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.

Demystify Me!

We have a blog, we have a podcast, ShrinkRapRoy does some tech/med/psych twittering, and now we're writing a book. We've given one talk together, and once we're finished writing the book, we'll plan to do more as part of marketing the book (and the blog, and the to-be-resumed podcast) There's nothing to say we won't find more projects that compel us as time and technology move on. It's got me thinking that we need some umbrella organization to encompass all the different aspects of our work. I had a quickly-thought-of name; Clink says she can do better. Roy asked what our purpose would be and I assured him we'd have a mission statement, something to do with promoting dialogue, demytifying psychiatry, and decreasing stigma for mental illness. Roy added that we'd want to promote the destigmatization of both psychiatrists and the treatment of mental illness.

It got me thinking about what we do, and the issue of demystifying psychiatry. Do people want their psychiatrists/therapists demystified? Is there something about having that element...that distance, that assumption that the therapist is a little bit mysterious, unreachable, or somehow special in a way that regular people aren't, that is helpful (even if it's just not true)? Sometimes my patients ask questions about my life, or express surprise that I'd like, or do, something that isn't in keeping with the image they hold of me. What might be uncovered? Maybe that doc eagerly taking notes is actually writing a letter to his mistress (I hope not!) or behind the wise therapist fascade is an ordinary person stressing about bills, or a sick parent, or an ornery child, or their own irritable bowel. So demystify or leave it all alone?

On a totally different note: Roy got a New Puppy today. Oh my, is it precious. I went over to bond and the little guy (and he is little) curled up and slept on me.

Just As I Was Thinking About You

I think I have ESP. Last week, I was thinking about a patient I hadn't seen in a couple of months, and he called, just as I was thinking about him. It's happened before with this patient. Today, I was walking to my car (where I'd left my cell phone, unsubmergered), and I started to think about a patient I haven't seen or thought about in some time. I've been treating her for over ten years, and issues of age and health have made it hard for her to get in to see me. It's been a year, maybe more, but every once in a while, she surfaces. So I'm thinking about her, wondering how she is, and I get to my car and there's a voicemail from her. Sort of eerie. I have ESP.

What I don't understand is the whole ShrinkRap with Bacon thing on our sidebar. I guess Roy did this. Why does anyone want bacon with our blog? It's just sort of weird. He couldn't have put ducks up?

And for a final thought: my husband is leaving on a jet plane. He texted to say there is a comfort dog in the next row. I can't wait to hear how the flight goes.

Thanks to everyone who's commented on our pre-draft of a chapter. I like the diversity of opinions. And to anyone who thinks their middle schooler might get something out of it, that would be wonderful!

I'll get a photo in later: let me know if you have any special requests....

I Need ---Non-Human--- Help!

In "Creature Comforts" (the NYTimes mag, of course), Rebecca Skloot discusses all forms of comfort and service animals. There's a difference, and yup, Ducks make the cut. There are miniature guide horses for the blind, monkeys for quadriplegics, and an assistance parrot for a man with bipolar disorder who is subject to tempter outbursts.
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What qualifies as a service animal? .... Can any species be eligible?

There are two categories of animals that help people. “Therapy animals” (also known as “comfort animals”) have been used for decades in hospitals and homes for the elderly or disabled. Their job is essentially to be themselves — to let humans pet and play with them, which calms people, lowers their blood pressure and makes them feel better. There are also therapy horses, which people ride to help with balance and muscle building.

These animals are valuable, but they have no special legal rights because they aren’t considered service animals, the second category, which the A.D.A. defines as “any guide dog, signal dog or other animal individually trained to do work or perform tasks for the benefit of an individual with a disability, including, but not limited to, guiding individuals with impaired vision, alerting individuals with impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a wheelchair or fetching dropped items.”

Since the 1920s, when guide dogs first started working with blind World War I veterans, service animals have been trained to do everything from helping people balance on stairs to opening doors to calling 911. In the early ’80s, small capuchin monkeys started helping quadriplegics with basic day-to-day functions like eating and drinking, and there was no question about whether­ they counted as service animals. Things got more complicated in the ’90s, when “psychiatric service animals” started fetching pills and water, alerting owners to panic attacks and helping autistic children socialize.
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The article includes issues about disease transmission, especially forms of hepatitis from monkeys, to issues of aggression, citing one service dog who killed another service dog on a bus. People, apparently, are not always comfortable seeing ducks walking down grocery store aisles (can someone explain that to me?)

The article concludes with:

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“Many people try to make this issue black and white — this service animal is good; that one is bad — but that’s not possible, because disability extends through an enormous realm of human behavior and anatomy and human condition,” Frieden told me. In the end, according to him, the important thing to remember is this: “The public used to be put off by the very sight of a person with a disability. That state of mind delayed productivity and caused irreparable harm to many people for decades. We’ve now said, by law, that regardless of their disability, people must have equal opportunity, and we can’t discriminate. In order to seek the opportunities and benefits they have as citizens, if a person needs a cane, they should be able to use one. If they need a wheelchair, a dog, a miniature horse or any other device or animal, society has to accept that, because those things are, in fact, part of that person.”

Because I Said So....

I recently linked to an article on the Well Blog about a child with Asperger's Syndrome in NYC. The boy's parents were at odds with their housing co-op about the boy's need for an emotional support dog in the no-pets-allowed complex.

Roy said that's what docs get to do: determine medical necessity.
Commenters on our blog and the Well blog were mixed, and I really don't have enough facts to feel comfortable commenting on the situation.

It did get me thinking about the concept of Medical Necessity and before I start rambling, let me say that I didn't see the term "medical necessity" on anything associated with the kid and dog case. What I read simply said that doctors thought a dog would help the boy, that the co-op agreed to let him have a small dog with many stipulations attached, and the feds, specifically HUD, took on the cause and felt the co-op discriminated against the family. You can read Here.
Medical Necessity is a funny concept, one I'm not always 100% comfortable with. I think the issue here is that when we as physicians deem something Medically Necessary, it implies some imposition, usually financial, but in the case of the service dog--furry-- on someone else. Usually we use the term to mean that it's something someone's health insurance should pay for that they don't (or may not want to) pay for. If there's not a cost (financial or otherwise), then one can leave it at "My doctor said to do ...." and there's not a reason to deem it "medically necessary." That's a term that goes in writing and means someone, somewhere will find it inconvenient.

I don't usually declare that things are Medically Necessary from a psychiatric viewpoint, except for specific medications-- sometimes Name Brands (as opposed to generics) and then because the patient has tried the generic and found that either they don't work as well or they cause side effects. The other Medically Necessary things I recommend are sessions (ie, treatment is medically necessary) or Hospitalization...ah, the joys of managed care. Sometimes I tell people to stay home from work, especially if I feel their behavior during an episode of illness puts them in jeopardy, and I'll write a note saying they need time off, or that they were at a doctors' appointment, but this usually doesn't require a statement of medical necessity, per se, it falls under sick leave. My stationery doesn't even say I'm a shrink, and unless I'm specifically asked, I don't volunteer that in "doctor's excuse" notes.

In the case of the dog and the kid, the term "medically necessary" wasn't used-- it was simply said that the dog might be helpful to the boy. What about another occupant who might require a animal-free environment? How do we determine whose rights trump whose? Maybe this is a bad example, because one can envision that one condo owner could live with a dog in such a way that the other people in the condo aren't disturbed by it and the presentation by the press left the reader feeling that the complex owners are unsympathetic child and dog hating meanies who were being unnecessarily arbitrary. I got curious and did a little googling-- it seems the dog would be going through a training process with the boy. The other issue was concern by the building about the area around the entrance to doctors' offices in the building.

So this is my concern with extending the definition of what is a disabilty and what we should do as a society to accommodate the needs of the disabled: if the issues get too diffuse, then ultimately the laws to protect the disabled hurt them. Don't want any autistic kids here because then we'll have to allow their dogs. Okay, maybe that's silly, but the issue isn't just what one group needs, it's also the fear of being sued because of the perception of injustice, or the fear of having to accomodate. The issue of medical necessity feeds into this unless we hold to a fairly strict notion of what is medically necessary, and as doctors.

If you want to read more about the kid with the battle for the dog:
Try this or this.

And just to be clear, this is a rambling post. Most often, 'medical necessity' is a term that has to do with Medicare reimbursement...somehow I've gone off about service dogs and co-ops and broader implications to society.

My Patient, Myself

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Don't ask me what Michigan surgeons would do...

Fat Doctor Feeds Her Kid Dog Biscuits!

I've just never heard of kids eating dog biscuits.

Press HERE to read about FD's day.

Paws for Reflection

[Posted by ClinkShrink]

One day I was standing at the prison gate waiting to be let in. I felt warm moist air puffing gently against the back of my knees. I turned around and there was a German Shepherd. A big German Shepherd. He was looking up at me and sniffing, taking a great interest in something I couldn't see. I asked the officer who was with him, "Does he eat shrinks?"

The officer laughed, but I noticed he never answered my question. That wasn't comforting.

"What's his name?"

"Oh, I can't tell you that. He's a working dog."

"Can I pet him?"

"No ma'am, he's on the job."

Since I couldn't pet him and I didn't know his name, I called him Harley. I saw Harley around periodically after that, as well as other drug detection dogs I got to know fairly well although not on a first name basis. There was the chocolate lab, the older German Shepherd and the yellow retriever who was my favorite. The retriever would prance through the jail like it was the favorite thing in the world for him to do. He was practically grinning the whole time. Mentally I called him Cute Dog.

One day the retriever's handler showed up without him.

"Where's the pup?" I asked.

"Oh, he's out in the truck," the officer said.

"Ha," I said. "Don't worry, by the time you get back he'll have the transmission fixed. That dog is smart."

I haven't seen Cute Pup for a while and I'm a little worried. Drug detection dogs are a key part of institutional security, but they also help out a little with staff morale. They're our version of Pets On Wheels.