What Doesn't Kill You Makes You Stronger

I wanted to share this with you -- I thought you might find Act 3 interesting.  It's about a woman with life-threatening OCD.  Act 3 starts just after the 36 minute point and lasts for about 15 minutes.

Doggy Genes and OCD

The timing couldn't be more perfect for an article in the New York Times on the genetics of compulsive behaviors in poochies.

In Scientists Find a Shared Gene in Dogs with Compulsive Behavior, Mark Derr talks about the work of Dr. Nicholas Dodman on doberman's who compulsively suck their flanks (hmm, what exactly does that mean?) and a genetic link:

Dr. Dodman and his collaborators searched for a genetic source for this behavior by scanning and comparing the genomes of 94 Doberman pinschers that sucked their flanks, sucked on blankets or engaged in both behaviors with those of 73 Dobermans that did neither. They also studied the pedigrees of all the dogs for complex patterns of inheritance. The researchers identified a spot on canine chromosome 7 that contains the gene CDH2 (Cadherin 2), which showed variation in the genetic code when the sucking and nonsucking dogs were compared.

Should ClinkShrink be worried? Might she adopt a dog with a psychiatric disorder? Should her would be pup have genetic testing? Derr goes on to write:

Recent rough estimates by Dr. Karen L. Overall, a veterinarian specializing in animal behavior at the University of Pennsylvania School of Medicine, suggest that up to 8 percent of dogs in America — five million to six million animals — exhibit compulsive behaviors, like fence-running, pacing, spinning, tail-chasing, snapping at imaginary flies, licking, chewing, barking and staring. Males with the problem outnumber females three to one in dogs, she found, whereas in cats the ratio is reversed.

Ah, but it's not just the poochies with this problem: other critters have compulsive behaviors, and treatment is available. Mr. Derr tells us:

Other domestic animals, notably cats and horses, as well as some of the animals at zoos, exhibit compulsive behaviors, including wool-sucking in Siamese cats, and locomotion disorders like stall walking and weaving in confined horses and pacing in captive polar bears, tigers and other carnivores used to ranging across large territories.

Although antidepressants, particularly selective serotonin reuptake inhibitors and clomipramine, a tricyclic antidepressant, and behavior modification have proved effective at controlling compulsive behavior in dogs and people, they do not appear to correct underlying pathologies or causes, Dr. Ginns said. Those causes are likely to be as varied as the compulsive behaviors and as complex as the interplay of multiple genes and the environment.

Surgery for OCD?

Benedict Carey writes about surgical treatments for obsessive compulsive disorder in yesterday's New York Times in "Surgery for Mental Ills Offers both Hope and Risks,"

In one procedure, called a cingulotomy, doctors drill into the skull and thread wires into an area called the anterior cingulate. There they pinpoint and destroy pinches of tissue that lie along a circuit in each hemisphere that connects deeper, emotional centers of the brain to areas of the frontal cortex, where conscious planning is centered.

This circuit appears to be hyperactive in people with severe O.C.D., and imaging studies suggest that the surgery quiets that activity. In another operation, called a capsulotomy, surgeons go deeper, into an area called the internal capsule, and burn out spots in a circuit also thought to be overactive.

An altogether different approach is called deep brain stimulation, or D.B.S., in which surgeons sink wires into the brain but leave them in place. A pacemaker-like device sends a current to the electrodes, apparently interfering with circuits thought to be hyperactive in people with obsessive-compulsive disorder (and also those with severe depression). The current can be turned up, down or off, so deep brain stimulation is adjustable and, to some extent, reversible.

In yet another technique, doctors place the patient in an M.R.I.-like machine that sends beams of radiation into the skull. The beams pass through the brain without causing damage, except at the point where they converge. There they burn out spots of tissue from O.C.D.-related circuits, with similar effects as the other operations.

Carey goes on to talk about the rigorous screening, the risks of surgery, and tells stories of both good and bad outcomes.

Clutter Free Reality TV and My Fantasies.

Patients have been talking about a TV show I'd never heard of: Clean House.
It's a reality TV show where they come in and help the clutter bugs get rid of their stuff. I've never watched it (obviously). This is entertainment? My patients say they watch it then go throw some of their stuff out. Entertaining and therapeutic. It's funny (as in kind-of-ironic, not ha ha), but people spend a lot of time in therapy talking about their clutter and the piles of paper they can't part with. I suggest bonfires, but hey.

So I started thinking about this whole reality TV show concept, and the fact that I'm writing about psychotherapy (now done with 2500 words of What Is Psychotherapy). I had this fantasy about having a real life therapy podcast. Roy once talked about how there was bound to be a reality therapy TV show. Couldn't I do a start-to-finish psychotherapy podcast and put it on iTunes? I've got the microphones, and I could probably get Roy to teach me how to use all these gadgets. It might be interesting, it might be something people could use to teach (Gosh, that therapist says dumb things!) or it could be really boring. How does one logistically recruit a patient for such thing? Is it ethical (hmmm...) to offer free psychotherapy in exchange for allowing it to be broadcast on the internet? Could anyone relax and be themselves? What if it got up close and personal and the patient wanted out? Obviously, you stop, but then what becomes of the therapy? Funny, they didn't deal with these issues in medical school.

Okay, it's not happening. It was just a fantasy. I'm going to clean out my closet now. For real.

Here's When You Need A Psychiatrist

Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

• When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
• Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
• For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
• Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
• When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
• Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
• Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
• Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
• If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
• Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.

Sorry, a little haphazard, maybe Roy can come in and add an addendum....

Nine Months And Counting....And Counting...

I started this post as an email to Midwife With A Knife to help her with her talk about perinatal psychiatric issues. It got long enough that I decided to turn it into a blog post instead. I see Dinah is also working on her part of MWAK's homework and it's a good one. Here goes.

Last November I went to an excellent CME lecture on perinatal OCD. I thought this would be a nice change from the usual maternity-associated illnesses like post-partum depression and psychosis.

First of all, obessive-compulsive disorder is an anxiety disorder characterized by obsessions or compulsions that are time consuming or interfere with social or occupational functioning.

Obessions are anxiety-producing thoughts, impulses or images that are excessive and beyond the range of normal worry about real-life problems. Sufferers usually recognize that they are irrational, and often try to ignore or suppress them. The most common types of obsessions are contamination obsessions followed by obsessions about aggression or the need for exactness.

Compulsions are urges to perform repetitive behaviors or mental acts. They usually happen in response to obsessions and are aimed at reducing distress or preventing some unpleasant event. The most common types of compulsions are checking rituals followed by cleaning or washing. There can also be mental compulsions (repeating words or numbers, counting or reciting prayers.)

The prevalence of OCD is about 1 in 50 people (2.3% of adults). The gender ratio is 1:1 male/female. The prevalence of perinatal OCD is 0.2 to 3.7%. Eighteen percent of new cases occur during the postpartum and 6% during pregnancy. Most women with pre-existing OCD have no change in symptoms with pregnancy, but one-third may have worsening or a change in symptom presentation.

The types of obsessions in perinatal OCD are different than in non-postpartum OCD. Postpartum obsessions are more likely to involve contamination fears or fears of violence (eg. intrusive thoughts to poke the baby's "soft spot", putting the baby in the microwave) than non-postpartum OCD. Patterns of compulsions are also different---postpartum OCD is more likely to involve checking, washing and cleaning rituals. Some OCD patients have been known to call their daycare multiple times a day to neutralize their obsessions.

About half of women with post-partum depression have co-existing OCD, but the OCD is less likely to be diagnosed because of patient concealment and embarrassment. And yes, fathers can get it too.

Treatment usually involves cognitive-behavioral therapy sometimes combined with medication. For the Ob-Gyn crowd, this would be the time to refer. Dinah is writing a good post about meds in the peripartum, so I'll leave that to her.

Hope this helps.

My Three Shrinks 5: Sex, Lies, and Neuroeconomics

[4] . . . [5] . . . [6] . . . [All]

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Today's podcast is brought to you by the letter "M" and the number "5".

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January 9, 2007:
Topics include:

• New Yorker Magazine (Sep 18, 2006): Mind Games: What Neuroeconomics tells us about money and the brain, by John Cassidy. The neuroanatomy and functional connectivity that lies behind our economic decisions and risk aversion. As measured by functional MRI imaging (fMRI), the constant tug-of-war between the orbitofront al lobe, the amygdala, and the insular cortex mediates everyday economic decisions. Related links include the Neuroscience Marketing blog, New York University's Center for Brain Imaging, Google "neuroeconomics", and the Omnibrain blog (one of our favorites).
• Book "Paving Wall Street: Experimental Economics and the Quest for the Perfect Market", by Dinah's brother, Ross.
• Dinah refers back to a Shrink Rap post on compulsive blogging and to another one on a combination Wellbutrin (bupropion)/Revia (naltrexone) pill called Contrave for weight loss.
• The Interview Room, a novel by forensic psychiatrist Roderick Anscombe, provides insight into how the brain betrays people's lies. His website provides 14 tips on how to spot the liar (very interesting reading).
• Washington Post (Oct 30, 2006): Using fMRI machines to detect lies. See also website for No Lie MRI.
• Be nice to Dinah, who had a bad day.
• Clink's Favorite Podcasts: BusinessWeek, NPR, State Department Press Briefings, Slash Dot Review, Byzantine Emperors.
  
• Roy's Favorite Podcasts: Comic Strip Live, FLOSS Weekly, Futures in Biotech, Inside the Net (now http://www.twit.tv/ITN), NEJM, This Week in Tech (TWiT).
  
• Dinah's Favorite Podcasts: "Umm, why would I want to listen to podcasts, anyway?"

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Find show notes with links at:
iTunes. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

technorati tags:psychiatrists, psychiatry, blog, podcast, psychology, neuroeconomics, fMRI, MRI, brain, scan, lies

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My Three Shrinks Podcast 2: Roots

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We'd like to thank our readers and listeners for your kind comments and suggestions about our first podcast. This one's a bit longer, at about 33 minutes. I think we'll get better about the time. About 20 minutes seems to be a good balance.

This is actually the second half of the original podcast, which went long so we sliced it into two podcasts. Don't expect to get a podcast every other day... if we do one every other week, I'll be pleasantly surprised (though I'm striving for every Sunday). Maybe we can be like Digg's Kevin Rose and Alex Albrecht and drink alcohol at the beginning of each podcast... that would be interesting.
Here are the show notes for the podcast:

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December 10, 2006: Roots

Topics include:

• Dr Anonymous is again not mentioned in this podcast (but we do thank him for the idea about the musical bumpers between topics)
• Thorazine Immunity: Clink reviews a 1992 case in which a prisoner sued the on-call psychiatrist for involuntarily medicating him with chlorpromazine due to violent, self-injurious behavior... but without going through any hearing panels for forced meds [Federal Code: Civil action for deprivation of rights]
  
• Dinah brings a duck to the "Shrink Rap Studio" (my kitchen table)
• FDA hearing on December 13 about adding a black boxed warning on antidepressant labels about the possibility of increased suicidality in adults: Will this reduce access to these drugs, causing undertreatment of depression and actually INCREASE suicide rates? (Check here for background materials)
• Recent PubMed articles and Corpus Callosum post about this whole antidepressants and suicide issue. Also, Dinah mentioned this, hot-off-the-press, Finnish article, showing an increase risk of attempts and a decreased risk of deaths.
  
• Treatment of social phobia [PubMed]
• Social phobia and alcohol [PubMed]
• Paxil- and other SSRI-related withdrawal symptoms [PubMed]
• Sexual dysfunction and SSRIs [PubMed]
• Putting roots on someone
• Psilocybin mushrooms for Monk's OCD
• Maryland psychologists discuss adoptions in gay marriages
• NYT: Gender dysphoric children
  

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This podcast is available on iTunes. You can also download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

technorati tags:thorazine, podcast, shrinkrap, civil, rights, duck, SSRI, antidepressants, suicide, depression, black, box, FDA, hearing, Paxil, Prozac, gay, marriage, adoption, gender, psychologist, psychiatrist, psychiatry, blog

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Mushrooms for Monk?

The most recent Journal of Clinical Psychiatry has an article about using the active ingredient in psilocybin mushrooms (which is a potent specific serotonin receptor agonist) to treat OCD. I wonder if anyone knows of folks with OCD who have tried LSD or other hallucinogens. The study suggests that, whereas traditional medications for OCD may take 3 months to work, this drug worked same day, and its effects lasted beyond 24 hours.

Roy: Blogs on a Plane

[Dinah, insert appropriate pic here. Roy: Done.]
I spent 5 hours on a plane Tuesday flying out to San Diego for a meeting (Foo, if you wanna meet up, holler) and killed some time writing this. BTW, I’ve discovered I can really extend my battery life by turning off the MacBook display and just typing, fixing all the typos when I’m juiced up (well, you know what I mean).

I read something in today’s (Tue) Washington Post about a study that demonstrated that thinking about past bad deeds, like shoplifting or cheating, increases one’s thoughts about washing your hands, brushing your teeth, and generally ridding your body of “dirtiness”. Think Lady Macbeth and “Out, damned spot.”

Makes me think of the tamest OCD symptoms one can have. This is a disease, mind you, where you have to compulsively perform an action to undo, or clean away, a particular thought. It’s not hard to imagine how this basic, apparently universal, urge to perform a cleaning task in response to some physical or mental soiling can be ramped up into an out-of-control illness. [Maybe describe the anatomy of OCD.]

Makes me wonder what Tom Foley is washing these days. (Or maybe certain college administrators, hmm?) I think this helps to explain why organizations tend to “cleanse” themselves of tainted individuals, rather than try to reform them, and why crisis management firms recommend that in these situations, the best thing to do is “come clean”, admit what happened, apologize, take responsibility for it, vow to make amends, and not do it again. It allows observers to “see” that one has cleansed themselves, so that they may now be more acceptable.

The article pointed to evolutionary benefits to avoiding poisonous, spoiled, or otherwise tainted, foods, places, and people. I wonder if our elected officials have showers in their offices. I can think of a few who probably need full-fledged decontamination chambers.

Link to Roy's reference in Washington Post article: http://www.washingtonpost.com/wp-dyn/content/article/2006/10/06/AR2006100601230.html (compliments of dinah)