent offenses.
  • Two states automatically drop misdemeanor charges against incompetent defendants, as required by their statutes.
  • One study found no correlation between a history of childhood sexual abuse and being a perpetrator or victim of inpatient violence.
  • Prisoners over the age of 65 are twice as likely to have at least one chronic medical condition compared to an age-matched sample in free society.
  • Medical students from UCSD who rotate in a jail for their psychiatry experience consistently rate this rotation as their favorite. One quote from the medical student survey stated: "I love jail!"


This is the poster that won my heart. We've discussed this on the blog and we mention it in the book. Now, the "official" word. A poster entitled "Noah's Ark: A Forensic Review of Service Animals in Psychiatric Settings" provided an overview of ADA requirements for service animals in hospitals and clinics. In addition to guide dogs for the blind, other service animal cases involved monkeys, chimpanzees, miniature horses and parrots. Animals may be excluded from operating rooms but not any other general treatment setting. Potential for infection cannot be used to exclude animals, nor can mere concern about safety separate from an actual safety-related incident. Animals have to be able to meet minimal expectations for cleanliness, orderliness, nonaggression and "unnecessary vocalization". The sole determinant of whether an animal is a service animal versus a pet is the patient's declaration: a health care facility cannot demand documentation that an animal is certified or trained as a service animal. Finally, there have been cases of fraudulent service animals: people who put homemade "vests" on their animals and falsely identified them as a service animal. In California this is a crime punishable by six months of incarceration and a thousand dollar fine. I'm not sure how you'd get a vest on a fake service parrot.

So there you have it. I'm bringing my duck to the next session.

Thursday, October 21, 2010

What I Learned: Part 1

For new readers, it's my tradition to put up posts summarizing tidbits I picked up at the annual American Academy of Psychiatry and Law (AAPL) conference. It's random, it's not explained in detail, but it's stuff I thought was interesting.

The conference started out with a keynote speech by AAPL President Stephen Billick. The title of his talk was "Be True To Psychiatry". His point was that forensic psychiatrists are clinicians first, and that even a forensic evaluation can have therapeutic effects. He cited many examples in his practice in which a criminal or civil evaluation had potential beneficial "side effects" regardless of the forensic opinion. His main point: the forensic psychiatrist's obligation to be neutral and objective does not preclude kindness. A point well taken, and appreciated.

A session on suicide risk assessment gave a very nice illustration of the basic problem inherent in these assessments: even assuming an "ideal" case situation with a "perfect" psychiatrist, a thorough suicide risk assessment would take four hours. Risk assessment is time consuming and inherently will be incomplete. We make the best decisions we can based on the limited data we have at the time. A malpractice defense attorney talked about inpatient suicides: he was shocked when he realized in the course of his practice that many doctors didn't know that most inpatient deaths occured by hanging. They do. About 1500 deaths per year, in fact. Seventy percent of suicide deaths take place in the patient's bedroom, bathroom or closet. One-third happen while the patient is on fifteen minute checks.

There were a few themes to today's conference: conflicts of interest, maintenance of certification, and neuroimaging. The luncheon speaker was the best one I've ever heard at an AAPL conference. Dr. Helen Mayberg has been doing neuroimaging studies for 25 years and was one of the creators of deep brain stimulation. She has testified in several death penalty cases regarding the limitations of inference in imaging, particularly in regard to forensic issues. She was balanced, impartial and scientifically impeccable. Notable quote: "Brain scans have no place in the court room." An afternoon session on "diffusion tensor imaging" and mild traumatic brain injury basically came to the same conclusion, albeit after an astoundingly incomprehensible explanation of "diffusion tensor imaging" technology.

There was a great overview of Munchausen's syndrome by proxy, including a summary of 38 family case studies in which a mother was convicted of MSBP. In this case series a third of the mother's had some health care training and 60% had previously had factitious disorder themselves. Ninety percent of the perpetrators did not admit their abuse even after conviction. Several factors were associated with a worse outcome for the child: reunification with the untreated mother, an absent father, and a history of MSBP abuse lasting over two years. If the child was abused by suffocation or poisoning, about a tenth of them eventually died two years after reunification. Siblings in these cases were also at significant risk of being victims of MSBP.

Another session I attended was a 15 year review of state and Federal case law regarding automatism defenses. An automatism defense is one in which the defendant alleges that a crime was due to some unconscious behavior, like sleepwalking or seizure. Without going into legalisms, I'll just say that states are divided on whether or not automatism is allowed as the basis of an insanity defense. It's clinically and legally complicated so I leave the details for a future blog post if I have the inclination to go into it. If you can't wait, there's a nice concise description here.

Finally, some interesting tidbits from the poster session:
  • There were two posters on forced meds for prisoners. One poster found a significant decrease in infractions and disciplinary problems for prisoners who were ordered to take meds against their will. Another poster found split results: some had fewer infractions, some had more. Infractions may be related to mental illness, but others are due to personality problems and involuntary meds may not touch this.
  • States are developing jail diversion programs for veterans, modeled after diversion programs for the mentally ill.
  • A study of suicides in New York's prison and jail system showed that 2/3rd's of completed suicides had no previous history of suicide attempts.
  • Dr. Paul Federoff and his colleagues had an interesting poster in which they found that increased LH and FSH levels correlated with violent and sexual recidivism. He had another poster session which described a nonprofit program that helped sex offenders transition back into the community. I'm always impressed by the quality of Canadian forensic research.
  • There are 5000 honors killings per year worldwide, and most are committed by fathers or brothers.
  • Mental health providers are not required to report threats against the President except for threats covered by state Tarasoff statutes.
  • Parasomnias sometimes result in violence, but this is rare. Most violence is from random thrashing movements, although there have been rare incidents of parasomnia-associated choking.
So that's it for today. Tomorrow's topics: murder in Iraq, AAPL interfacing with the American Medical Association and the American Psychiatric Association, the forensic sciences sampler (my favorite!! This year the topic is computer crime), and the "Zolpidem defense".

I'll be tweeting throughout the conference. The preliminary program is available here, and I'll consider requests about which sessions to attend.

Monday, October 18, 2010

Funny: At the Expense of Whom? Please vote

There's this funny thing about humor: it's not funny to everyone. I tend to like the unexpected, what's dry or witty or sarcastic. ClinkShrink, bless her Midwestern soul, likes puns. And Roy, well he still likes potty humor.

Jokes are often made at the expense of a group, and I don't understand a lot of ethnic, racial, put-down humor. That said, the other day I went to put up a post, and since I've recently written about how to find a psychiatrist, and what makes mental illness bad---both serious posts that took me a while---I thought I'd opt out and just went to youtube and searched for "psychiatry humor." Lazy, you say. Yup! But I listened to the audio of Psychiatry Hotline and I laughed out loud. Even though I hesitated for a moment, I posted it.

Two readers and Roy pointed out that this YouTube makes fun of people with mental illnesses. Does it? I had trouble seeing this as the same phenomena as your usual make-fun-of-a-group in a hurtful way type joke. For one thing, the "if you're a nymphomanic press...." was the part I laughed out loud at, and nymphomania is not a psychiatric diagnosis. Hypersexuality is a symptom of some disorders, but if I can't laugh at a nymphomania joke, maybe I should go home and learn to like bad puns. If you're co-dependent, have someone help you press 5. Ah, co-dependence is not a psychiatric diagnosis either, but a lay designation used to describe a constellation of behaviors in a way that some people find to be meaningful and helpful. The rest of the tape....okay, I admit, it pokes fun of people with illnesses. Somehow, I couldn't come to terms with this as being bad. I still own a Prozac mug and my friends comment when I serve them coffee in it---- is that bad? It certainly gets more of a reaction than a Lamisil mug would get.

Here is the thing though, something invaluable that I learned from Dr. Fox who taught us family therapy behind a one-way mirror : Insults and offenses are defined by those who are insulted or offended. If someone is injured, that's what counts and the offending party is left to recant. The reality isn't in "Oh, but you should find this funny" or "It's not offensive." The reality is that someone is offended and those feelings are valid. With that, I should take the post down. However-- and do forgive me, Dr. Fox--but it is hard to negotiate life (much less a blog with a duck mascot) if one tiptoes through afraid of insulting or offending any one of the 2,500 weekly unique visitors.

So I'm taking a vote. And I want to know if YOU are offended personally, not if this is potentially offensive to someone somewhere.

Here's the link if you want to listen again:

And here's the ballot:

Sunday, October 17, 2010

Pull & Pray - zDoggMD's Safe Sex Song

ZDoggMD's rapping video about safe sex is a beautiful example of how to grab the attention of your target audience using a medium and tone that they can get down with.

While you are on ZDogg's site, check out their first News Per Rectum podcast, Potty Mouth (punchline: "I gave a crap today"), about fecal transplants for pre-diabetes. Coincidentally, our first podcast also had the word "potty" in it (Podcasting Makes You Potty).

So, I gotta say... these guys are hilarious. Educational (sometimes marginally so) while being thoroughly entertaining and mildly offensive. Their production value is quite good, as well.

That being said, I don't expect us to follow in their vlogging footsteps.  But keep an eye on these guys.

Saturday, October 16, 2010

Shrink Rap: Grand Rounds is up on

This week's Grand Rounds is hosted by, their first time to host GR, and is dedicated to Dr Tom Ferguson, founder of and the Society for Participatory Medicine.

Wednesday, October 13, 2010

What Makes Mental Illness Bad?

So why is it that some people have a psychiatric disorder and they bounce back and it's not a big deal, while others struggle terribly? For the unlucky ones, mental illness defines them.

Here are some factors that affect how much impact psychiatric illness has in a person's life:
(Note to Roy: did I get the effect/affect thing right here?)

1) The severity of the symptoms.
Any way you dice it, mild-to-moderate anxiety can often be hidden and isn't as disruptive as an episode of psychosis with hallucinations and paranoid delusions.
Just to give an example.

2) The duration of the episodes.
So a chronic depression or severe obsessive compulsive disorder may be more disabling than a brief episode of psychosis.

3) The form of the symptoms.
Some symptoms are intrinsically more public than others, or more difficult to bounce back from. In terms of "Can I be a doctor if I have bipolar disorder?," one episode of walking around the hospital naked may be all it takes to get sent home.

Form and severity of symptoms, and the duration of the episodes, are likely to be intrinsic to the disease and not something the individual controls.

4) How responsive the illness is to treatments.
Some people have very severe symptoms that are very responsive to treatment.

5) External support systems: access to good care, chicken soup, and TLC. Job flexibility may enable some people to quietly take time off when the going gets rough. Understanding friends & family-- these are all good things.

6) Individual personality features that support good coping. This is vague and I just made it up, but it's the best I can do--- maybe 'resilience' is another term for it.

7) Individual special features which help a person compensate. So being extremely intelligent, or extremely efficient and diligent, or very charming and charismatic, may make everything else a bit easier.

8) Stress load. This is hard to say for all people--- many people really struggle when things go wrong, and not all people with psychiatric illnesses relapse under severe stress, but all things being equal, it's probably better to not have a lot of loss and stress in life if one is trying to cope well with mental illness.

9) Co-morbid substance abuse. People with psychiatric disorders and drug or alcohol addictions just don't do as well. Often, it's a toxic combination.

10) Co-morbid medical disorders.

11) A willingness to devote time, energy, money and resources to a healthy lifestyle.
(It can't hurt)

What'd I miss?

Sunday, October 10, 2010

Podcast Number 53: URAC? MY Rac? You're Sure?

Podcast Number 53: In Which We Teach Dinah How to Edit and Post the Podcasts

Roy and ClinkShrink are the tinkering Geeks, and finally, they are teaching Dinah to edit and post the podcasts. Roy has declared he'd rather poke his eyes out with a fork, but ClinkShrink has endless patience (and patients). Four minutes into the editing and Dinah said, "Wait, we've been talking for four minutes and we haven't said anything!" Clink responded, "Exactly." And so we ramble about the following:

  • We invite listeners to give an iTunes review and Roy longs for a Wikipedia entry for Shrink Rap.
and who can figure out if Dinah liked it or not? And where's the photo of the wife?

  • A brief mention of Koro, a delusion about shrinking genitals

  • Whether or not people like obnoxious TV doctors, and again we're back to talking about House (and Frazier, and Tony Soprano and Mad Men, and Apple TV.....)

  • M: The first movie ever made about a serial killer in 1931: ClinkShrink gives it two thumbs up.

  • URAC: An insurance accrediting company that Roy likes.

We're hoping to get on a more regular podcasting schedule! Thank you for listening.


This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from
Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Saturday, October 09, 2010

How To Find A Psychiatrist

Seems like a simple enough questions: How do you find a shrink?

It's not that easy to answer. There are all sorts of shrinks who do all sorts of things (therapy, not therapy, specific forms of therapy like psychoanalysis or CBT), and then there's the overriding insurance question. Not to mention location, location, location.

We've talked before about insurance, and if you haven't read Why Shrinks Don't Take Your Insurance, please do. It's a good place to start. In areas where shrinks are in short supply, often, they do take insurances and they only see patients for medication management. In areas where there are more docs and people have treatment options, they may split between those who do and don't take insurance. You should be aware that if a shrink doesn't take your insurance, you will likely still get reimbursed, but there may be a higher deductible, you'll need to mail in the form yourself, and there will be a long wait (and assorted hassles) for the money to come back. Some people are reimbursed very well, others or not. If your insurance is an HMO or has no out-of-network benefits, then a non-insurance doc will costs you the entire fee.

So start here:
--Does it matter if the shrink is in your insurance network?
If it does, and you live in an area where many shrinks don't participate with insurance, then call the insurance company and get names and numbers and do hope they aren't all dead or not-accepting patients.

--What kind of shrink? If the patient is under age 16-18, your best best is a child & adolescent psychiatrist. Be aware that many psychiatrists at academic centers run research projects and teach, and don't see many outpatients. That's not to say never---and most have a few patients, but they are often a bit harder to reach, especially when they are presenting at conferences or have grants dues, and may have difficult parking. So child, general adult, or is there some specialty need which may be very restrictive---for example treatment of sexual or eating disorders or psychoanalysis? For ClinkShrink, I will throw in that if you are looking for evaluation for a matter pertaining to the legal system, you may want to look specifically for a forensic psychiatrist.

--Finally: does it matter to you if the shrink does psychotherapy or are you fine seeing one person for therapy (if necessary) and another for meds? If it matters, you need to clarify this upfront.

Now you've got the big three questions. There are other obvious ones: parking is always a biggy, the setting may be a concern (is your ex-lover working in the same practice?), how difficult is it to get an appointment? How long do appointments last? If the first evaluation is routinely scheduled for under 50 minutes and you have a choice as to where you go: then go somewhere else. In an institution---jails, a substance abuse clinic, the medical unit of a hospital, an emergency room--- evaluations may be very brief, but in these settings your records may be available for review and the evaluation may have a very specific and limited purpose. But for a thoughtful, comprehensive evaluation before beginning on-going treatment, the usual is a minimum of 50 minutes and often 90-120 minutes. Some psychiatrists do their evaluation over several sessions.

Okay, so to start:
If you have no insurance and no money, your options are limited. The traditional place for treatment in this case is a local Community Mental Health Center or CMHC and the standard has been to have one per geographic catchment area. These clinics usually offer split care, there may be a wait, and you don't get to choose your shrink. They take Medicare and Medicaid, and they sometimes don't take private insurance. How do you find your CMHC (or OMHC)...I'm not really sure. Try Google, and then call any clinic in your area and have a heart-to-heart with the receptionist. He may be able to give you the number of the clinic that serves you.

There are other agencies that over care for the indigent. In Baltimore, HealthCare for the Homeless offers psychiatric treatment, and The Pro Bono Counseling Project will give referrals for free or discounted care from professionals in the community who have agreed to volunteer their time. Again, there's no choice in which shrink you get.

If you have insurance and want to stay in network: Call your insurance company for a list of names.

Aside from money concerns, here are the best ways to find a good shrink:

  • If you know someone who likes their doc, see that doc!
  • If you know someone who like their doc, but you can't see their doc, ask your friend to get some names from their doc, or call yourself.
  • Call your state psychiatric society and ask for a referral. If the office is located near where you live, the staff may well know some of the psychiatrists and you can ask for a nice one.
  • Ask your primary care doctor, they are used to making referrals.
  • Ask a Shrink. Ask any shrink---shrinks tend to know each if you can get one on the phone, they may give you names even if they can't see you. In our state, we have a shrink listserv, and people frequently post, "Does anyone know a psychiatrist in Timbuktu?" for a patient who is moving, a child of a patient, friend of a friend of a friend. As a rule, shrinks don't know what insurance networks other docs participate in.

  • Ask a doc, any doc. A random doc may not be able to help you, but they may. My favorite was the friend who asked me for a referral for a breast surgeon in another part of the state. Not something I'd know, but my neighbor the breast radiologist was able to give some names and so I was email-helpful. Between listservs, Facebook, email, etc...people can sometimes find names.

  • If you're a student, try the school's counseling/health center. They may also be able to suggest off-campus referrals.
What to ask on the phone (besides the obvious money issues):
It's fine to tell someone the one-sentence version of what you want help for and to ask if they are taking new patients. It's probably a burden to try to tell them your whole history.
It's fine to ask how long the evaluation is, how long a typical appointment is, and if the shrink sees people for therapy or just meds.

Wednesday, October 06, 2010

My Friend, My Shrink

I just finished reading Dr. Gary Small's book, The Naked Lady Who Stood on Her Head. I talked about it during our podcast, and maybe, someday, that podcast will be posted.*

In the final chapter of the book, Dr. Small talks about his mentor, friend, and father-figure who has been mentioned throughout the book. The mentor approaches him on the golf course, where they meet to talk, and says he needs psychotherapy and Gary is the man to do it. The author is surprised, hesitant, and a bit uncomfortable with the demand (it comes as more than a request). His wife likens it to the need for a plumber or a dentist, and Dr. Small takes on the task. The mentor calls all the shots: where the meetings will be, what pastry they will eat, the form of his payment. The author initially misses the diagnosis and uses this as an example of how one can be blinded.

So is it okay for a friend to treat a friend?

I was in an institution where the resounding feeling is that psychiatric disorders are medical diseases like any other: the patient should go where the care is best. Obviously, our institution gave the best care, and so there was no taboo about faculty being treated (or even hospitalized) within the department. This is not to say that everyone treated their friends, but people might not move their care as far away as one might imagine (and sometimes people treated their friends).

At the same time, the standard professional boundaries suggest that friends should not treat friends, and that such arrangements are not kosher, especially after the fact if the treatment is called in to question.

Dr. Small talks about a delay in diagnosis. He doesn't talk about the fact that the patient here is dictating the care in a way we generally don't view as being helpfu to patients-- even VIP patients-- or that the desire to please authority figures can be very powerful.

* Regarding the My Three Shrinks podcast: We've decided that I, the non-geek, should try to produce the podcasts for the near future. Roy said he'd rather stick a fork in his eye than teach me to do this. Clink is trying, but even the process of transferring the recordings to my computer has been rough, not to mention that our podcast programs don't sync. Soon... we hope.

Monday, October 04, 2010

I Have Bipolar Disorder. Can I be a Doctor?

Ah, one of our readers asked this.

It's one of those questions to which there is no real answer. Being a doctor takes a long time, it requires reliability, diligence, and a willingness to learn things you may not want to learn (organic chem anyone????) and do things you may not want to do. It requires endurance and passion. You need to be tolerant of many things: arrogant supervisors, irritable colleagues, sick people who may not be charming and who may, in their distress, be down-right nasty. You have to tolerate a militaristic order and be willing to work with a system that may be very difficult, wrong, and demand your obedience in ways that may be uncomfortable. Oh, I am so happy to no longer be a medical student or a resident in training.

So can you do it with bipolar disorder? Can you do it with diabetes? Can you do it with attention deficit problems? Can you do it if you're disorganized or ugly?

The question assumes there is one bipolar disorder, that for everyone it has the same course and the same prognosis. Some people have an episode a few times in a life, and between episodes, their mood is stable, their emotions gentle. Others cycle from one mood to another, feeling the whole bipolar thing most minutes of most days. Some patients with bipolar disorder are in and out of the hospital, behave in impulsive and criminal ways when ill, and can't hold any job. Some do fine with medications and therapy, while others have refractory conditions that defy the most creative of cocktails and the best of therapists, even with their total compliance. And some people become doctors and then get bipolar disorder.

So, maybe.

What do we think Kay Jamison would say?

Saturday, October 02, 2010

Guest Blogger Dr. Mitchell Newmark: The Relative Unimportance of Diagnosis in Psychiatry

Look, he came back! Guest blogger Mitchell Newmark, M.D. put on his armor and came to blog with us again.

The Relative Unimportance of Diagnosis in Psychiatry

As we will soon be witness to the emergence of DSM-V, the new rule book for psychiatric diagnosis, I am reminded of all the pitfalls of diagnosis in psychiatry. In other fields of medicine, diagnosis is based primarily on etiology, with objective findings, rather than on symptoms alone, as it is in psychiatry. When you go to your internist with stomach pain, there’s an endoscopy to look for ulcers, a sonogram to look for gall stones, a blood test to look for hepatitis. But in psychiatry, there is no CT scan to check for Bipolar Disorder, no blood test to assess if the patient has Schizophrenia, no spinal tap to check for Major Depression.

For the psychiatric community at large, diagnosis is important for many reasons. It helps doctors sort out patients so that clinical trials can be conducted on similar groups of patients. It enhances communication among psychiatrists when behavioral, affective and cognitive symptoms can be categorized. But for the individual patient, it is less useful. Some patients fit nicely into DSM categories, and others don’t. There are many patients who have unique combinations of symptoms across several diagnostic criteria. This leads to assigning multiple diagnoses, and confusing the treatment picture. Since diagnosis is based on symptomatology, treatment should also be based, more often than not, on symptoms, regardless of the “official diagnosis.” Latching on to a diagnosis may often limit the treatment options because medicines or psychotherapies designed to treat one disorder are considered inappropriate for treating another disorder. Flexibility is essential for coming up with the best treatment plan for an individual, especially those patients who do not fall neatly into a diagnostic box.

I am always happy to discuss diagnosis with patients, but even this can cause difficulties. For example, when I see a patient in their late teens or early twenties with protracted psychotic symptoms, not due to drug abuse or medical issues, and without the mood changes seen in depression or mania, I am asked “Is this schizophrenia?” According to the DSM, the answer is yes, but many patients recover from these episodes completely. The psychiatric answer is “this seemed like schizophrenia, but it must have been something else.” Meanwhile, the patient has had to cope with being labeled with a devastating diagnosis. I would prefer to answer, “these are the symptoms you have, so let’s treat them with the appropriate medicines. We may discover over time that you have schizophrenia, or an illness like schizophrenia, an illness that does not have a clear cut diagnosis, or this episode may resolve completely and indefinitely.” And that’s the truth.

Someday I may be able to send a patient for a PET scan and get a report back stating “Impression: Bipolar Disorder, Type !!.” By then the DSM will be a thing of the past.