Falling: Faces of Depression and Anxiety (by Clara Lieu)

Clara Lieu is an artist at Rhode Island School of Design.

She has this amazing gift of observation. For example, she has this series on her website (claralieu.com) called Waiting. Here is how she describes it.

I am interested in the contradictions found in waiting figures: even though these figures stand in very close physical proximity to each other, it seems apparent that there is a significant emotional distance between them. Each figure seems locked within their own existence, unaware and unresponsive to the other figures surrounding them. Yet simultaneously, waiting in a line creates a situation where the gesture of one figure leads directly to the next, creating a fluidity between all of the figures. I am engaged by the individual and group anxiety that seems to permeate such silent and still scenes.

So true. My first iPhone line was like that.



She also completed a very impressive series of drawings and sculptures called Falling. This series, unlike her others, are very personal, based on her own experience with depression.

She emailed My Three Shrinks to let us know about her work. I was so impressed that I asked her more about herself and the motivation to show such an intimate view of her anguish.

I developed depression and anxiety at a young age, and lived with the condition for most of my life before being diagnosed and treated just a few years ago. It was startling to see myself clearly for the first time, free from the disease. Only at that point did I have the emotional distance that allowed me to to be in position to address this subject artistically. I knew at that point that I felt an uncontrollable drive and compulsion to make the work.

"Falling" was an unusual project me for in that it was told from a very personal, intimate perspective unlike my previous projects, which approached the subject matter with an emotional distance. Depression is something that happens privately, behind closed doors; it's a secret that most people keep hidden and never talk about in public. Unfortunately here's still a social stigma associated with depression that causes people with depression to conceal their true emotions from others. On a broader level, I'm looking to open a dialogue about a topic that is rarely discussed openly by exposing my own personal experience. 

She goes on to describe this body of work:

"Falling" is a visualization of personal experience with depression and anxiety. The condition brought on frequent episodes where I felt emotionally and physically out of control. Unable to “release” myself from these episodes, I waited for the physical limitations of my body to end them. Recounting the affected years, I realize how accustomed I became to depression’s influence; many emotions and feelings belonged to it and not my own personality. After an extended, untreated struggle, a diagnosis brought relief, and the process of unearthing myself from the disease began. 

Her work can be found at claralieu.com.




Note: October 11 is National Depression Screening Day.       Get screened.

WhatsMyM3?

NBC-4 News Clip from Doreen Gentzler (May 16, 2012)

What’s your mental health number?

This is the question that the Bipolar Collaborative is asking, using its WhatsMyM3 screening tool [PubMed]. “Many other illnesses have a 'number' that one can track – cholesterol, high blood pressure, diabetes. What’s the number for mental health?” asks Michael Byer, president of M3 Information, based in Bethesda, Md.

~from Clinical Psychiatry News

Today's USA Today newspaper ran a story titled, "Screening for mental illness? Yes, there's an app for that," by Michelle Healy.


WhatsMyM3 is a validated, 3-minute tool that screens for symptoms of depression, bipolar disorder, PTSD, and anxiety, and can be used to monitor changes in symptom severity over time.

One of the developers, Michael Byer, approached me about a year ago for my opinions on development and use of the screening tool. Disclosure: After reviewing the research and seeing how useful it is, I have become more involved in the organization, becoming an adviser to the group that was started nearly ten years ago by past NIMH chief, Robert Post MD. (listen to podcast #63)

It differs from other mental health screening tools, such as the PHQ-9 and the MDQ, in that these are all unidimensional -- they only measure one domain of symptoms. The M3 is multidimensional, measuring four areas of symptoms. Furthermore, when compared to results from the standardized interview tool, the Mini International Neuropsychiatric Interview (the MINI measures for 15 different mental illness diagnoses), WhatsMyM3 provides a total mental health score that is 83% sensitive in finding true positives and 76% specific in finding true negatives. In addition to the total score, there are four subscores, one each for depression, bipolar, PTSD, and anxiety.

Put another way, the negative predictive value of the total score is 89%, meaning that if you score under the threshold, there is an 89% chance that you do not have any mental health diagnosis by the MINI. As with most screening tests, you want the negative predictive value to be high so that you don't have to subject the "negatives" to more specific testing. The positive predictive value, or PPV, is generally lower for screening tests. It is 65% for WhatsMyM3, meaning that if you score positive (total score >= 33 and positive for functional impairment), the odds of you having a diagnosis is almost two-thirds. A clinical evaluation can then help to determine if you do have a diagnosis. (Note: this tool cannot give you a diagnosis; it can only describe your relative risk of having, or not, a diagnosis.)

What people have found to be most helpful is using WhatsMyM3 to monitor their symptoms over time once they do have a diagnosis. This can be done for free on the website, or for $2.99 using the iPad or iPhone apps, or the Android app. For mental health clinicians, they can download the free M3Clinician iPad app and then screen their own patients. For about a dollar per screen, they can register their patients who want to track their symptoms over time and share their scores with the clinician. Primary care providers also purchase screens, and can even obtain insurance reimbursement by billing for an annual health risk assessment. The patient reports can be viewed by logging into m3clinician.com.

A sample report for a fake patient can be viewed here.

I think this sort of tool, or app, is exactly the sort of mHealth thing that empowers consumers to better manage and become engaged in their health care needs. This is happening in other areas, like diabetes, heart disease, and obesity. Mental health is also making great strides in mHealth.

---

I should also point out here that the folks at M3 Information were the only ones to take us up on our offer of a free "advertisement" on Shrink Rap in return for donating at least $200 to our NAMIWalk for Mental Health Month (we don't typically accept display ads). A logo ad will be running soon on Shrink Rap soon for two weeks in recognition of their charitable donations. It will look like this and link to the iPhone and Droid apps. [We received no money ourselves from M3 nor from NAMI. We've never accepted any money from Pharma companies, nor does M3.]

Neurotic

Benedict Carey has a good read in last week's New York Times about the gradual disappearance of the Freudian term "neurotic," as in "The neurotic is always half-drowning in anxiety, and always being half-rescued." (Mignon McLaughlin, The Neurotic's Notebook, 1960).

Carey's analysis reviews the history of this term, and explains how is was expelled from the DSM back in 1994. He quotes Michael First, MD, "With the general decline of value of Freud in our society, it is ultimately anachronistic." In fact, it made me realize that I almost never use this word. When I do hear it in a professional context, especially as a noun referring to a person, it is generally by someone a good 15 years my senior.

Psychiatrists don’t ultimately shape the language we use, after all — we all do — and neurosis has at least as much going for it as other Freudian keepers, like ego and id.

 And I never hear about, nor talk about, the id.

So, the story talks about how we used to put everything into the neurotic bucket, but have since split things up into multiple, more narrowly-defined, terms, such as social phobia, generalized anxiety disorder, and obsessive-compulsive disorder. These used to all fall under the neurotic label.

The good part about this change is that defining these types of anxiety disorders has led to improved treatments, and has allowed us to accept more common, less disabling, concerns as just a spectrum of normality. Carey points out, though, that our new technologies have turned many of us into unlabeled neurotics.

But another way to read those numbers is not as a measure of mental makeup but of cultural change. People of all ages today, and most especially young people, are awash in self-confession, not only in the reality-show of pop culture but in the increasingly public availability of almost every waking thought, through Facebook, Twitter and other social media.

If chronic Facebook or Twitter posting is not an exercise in neurosis, then nothing is.

Yet Another Entry for DSM-V: Nomophobia?

From The Indian Journal of Community Medicine, a study by Dixit, Shukla, et. al.


Nomophobia(1) literally means no mobile phobia that is the fear of being out of mobile phone contact. If a person is in an area of no network, has run out of balance or even worse run out of battery, the persons gets anxious, which adversely affects the concentration level of the person. In recent times there seems to have been a transformation of the cell phone from a status symbol to a necessity because of the countless perks that a mobile phone provides like personal diary, email dispatcher, calculator, video game player, camera and music player.(2) Indian market has emerged as the second-largest market after China for mobile phone handsets. Our study was undertaken to find out the prevalence of nomophobia in the Indian scenario considering the tremendous increase in the number of mobile phone users in the past decade. We decided to conduct the study in our college since the younger generation is the latest consumer of the mobile phones, and the under 25 year age group in professional colleges like medical colleges use mobile phones quite frequently since most of them reside in hostels. Day scholar students too want to be in constant touch with their family members and friends since they are out of their homes for the whole day and at nights while studying in colleges and working in hospitals.

The study goes on to say:


A study from United Kingdom on 2163 people revealed that 53% of the subjects tend to be anxious when they lose their mobile phone, run out of battery or credit or have no network coverage. The study found that about 58% of men and 48% of women suffer from the phobia, and an additional 9% feel stressed when their mobile phones are off. About 55% of those surveyed cited keeping in touch with friends or family as the main reason that they got anxious when they could not use their mobile phones.(1) A study conducted by Market Analysis and Consumer Research Organization (MACRO) in Mumbai to study the various patterns and association of mobile phone usage reported that 58% of the respondents could not manage without a mobile phone even for a day.(2)

The Opinionater on The Age of Anxiety

Before I start, two things: 1) if you'd like to hear our interview with Dan Rodricks on WYPR today, go here.  2) If you've ever been forcibly certified to a psychiatric unit and you haven't taken our poll yet, please do so here.  And now for our next post:
 
Over on the New York Times "Opinionator," Daniel Smith has an article called ""It's Still the Age of Anxiety.  Or is it?"  Smith talks about W.H. Auden's Pulitzer Prize winning1948  poem, The Age of Anxiety, (it's boring, he tells us, as well as 'illusive, allegorical and at times surreal') and he tells us about his own anxiety.   Smith writes,


From a sufferer’s perspective, anxiety is always and absolutely personal. It is an experience: a coloration in the way one thinks, feels and acts. It is a petty monster able to work such humdrum tricks as paralyzing you over your salad, convincing you that a choice between blue cheese and vinaigrette is as dire as that between life and death. When you are on intimate terms with something so monumentally subjective, it is hard to think in terms of epochs.

And yet it is undeniable that ours is an age in which an enormous and growing number of people suffer from anxiety. According to the National Institute of Mental Health, anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison, mood disorders — depression and bipolar illness, primarily — affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated. Last spring, the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug alprazolam — better known by its brand name, Xanax — was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010.

Just because our anxiety is heavily diagnosed and medicated, however, doesn’t mean that we are more anxious than our forebears. It might simply mean that we are better treated — that we are, as individuals and a culture, more cognizant of the mind’s tendency to spin out of control.

Smith concludes that it's not the world we live in, and that it's perhaps dangerous to make that assumption.  He notes, " If you start to believe that anxiety is a foregone conclusion — if you start to believe the hype about the times we live in — then you risk surrendering the battle before it’s begun."

What do you think?  Are we more anxious than we used to be?  And why is that?  Is it the world we live in--now or in 1948?  Or is it just our own personal psyches?   

Note, the graphic above is from a book by Andrea Tome. 

The Patient Who Didn't Like the Doc. On-Line.

KevinMD has a post up today by Tobin Arthur called

Online reputation can have career implications for physicians

Arthur also refers to a post on the AMA's website back in October by Amy Lynn Sorrel,

Negative online reviews leave doctors with little recourse

Good timing because I wanted to post a vignette about a friend who is distraught about the on-line reviews he's gotten from patients. To protect both the innocent and the guilty, I'm confabulating the details & demographics, but the gist of the story is real and I'd like to hear your comments.

Dr. Tom Shrinky (not his real name) is a friend of mine who practices in Sanetown, PA (not a real place). He's an excellent psychiatrist with a great reputation, a packed practice with a long wait for new patient entry, and he's as conscientious as they come: he carries his cell phone everywhere and he returns all calls within the day. Plus, he's a nice guy, though I may be biased because we're friends.

One day, a patient says to Dr. Shrinky, "Doc, you know, I Googled you, and it wasn't pretty." Alarmed, Tom goes to Google himself and discovers that he's got a patient review up on one of these rate-your-doc sites. The comments are strangely personal, they comment on his recent weight loss, and say that he's in bed with the drug companies. There are a couple of other reviews, all 5 star, all saying how he's the best shrink in the world, but his overall rating is 3 star, and you'd wonder if he wasn't dying from the comment.

Okay, you hate a restaurant, you zing it on Yelp and you don't go back.

But Tom believes he knows who put these comments up. He has a patient, a lawyer he sees for weekly psychotherapy sessions. The patient is often hostile towards him, often treats him in a demeaning fashion, and this relationship does not feel good. The patient left treatment once briefly, years ago, but returned because, "You shrinks are all nuts and you're better than Dr. Cashew." Why Tom took him back, I'll never know. Tom tries to get the patient to focus on his hostility as part of the treatment.

So, a drug rep did stop by the office once to drop off samples while the patient was in the waiting room, and the patient had made a comment about this. And Tom had lost a lot of weight recently-- he'd taken up running and before he knew it, he was doing half-marathons. He cut back on carbs, beer and soda, and 60 pounds had dropped off him over 14 months. He looked great, and everyone commented including his patients. This particular patient, however, had said nothing, and one day walked in, looked Tom up and down, and said, "Have you got cancer or AIDS?" So the comment on the review about how he'd lost a lot of weight recently and looked like he had cancer. Tom could think of no one else who was unhappy with him or who would do this.

Unlike the restaurant patron, Tom's patient continues to show up weekly for psychotherapy. Tom feels a bit intimidated by him (this is not new) and is always happy when he cancels. So far, Tom hasn't asked if he wrote the review, but it bothers him. Others have put up counter-reviews, but there is a second bad review, and Tom thinks this is also the same patient. A colleague mentioned that a patient he tried to refer would not see him because of the reviews.

So, my thoughts, and then please do add yours:

--It seems to me that sometimes people have negative feelings in the course of a psychotherapy (ah, we might call this transference, but it would be dismissive to attribute all negative feedback to negative transference). In this case, it's no longer a doctor-patient issue, but one that has potentially included the entire world via the Internet.

--Should Tom ask his patient if he's put up the reviews? What does that get him? The patient may become embarrassed or defensive, or he may say he didn't do it (and maybe he didn't?) and be angry at the accusation.

--How does a psychiatrist (or any doctor) continue to treat someone who publicly struck at their reputation?

--And here's another problem for the doc--- a patient who would do this might also go to the physician licensing board and complain, and so Tom may worry that to terminate this patient's care may incite the patient's anger and result in a complaint and investigation of his practice. The patient is a credible professional and a complaint from him would likely be taken quite seriously. While Tom is certain he's provided responsible care and has not violated any standards of practice, he's well aware that a Board investigation (if a complaint did progress to that) takes years and causes a great deal of expense and agony, and so he may well be worried about fanning any flames.

--And finally, Tom is worried about upsetting the patient. He's been taking care of this patient for years, and he doesn't want this to end badly.

So what should Dr. Tom Shrinky do?

We're All Going To Die

I heard Irvin Yalom speak today. He's a psychiatrist/writer/ very famous shrink at Stanford, and he was at Johns Hopkins today to give the Jerome Frank lecture. The title of his talk was "Staring at The Sun: Overcoming the Terror of Death." It's also the title of his latest book. The auditorium was packed---no surprise here. When I heard Dr. Yalom was coming, maybe a month ago, I made a point to block off the time to be there-- I've never heard him speak and I was looking forward to this. Please let me share the experience with you.

Dr. Yalom is a gifted writer. He writes about his work in colorful and accessible ways, and he speaks about it this way as well. He lectures an audience of hundreds as though he is talking to a single friend. No notes, no hesitation, and he seems so at ease as he talks openly about work that is quite intimate. His specialties are group psychotherapy and existential psychotherapy, and he classifies the existential issues as death, isolation, freedom (as in freedom to make decisions and to steer the course of one's life, not political freedom), and meaning. "We are unfortunately meaning-seeking creatures heralded into a universe that has no meaning." Now he tells me!

Dr. Yalom started by talking about Dr. Jerome Frank (for whom the lecture is titled)--one of his mentors --and talked about a poignant visit with him near the end of Dr. Frank's life. Dr. Frank was also one of my psychotherapy supervisors, perhaps at a time in my training when I took such things for granted and had no true appreciation of what an amazing gift it was to be his student. Dr. Yalom talked about his memories, and I revisited my own.

Dr. Yalom talked about his own psychotherapy experiences: his three years in psychoanalysis in Baltimore "There was so much attention to the distant past and so little to the future and our death." Later in life, in California, he spent two years in therapy with Rollo May.

Death anxiety, Yalom contends, is an issue for many people--one patients won't necessarily bring up on their own, one they avoid if they sense the therapist is uncomfortable, one that, indeed, makes therapists uneasy as they, too, have their own death anxiety to face. Perhaps it's easier to avoid the topic; after all, there's nothing to do about it. We're all going to die. The therapist, he says, has a role in discussing death, and therapy can diminish the anxiety.

He talked a little about his work with cancer patients and how facing death can have a transforming effect; people get a better sense of priorities. "What a pity I had to wait until now to learn how to live," one dying patient told Dr. Yalom.

By far, the most interesting parts of the talk were when Yalom talked about specific examples of his own work with patients and the interactions that transpired. He talked about a patient--a psychotherapist--- who asked him about his own death anxiety (he responded) and who talked about his concerns about how Dr. Yalom might judge him. One nice thing about being Irvin Yalom is that you can get up in front of an audience of hundreds and talk openly about your work, boundary violations and all. He ended with the statement, "To become wise, you must listen to the wild dogs barking in your cellar." --a version of a quote by Nietzsche. I'm still thinking about that one.

It's been a while since I've heard a lecture like this. We've become so focused on psychiatry as the treatment of illnesses, of which drug at what dose, for how long, or which type of psychotherapy, and certainly we assume that what goes on in therapy includes talking about issues that having meaning to patients--including things that evoke anxiety, and the nuances of life that include meaning. We know we talk about these things behind closed doors--but we don't often talk about the process of such transactions.

Coming Soon: Understanding the Anxious Mind

This is for Meg who has an eye for Shrinkrappable stuff, and who is being our test reader for Off the Couch.

You read it hear first-- from next Sunday's New York Times Magazine in the October 4th magazine, Robin Marantz Henig will write ( or so my crystal ball says...) in "Understanding the Anxious Mind" about the work of psychologist Jeremy Kagan:


They have also shown that while temperament persists, the behavior associated with it doesn’t always. Kagan often talks about the three ways to identify an emotion: the physiological brain state, the way an individual describes the feeling and the behavior the feeling leads to. Not every brain state sparks the same subjective experience; one person might describe a hyperaroused brain in a negative way, as feeling anxious or tense, while another might enjoy the sensation and instead uses a positive word like “alert.” Nor does every brain state spark the same behavior: some might repress the bad feelings and act normally; others might withdraw. But while the behavior and the subjective experience associated with an emotion like anxiety might be in a person’s conscious control, physiology usually is not. This is what Kagan calls “the long shadow of temperament.”

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"

That's exactly why we're blogging and podcasting about this. Thank you.

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....

Carbonated Panic Attacks

Don't forget to read Dinah's post below: Click Here.

Panic attacks are an acute, dramatic form of anxiety, including symptoms of shortness of breath, lightheadedness, tingling sensation, and fear of impending doom. One of the theories about the biological basis of panic attacks is the false suffocation alarm theory proposed by Klein, which suggests that the brain's sensor that detects elevated carbon dioxide levels is overly sensitive in some people, triggering panic attacks for no clear reason.

Eric Griez, a psychiatrist from the Netherlands, has published an article in the open source, online journal PLOS One, demonstrating further evidence of this connection (see also review in Science Mag). He exposed volunteers without an anxiety disorder to high levels of carbon dioxide, thus triggering the suffocation alarm at appropriate levels of CO2.

"Sixty-four healthy subjects underwent a double inhalation of four mixtures containing respectively 0, 9, 17.5 and 35% CO₂ in compressed air, following a double blind, cross-over, randomized design. Affective responses were assessed according to DSM IV criteria for panic, using an Electronic Visual Analogue Scale and the Panic Symptom List. It was demonstrated that carbon dioxide challenges induced a dose dependent negative affect (p<0.0001).>

The top graph shows a dose-dependent increase in panic symptoms, while the bottom part shows that younger people (solid line) developed panic symptoms more easily than older people (dashed line), suggesting that perhaps the triggering mechanism becomes less sensitive over time.

This falls under the what's-old-becomes-new-again category, as I recall this area of research 15 years ago. Still, it may be worth stirring up again, especially if it leads to more effective and safer treatments. In fact, Klein and Preter just published an amplification of the original theory, including evidence of involvement of opioid receptors in the response to the alarm being triggered.

Anticipatory Anxiety

One doctor is back. Sort of. For the moment. And yes, I have coverage.

A week in Canada, all that free national health care, and the place is kind of pretty, too.

Talk about a room with a view:

Traveling with teenagers, though, you can't just Look at it, ya gotta DO something. Hiking led to some amazing views, a surprise waterfall, a tea house in the sky, even a rainbow, but was still deemed "boring," "pointless," and ultimately, "not worth it."




I decided we needed to go whitewater rafting on the Kicking Horse River. Note, this was my idea.

I've been rafting once before, decades ago in Montana during a draught when there was no whitewater to be had. We floated along scraping the bottom. And I've been on a canyon float trip, this isn't what my kids were looking for. So, credit card in hand, I signed us up for the non-refundable Classic-- all participants had to be over 12 years and over 90 pounds-- and the half-day trip provided a barbecue lunch (these I'm good at) and Class III and IV rapids. The other option was a shorter Family-friendly trip suitable for children over the age of 5. That one sounded nice. It sounded safe, too.

I asked the Concierge if I'd be okay.

"I don't like roller coasters," I said.

"Sit in the back of the raft," he told me. Everyone returns alive. I'd be fine.

Still, I worried. The next day I asked another concierge, a nice young man named Rory.

"Will I have a heart attack?" I asked.

"Yup," he said.

"What should I do?"

"Go on a different trip than the kids."

Gee, thanks Rory.

"You'll be fine, Mom," Kid said.

You know, I wasn't really worried about injuries or death. I don't like roller coasters and it's not that I think they're unsafe-- it's that I'm afraid I won't like the feel of my stomach being stuck inside my knees, or that I'll get sick, or terribly frightened, or that I'll want to get off really badly and I won't be able to. If safety were the issue, I would be worried about my family. No, I was worried about the possibility of Unpleasant Sensations.

We drove an hour and a half to the rafting place and went to sign in. I was handed a bunch of waivers to initial in three places and sign on the bottom. I promised not to sue if I died. Okay, now I was worried about safety.

"Does anyone get hurt?" I asked the young woman with the Australian accent who told us that a 45 minute safety session would precede the adventure.

"Well, yes. But, it's rare. It's not like someone gets hurt every week. It's not like someone even gets hurt twice a month."

This didn't sound so Rare to me.

"How hurt?" Scrapes, right?

"Oh, about as bad as it can get," she said.

My anxiety mounted. Maybe we shouldn't do this, I told my husband. My family glared at me.

The trip was delayed for hours. They were clearing a log jam-- an event that entailed sending swimmers into 42 degree water with chainsaws to chop up a tree and make the river safe. I ate a buffalo burger. Really. I worried. The safety lecture began.

We were instructed on how to put on wet suits, life jackets, and helmets. (No pics of this folks). How to hold the paddle so that it doesn't knock out any one's teeth. And what to do if you fall into the river, how to pull someone back onto the raft without dislocating their shoulder. What to do if you get separated from the raft. What to do if you miss the line that's thrown to you. What to do if the entire raft capsizes and everyone is in the river. What to do if you get trapped under the raft. What position to take while being reeled in and another position for being swept away. Don't get caught in a log jam-- too much paperwork. Really, don't get caught in a log jam. This is rare, I'm thinking, how often do people actually fall in? Oh, on a trip this size of roughly 70 rafters, 1 or 2 usually fall in. 42 degrees in the water. I waddled in my wet suit. This really wasn't sounding like a good idea.

We split into "teams" of 9 and boarded our craft. No seat belts. We sat up on the sides of the raft and Darren, my very experienced guide, showed us how to hold tight, get low, cross over to balance weight of the raft.

"When I tell you to row, it's a command, not a suggestion," he said. "Any questions?"

"Is there a seat for someone who wants to just sit and pray?" I asked. Darren glared at me. My kids wanted to die.

I got on the raft. I paddled when I was told to, even when I'd rather have been holding on. When we hit the rapids we bounced about, I got wet, and I laughed out loud. It was fun in an addictive sort of way. No one fell out and any sense of danger dissipated. No Unpleasant Sensations whatsoever. And to think, I almost bailed before we even began; after the fact, all that worrying was a waste.

Of course, there was my emotional support goat up on Sulphur Mountain:

Why Docs Don't Like Xanax (some of us)

[BTW, you might also be interested in checking out our related podcast, #19: Xanax Blues.]

This is in response to JW's question below about the "rules" docs use about prescribing Xanax/alprazolam. Not all docs feel this way, but here's how I think about it. Of course, I am not suggesting that, if you are taking this anti-anxiety drug, you should stop it. I'M NOT. Talk to your doctor if you have concerns.

The half-life for Xanax is short... on the order of 6-20 hours. Halcion is the only similar sedative that has a shorter half-life (and that one has even more problems). Thus, it doesn't stick around long. It is also quite lipophilic, meaning that it quickly gets into the brain. So, it has a quick on, quick off way of working. Sounds great, right?

The quicker a drug works, especially one which makes you feel good in some way, the more addicting it is, as the cause (taking it) and effect (feeling it) are close in time, making it very reinforcing. This is fine if you just take it on those rare anxious moments where you need something to get through it. However, since it works so quickly, many folks start taking it more and more often, until it gets to the point that they are taking it daily. Then they start taking it as soon as they feel it wear off. Before you know it, you are taking it 3-4 times per day. Now, that's not the big problem.

The big problem is all because of your brain's laziness. See, your brain makes it's own natural Xanax-like substance, called GABA. GABA works by inhibiting the brain's natural tendency to speed up. It's like a brake pedal, where the accelerator is stuck in the pedal-to-the-metal mode. GABA keeps your brain from over-working. Xanax (and other sedatives, and alcohol) works by acting like GABA in the brain (sort of). If you start taking it daily, your brain starts thinking "I guess I don't need to make so much GABA because this Xanax stuff is here, so I'll only make 20% of what I usually make." It takes a week or more for your brain to stop making the GABA (which is why just a few days on Xanax won't lead to much trouble), and a week or more for it to start making it again when you stop taking the Xanax.

Here's where the trouble begins. If Xanax wears off in just a few hours, but it takes a week for your brain's natural Xanax to kick back in, what happens in the interim? Withdrawal. What does that feel like? It feels like a panic attack, but worse. High blood pressure, rapid heart beat, tremors, confusion, delirium, hallucinations, seizures. What do folks do when they feel a panic attack coming on? Take another Xanax.

As a hospital-based physician, I see lots of folks, often older, who wind up with severe withdrawal problems from Xanax. It's usually because they run out of the drug, decide to cut back or stop taking it, or something else happens (eg, stroke, get sick) and they forget to take it. Or they don't tell their surgeon they are on it, and 2 days after their hip surgery I get called because they are hallucinating.

Some prescribers think it is a good antidepressant (it's not). Or that, because of the short half-life, it's not as addictive (it is).

So, here are my rules of thumb about Xanax:

1. Avoid it.
2. Keep the doses small.
3. Do not use in older folks or forgetful folks (more likely to forget it, thus more likely to have problems).
4. Do not use in anyone with a history of alcoholism or addiction (yes, that means you have to ask).
   
5. Tell folks to avoid from daily use.
6. If they are on it, warn them that stopping it suddenly, even for a day or two, can result in confusion, hallucinations, seizures, and even death.
   

My Three Shrinks Podcast 2: Roots

[1] . . . [2] . . . [3] . . . [All]

---

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:

---

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
  

---

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

Blogged with Flock