Please Pass the Chocolate

Ah, I didn't win the lottery.  So sad, I had such wonderful plans.


In this week's happiest of news, we learn that people who eat chocolate more weigh less.  Who know?  Yes, I went out and got me some chocolate, per the New York Times suggestion. 


Dr. Golomb’s study, published in Archives of Internal Medicine and financed by the National Institutes of Health, involved roughly 1,000 adults. The researchers looked at data on how often they exercised, the amount and type of calories they ate — including a breakdown of the types of dietary fat they consumed — and how their health and weight related to their chocolate intake. On average, the subjects were middle-aged, exercised about three times a week and ate chocolate about twice a week. There was no breakdown of the kinds of chocolate they ate, whether dark, milk or white.

The people who ate chocolate the most frequently, despite eating more calories and exercising no differently from those who ate the least chocolate, tended to have lower B.M.I.’s. There was a difference of roughly five to seven pounds between subjects who ate five servings of chocolate a week and those who ate none, Dr. Golomb said.

So nice to read something positive.  I'm still recovering from the sadness of learning that diet soda is bad for your heart (are there no guiltless pleasures?) and that red meat is also on the no-no list.  

Off to eat my chocolate....

Happy Birthday in the Weird World of Social Media

I remember when birthdays were a quiet thing. A few phone calls from first degree relatives. A couple of cards from extended family members. A special meal with family, and a couple of gifts.

Now there's Facebook.

Birthdays are have become a multi-media event. The phone rings, repeatedly, a friend drops by with a giraffe toilet paper holder, there are text messages from ....my cousin, my kid, my kid's girlfriend, a friend of my other kid, and yes, a text message from the Vision Care place where I get my contact lenses. My father-in-law sends an e-card with music. Forty of my closest friends, including people I haven't talked to since elementary school, and my prom date, wish me the best. The request to serve on yet another committee comes in an email and notes "Happy Birthday." And yes, the Vision Care place also sent a happy birthday email, complete with animated balloons. For the first time ever, my beloved sibling seems to think that writing on my Wall suffices and I don't warrant a phone call, and this year, I did not get a greeting card from the Toyota dealer.

As long as the roses and chocolate continue IRL (in real life), then count me in! When the cake turns virtual, I'm signing off.

Emotion versus Mental Illness

My favorite commenter, "Anonymous," wrote in to my Duckiness post to say that it was good I could post something totally silly without being told I need more meds. Oh, if life were that simple. And it is true that once someone has a diagnosis of bipolar disorder, not only does the world question their emotions in a black & white "are you sick again?" kind of way, but patients don't trust themselves to feel for it's own sake.

If you're not sick, then being asked if you took your meds is insulting and degrading. And so I thought I'd put together some guidelines for Emotion versus Mental Illness. I'm inventing this as I go, with no evidence-based anything, so take my suggestions at your own risk.

• If you are ultra-successful, rich, brilliant, gorgeous, famous, and comfortable with your diagnosis, you may want to consider telling people you have a mental illness because it decreases stigma and people like being with the ultra-successful rich, famous, brilliant and gorgeous and won't care that you have a mental disorder. It helps even more if you're charming.

• If you're not ultra-successful, you may want to pick and choose who you tell that you've been ill and are on medications. This isn't always possible, especially if your illness is evident to others or if the presentation of your symptoms resulted in a hospitalization. It's good to tell close family members.

• If multiple people are looking at you strangely, or commenting on your behavior, or saying you need medications, you might want to at least entertain the option that you could be sick. Unfortunately, poor insight and judgment are symptoms of mania.

• Tell the people close to you not to make medication jokes. It confuses the issue if you seriously do need medication changes, and it's rude, degrading, dismissive, and disrespectful. There, I said it.

• If you want to be silly, go for it. Be silly when you're well so that being silly is part of your baseline personality and no one equates this with being out-of-character. You'll note the duck invaders did not come after me, rather they said, "There's Dinah posting yet another stupid duck post." If I'd posted about why chocolate should be outlawed and made into a controlled substance, those same duck invaders would be asking "What's wrong with Dinah?"

• Mental illnesses come as constellations of symptoms. There is no "Sending out silly duck stuff" as a symptom. People think about mania when the ducks are combined with more energy, racing thoughts, a decreased need for sleep, increased mood OR irritability, and other symptoms of mania. Know the list and if someone bothers you, say, "I posted about ducks, I do not have any other associated symptoms." Recite them if necessary. If you do have the other symptoms, refrain from posting about ducks. I don't want Posts Duck Blog Posts to show up anywhere in DSM-V and these days you just never know.

• No one controls how any other person thinks of them or judges them and it's not reasonable to live life ruled by a desire to be perceived in a certain way . It's another form of poultry, but Don't Let the Turkeys Get You Down. There are a lot of turkeys out there.

Moods happen on a spectrum. Some people have large variations in their mood---large enough or severe enough such that it causes suffering, and we call it an illness. Some people don't have much variety to their moods and live in a calm, even-keel place, and it's great that we have such people. But, I absolutely promise you that if we lived in a world where everyone had a very narrow range of mood, this would be one terribly boring planet. We should celebrate our diversity, not condemn those who like ducky stuff.

Please Pass The Chocolate

This is for Victor, who sent us the link to a CNN article looking at mood and chocolate consumption: Chocolate and Depression Go Hand and Hand by Denise Mann. So here's the scoop, people eat more chocolate when they are depressed. Mann writes:

Although gorging on chocolate and sweets to beat the blues has become a cliché thanks to sitcoms and romantic comedies, there's been "little prior scientific literature linking chocolate and depression," says the lead author of the study, Dr. Beatrice Golomb, a professor of medicine at the University of California at San Diego School of Medicine. The study, she says, provides evidence to support "the popular perception that when people need a pick-me-up, they pick up chocolate."

It's unclear, however, whether depressed people eat more chocolate simply because they crave it, or whether chocolate consumption itself somehow contributes to a depressed mood.

In the study, Golomb and her colleagues surveyed more than 900 people about their weekly chocolate consumption and their overall diet. They also gauged the moods of the participants using a standard questionnaire used to screen for depression. (People who were taking antidepressants were excluded from the study.)

It's not really clear from the article if the article is talking about people with transient sadness or people with clinical depression, but if there's any link between chocolate and emotional states, then we're happy to link to it on Shrink Rap.

Victor: may your salsa win the contest this weekend. And I don't want to hurt your feelings but I've never been able to eat that chocolate bacon bar you gave me.

The Human Experiment, Part 2

Earlier this month, I posted about my own efforts to deal with insomnia, and how I inadvertently threw myself into caffeine withdrawal. I'm following up here.

So to summarize my experiment on myself, I manipulated the following variables, all at once, with no control group, and no way of knowing which variable was responsible for any changes I saw.

1) I stopped all caffeine. Well, mostly. After the caffeine withdrawal headache and fatigue, I decided there was no real rationale for this, and I've been drinking half a cup of coffee most mornings. In anticipation of the crowds and a purported 1:5000 person: porta-potty ratio at Obama's Inauguration, I did not have any coffee on that morning. I've had no Diet Coke (yes, this is possible) and my efforts to completely stop chocolate have been unsuccessful. So my caffeine intake has been limited to half a cup of coffee in the morning and episodic chocolate in reasonable (mostly) quantites. No artificial sweeteners.

2) I stopped drinking alcoholic beverages.

3) Since I have trouble falling asleep, but don't have trouble with daytime sleepiness, I wondered if I've simply come to need less sleep and I tried setting my alarm significantly earlier in the mornings. I am not a morning person, and this was awful (it lasted 2 days) but perhaps because it co-incided with my caffeine withdrawal. After that, I started going to bed at least an hour later than I was used to.

4) I increased the amount of exercise I was getting...oh, at least for a while. I also tried to add on some evening exercise to manipulate my body temperature several hours before bedtime-- a few minutes until I got flushed, but not sweaty enough to need a second shower. It was going well until a few days ago when I turned into a human slug. I resume a normal exercise schedule today.

5) Stress-- I started this plan during a time when stress was low and there was a long weekend in there. I've had some stuff going on since, and I spent a night away from home and my usual routine. Sometimes, life is just what it is.

My findings:

• It is easier to give up Diet Coke than it is to abstain from Chocolate.
• It is easier to give up alcohol than it is to abstain from chocolate.
• Decaffeinated tea is as happy an event as regular coffee.
  
• My daytime energy level has not changed with less morning coffee.
  
• One can actually have mild cravings for Diet Coke.
• It's easier to go to bed later than it is to get up earlier
• It's a pain in the neck to exercise every single day
• It is notably cheaper to eat in restaurants when there is no alcohol, soda, or after dinner beverage involved (I don't like decaf coffee).

Oh, and the results: most nights, I'm falling asleep within minutes and sleeping through the night.

Sweet Dreams!

Accountable To Whom?

In psychiatry, we talk a lot about the treatment of mental illness. Sometimes we talk about the treatment of disordered behavior, but often that discussion falls into the realm of other specialists such as psychologists, social workers, or lay support people (is that what I should call them?)-- members of self-help groups, personal coaches, and others.

Just to be clear, I'm talking about addictions and motivated behaviors-- people who can't stop doing what they're doing and seem to be driven by something other than logic. So the alcoholic who keeps drinking despite horrible repercussions, the smoker, the drug addict who keeps using when he's lost so much, the over-eating overweight person who grabs the next chocolate cupcake, the bulimic, the gambler, the internet sex addict, the pedophile, oh, name your "addiction." Illness or choice? The owners of such problems struggle, and often unsuccessfully.

This is what's frustrating about treating disordered behavior: we're not very good at it. It's really hard to get people to "Just say No." Actually, almost no one just says no. Sometimes people seem to have their own epiphanies-- something clicks-- and they change. Sometimes they "hit bottom" and they turn around. Some people just live in their ditches.

So how hard is it to change behavior? I think it depends on the person and on the addiction. Many people stop smoking-- for some it's harder than for others. The stats are that something like 95% of people regain lost weight within 2 years. I don't quite believe that, seems like I know people who've lost weight and kept it off, though not most. In the course of taking many psychiatric histories, I've heard of many people who've gained better control over a variety of behaviors. The most desperate often seek help, sometimes more than once, sometimes in a variety of places.

Here's my caveat:
I'm not very good at getting people to change behaviors they don't want to change. I've made some observations, I've tried to change some of my own behaviors (-have you seen the chocolate?), I've watched lots of people struggle with big things and small things.

Support helps. A lot. And accountability helps--perhaps it's essential. 90 meetings in 90 days, the mantra of starting in a 12-step program. And having a sponsor, or a therapist, or a coach--someone to be accountable to, helps. Are there things about a sponsor or therapist or doctor that increase the success of the person trying to change? I believe at some level, the "coach" (I just need a term here, let's go for this one) has to be someone the patient respects. It helps if the coach is not judgmental, is optimistic, encouraging, and believes in the patient's ability to meet their goal. It helps if the patient wants to please the coach, but isn't so worried about a negative reaction that he (the patient) lies and says he's meeting goals when he isn't. If the coach is a forbidding character, the patient may simply never return. Frequency of accountability helps: whether by checking in or by face-to-face. Having reasonable goals helps.

Oh, I'm rambling. You tell me what helps a patient change...

Climb Every Mountain

Subtitle: "Blood On The Bike"

I'm back from vacation. Roy's been posting about his camping experience in Maine and by pure coincidence I also planned my summer vacation to Acadia National Park. I called Roy and tried to catch up with him, but for the most part I didn't have cell phone coverage when I was there.

Let me start by saying: it was wet. More than wet, it was a deluge that first day. The tent held up with only mild dampness, but I knew I was in trouble when a park ranger stopped me on the way back from my hike to warn me to take shelter. He said there were 60 mile per hour winds predicted, with lightening and hail. Yes, it was wet. There wasn't any hail and the wind wasn't that bad, but we did get three waves of lightening storms through the night. Since it couldn't get any worse, I went for a swim in the ocean in the rain. Cold truly can be painful, and that water was frigid.

Day Two was drizzly and overcast, but clear enough to ride bikes. I made it up Cadillac Mountain (1500 foot elevation) at all of about 4.5 miles per hour. It took about an hour to get to the top, but the ride down was fantastic. I had to keep braking the whole way down to keep from flying off the edge of the switchbacks. I was at the bottom in about seven minutes.

Day Three finally gave us a break in the weather, enough to get some hiking and more biking time, as well as a nice sunburn sitting on Sand Beach.

The most unique part of the whole trip was the climb up Mount Champlain. Now, this climb is optimistically referred to as the Precipice Trail but it's not a hike by any stretch of the imagination. It's pure rock climbing. There's a sign at the bottom of the mountain that warns people not to bring children up because people have died on the climb. I was too busy trying not to slip, digging my fingernails into solid rock, that I didn't take any pictures. Besides, I knew some other brave or foulhardy soul with better photography skills had probably already put some pictures up on Flickr so here is a link to those pictures of the Precipice Trail. (It's steeper than it looks in the pictures.) I've never been so terrified. There are iron rungs you can climb, but what they don't tell you is that when you're as short as I am there is sometimes a gap between rung sets that requires you to traverse over a narrow sloping ledge that hovers over a steep plummet. By the time I got back to the base I wanted to shout "You're all going to die!" to anyone starting up the trail. I resisted.

By this time I was dirty, sunburned, sore and needed a hot shower. Badly.

Thank goodness for Isle Au Haut. More specifically, for the Inn at Isle Au Haut. It's beautiful but isolated, and you can only get there by mail ferry. Innkeeper Diana Santospago took me in, tucked me into an amazingly soft bed and then fed me incredibly good food for two days. I had sea scallops with cream sauce, squash fritters, mushroom onion soup, soft-shelled lobster, stuffed squash, triple chocolate cake surprise (you have to guess the surprise), as well as hand-packed lunches for the day trips. I wasn't surprised to learn I had gained a couple pounds while camping in spite of the 1500 foot bike ride up the mountain, the climb up Mount Champlain, and the 50 mile ride I took after I got back to Acadia. The Inn was a perfect break even for a seasoned camper. The side trip to Isle Au Haut was rounded off nicely by a stop at Black Dinah's chocolate shop where I took shelter from yet another downpour. (Well OK, the truffles were a good reason to stop, too. They were delicious, not to mention quite beautiful.) I was treated to a short game of Scrabble to while away the time until the ferry took me back to the mainland.

OK, so to tie this in to psychiatry---this is a psychiatry blog, right?---I have to mention that I didn't really 'get away from it all'. During one breakfast stop I couldn't help overhearing the man at the next table explaining to his party what the Mini-Mental State Exam was and what it was used for. And at the Inn, one of the other people staying at the Inn while I was there was a psychiatrist. It's a wierd, small world but fortunately still a protected and well-tended one at Acadia National Park.

Scurrilous Lies

I checked my email this morning only to find a forwarded blog post that suggested I don't like chocolate. Lies! Scurrilous lies! I had to post to the blog immediately to stamp out this vicious rumor.

I was at the Chocolate Affair. I was there 45 minutes before Dinah. Dinah thinks I hardly ate any chocolate because she was late and doesn't know what I was doing while I was waiting for her. She should be glad I left some for her.

It was amazing. There was chocolate cocoa with peppermint marshmellows, flavored chocolate liquers, little tiny pancakes with elaborate chocolate toppings, chocolate truffles, chocolate cake, chocolate ice cream, chocolate flavored risotto....use your imagination and the reality was better.

I never knew it was possible to have a chocolate hangover. Trust me, it is. It's a combination of a lingering caffeine buzz with incipient chocolate cravings. This is why they only do this event once a year.

Of course, there's a certain amount of irony here. It was an elaborate affair and the creme de la creme of Baltimore society was there including our fair mayor who was "getting her chocolate on" as well as the chief state's attorney for Baltimore. There were fancy dresses and suits and spike heels and jewelry, all for the benefit of my patients. I kept thinking about my patients who wear baggy jeans and t-shirts with "DOC" stamped on them when they're released homeless. The mental culture clash was a bit jarring.

So that's the truth of the matter. I love chocolate. Don't let anyone tell you otherwise.

And Dinah looked fantastic in her tiara.

Chocolate, Chocolate, and More Chocolate

This post is dedicated to Fat Doctor who is on a very low calorie all liquid diet. Bless her.

Tonight, we attended The Chocolate Affair at Raven's Stadium, a decadent, chocolate over-flowing fund-raising event for Baltimore's Health Care for the Homeless. My husband came willingly. Roy is on vacation (but promised to send a donation---don't forget, Roy!), and ClinkShrink resisted. I threatened her: Go or I tell everyone your Chocolate enthusiasm is a lie. I'll scream it on the blog. So Clink posted, but she didn't eat very much chocolate.

In case you're wondering, I ate lots and lots of chocolate. I tasted sweet potato ice cream. I ate truffle after truffle, chocolate fondue, brownie-type stuff, assorted real foods, too. Somehow, and I'm not sure how or why this can be, I'm not feeling sick. I guess I have a high chocolate tolerance.

Diet starts tomorrow....

When Hummingbirds Bonk

In cycling and running there's a phenomenon known as "bonking". Bonking is when you just suddenly get overcome by exhaustion and you collapse. To be scientific about it, you 'deplete glycogen stores' and can't go on. A friend of mine tells me that this happens to hummingbirds. They can be found collapsed on the ground, exhausted, which isn't too surprising for a creature whose heart beats up to a thousand times a minute. Fortunately they can be revived with a little sugar water.

There are days when I can really identify with those little guys. On days when I see twenty-plus patients, when everyone is in crisis, when I just can't seem to find a chart (or the medication nurse can't find my order), at some point you hit the wall and bonk. It's that moment when I think to myself that I will just walk out of the facility and never come back.

Unfortunately, sugar water just doesn't do it for me.

This is what to do to revive a correctional psychiatrist in case you ever find one lying on the ground, exhausted, with a heart rate somewhat lower than a thousand beats a minute:

Administer coffee immediately, followed by judicious amounts of dark Belgian chocolate. Don't worry about checking for consciousness first, just hit the Starbucks.

If this doesn't work consider depositing a large, warm, furry and loudly purring cat on the psychiatrist's stomach. This is also a test for consciousness since those tiny sharp kneading claws are bound to get a reaction.

Once revived, deposit the psychiatrist in the middle of a large quiet forest with miles of hiking trails (trail map included). Allow time for staring up at tree branches, listening to the wind whistle, admiring large fungi and searching the stream for minnows.

Repeat, ad infinitum, until smiles return.

I suspect every psychiatrist has their own particular favorite ways to recover from the hummingbird bonk. Dinah is relaxing in a warm, sunny place and Roy seems to find comfort in buying new very large computer monitors (I'm jealous). Regardless of the recovery method, we will all find our way back to Shrink Rap eventually.

My Three Shrinks Podcast 38: New & Improved!

[37] . . . [38] . . . [39] . . . [All]

---

Okay, this podcast is a milestone for us. Dinah bought several hundred dollars worth of sound equipment (Alesis MultiMix8 w/Firewire, Behringer C-1 mics), which took us several hours to properly set up to record so that each of us comes into the MacBook as a separate track, thus letting us have more equal sound volumes (before we all shared the same mic, so our voices were at different levels).

I've set it up so that if you listen to the .m4a version (that's what gets downloaded from iTunes), Clink's more on the left channel, Dinah's more on the right, and I'm in the middle. Let us know how you like it. I'm still figuring out how to use it all to achieve the best sound quality, but I think #38 is the best one we've ever done so far.

---

November 11, 2007: #38 New & Improved!


Topics include:

• MacArthur Foundation Grant. Decision-making, substance abuse, and brain abnormalities. Developing guidelines for judges about neuroimaging and brain function.
  
  
• On our Shrink Rap blog, Clink blogs about What She Learned (Part 1, Part 2, and Part 3) at her AAPL conference.
  
  
• Delirium. Roy discusses delirium, or encephalopathy, what it is and recent findings about longer term damage. This was on the front page of a recent WSJ.
  
  
• Shrink-proof containers. Clink brings back a hotel bottle of mouthwash that she could not open.
  
  
• Q&A: Gerbil brings up recent study on chocolate lovers.
  
  
• Online CBT for Depression. Study finds it helpful for mild-moderate depression. Eliza.
  
  
• Telepsychiatry. We just chat about some of the issues.
  

---

Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

got cocoa?

The news is abuzz with the latest research, suggesting that chocolate -- specifically, one of the ingredients, epicatechin -- is one of the most important medical discoveries since penicillin.

Why? Apparently, folks in the Kuna tribe, near Panama, have incredibly low rates of stroke, hypertension, heart disease and cancer. They also drink an average of 5 cups of cocoa per day.

The stuff appears to be a great antiinflammatory drug, as well as an immunomodulator which helps to prevent cancer. What the hell... let's say it's a great antidepressant, antipsychotic, and antianxiety treatment. We three shrinks are going to open up a posh, inpatient psychiatric program, called The Cocoa Retreat, where i.v, i.m, and p.o. forms of chocolate flow ad lib. You can bathe in it, too, because (of course) it prevents wrinkles. We will only take cash (or its equivalent in cocoa).

My Three Shrinks Podcast 10: Be Mine

[9] . . . [10] . . . [11] . . . [All]

---

Valentine's Day is soon upon us. Hearts, flowers, and chocolate abound. This got us three shrinks wondering about why chocolate holds such a high position in this whole love-related endeavor.
We talk about the psychopharmacology of chocolate, while we simultaneously try a taste of own pharmacocoatherapy.
Oh, and this is our TENTH PODCAST! (woo)

---

February 11, 2007:

Topics include:

• AJP: False positive drug tests on Effexor XR (venlafaxine) (positive for PCP, or phencyclidine).

• Chocolate and Mood [PubMed]: a look at chemicals in chocolate which affect mood, such as theobromine, caffeine, phenylethylamine (PEA), and anandamide.
  
• First study mentioned by Clink, on chemicals in chocolate.
• Second study, about mood modulation by food.
• Third study, about chocolate and atypical depression.
  
• Green M&Ms. Also, design your own M&Ms, even what is printed on them.
• Dogs: Don't eat the chocolate.
  
• Children of Psychiatrists (The Last Psychiatrist). Do psychiatrists have crazier children? (See Dinah's post)
  
• Suicide risk in physicians. A European study (Hawton 2001) found that female doctors, and not male doctors, had increased suicide risk. Furthermore, specialties at highest risk included anesthesiology, generalists, and psychiatrists. A meta-analysis (Schernhammer 2004) found that physicians in general were 1.4 (men) and 2.3 (women) times more likely to commit suicide than the general population.
• Questions for us? Email at mythreeshrinksATgmailDOTcom. We'll answer some starting with Podcast #11.
  

Next week: Black market price of psych meds; side effects of psychotherapy.

Last week's musical snippet was from 1983 release, Genetic Engineering, from the Dazzle Ships album by Orchestral Manoeuvres in the Dark (OMD).

---

Find show notes with links at:
http://psychiatrist-blog.blogspot.com/2007/02/my-three-shrinks-podcast-10-be-mine.html
This podcast is available on iTunes (feel free to post a review). You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

technorati tags:psychiatry, psychiatrist, psychology, mental, health, medicine, podcast, psychiatric, chocolate, psychopharmacology, theobromine, caffeine, suicide, mood, depression, valentine, valentines

Blogged with Flock

Roy Unleashed!

[posted by dinah]



I checked the blog yesterday was surprised to find three, count 'em, three new posts by Roy! Is he manic, I wondered? Oh, probably not...just unleashing his pent-up blogs which have been festering... I can only speculate. But this brings me to an interesting study I found, one that pertains to Roy's comments on most frequent diagnoses among psychiatric patients. A landmark 1998 study by Sille, et. al. revealed that the most common psychiatric diagnosis among bloggers is, in fact, Bipolar Disorder, accounting for 61.8% of all psychiatric diagnoses (most recent episode being a Mixed State), followed by Obsessive Compulsive Disorder, with compulsive writing being the most common symptom, followed by compulsive email checking. In a follow-up study done by Monke in 2001, it was found in a randomized, placebo-controlled, double blind study that manic bloggers were more likely to report remission of symptoms, a return to euthymia, and a decrease in compulsive blogging, when treated with a combination of Depakote, chocolate and caffeine. Interestingly enough, none of the bloggers studied responded to either Lithium or any of the novel anti-psychotic agents.

Okay, so I made it all up, but I had fun doing it!