Quacks....

From Broom Hilda

With thanks to Ross who sent me the link to this cartoon.
I'm wondering what she wanted validated?  Her parking ticket, perhaps?

Guest Blogger Dr. Darell on Not Being Funny in Psychotherapy

A while back, I put up a YouTube video that I thought was funny. A commenter didn't like it and felt it promoted stigma. So I took a vote, and while most people were fine with it, a number did not like it, and I took the post down. We received this note, and I thought it was substantial enough to be it's own guest post (with permission, of course).
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Hi. I am a practicing psychiatrist based in New York City. I find your blog interesting, informative, and, at times, funny. Now, can you guess which entry I'd like to comment on?

Mel Brooks once said, (paraphrased), that if you slip on a banana peel and land on your butt, it's comedy. If I fall down a flight of stairs, it's tragedy.

I've had a long-term interest in humor, and a brief career as an unpaid stand-up comic in L.A. (Brief because my bombing to "killing" ratio was about 15 to one.)

With respect to my experience as a therapist, I now occasionally utilize humor in my treatment, but only extremely judiciously, once I have gotten to know my client.

I learned my lesson early. At the beginning of my residency training, during my second session with a client, I commented that perhaps he felt like Groucho Marx when Groucho said that he wouldn't want to be a member of any club with standards low enough to accept him. I sat back, feeling as if I had made the interpretation of the century, and waited for a reaction. I got one. The client stormed out of my office and never returned. My supervisor later told me that, as I suspected, I had screwed up royally.

This memory resonates with Dinah's statement that it's the recipient's reaction to a joke or a comment that counts. So know thy audience, and know thyself. You're obviously on much safer ground if you make a joke about a community or an ethnic group that you belong to. We do, however, live in an era of enhanced sensitivities and political correctness, and need to be extra careful not to anger or offend.

With respect to the Youtube audio, I, like a number of your readers, have heard other versions and have become desensitized to it. Ironically, I read about a version of it being told by a psychiatrist moonlighting as a standup comic years ago. My immediate reaction was, "Keep your day job, doc!"

Since "Psychiatry Hotline" is available to a large and varied audience, including people suffering from mental illness, I would not personally have posted it. Although it appears comparatively innocuous, I voted for it as offensive from a psychiatrist's point of view because it trivializes mental illness and is potentially hurtful to many.

Warmest regards,

Edward W. Darell, M.D.

Blog: ShrinqueRap (on Wordpad). Very soon to be updated. Please do not sue me. I registered the domain name before hearing of your blog, and my pockets are extremely shallow. (just short of being inside-out).

URL: www.shrinqerap.com

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And while we're on the subject of humor---- a nice break before I start writing about In Treatment tonight--- Sarebear sent us a link on A Proposal to Classify Happiness as a Psychiatric Disorder. Hmmm...it's a joke, right?
And don't worry, Dr. Darell, we're not going to sue you, but do keep your day job.

Funny: At the Expense of Whom? Please vote

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

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

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

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

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

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

http://psychiatrist-blog.blogspot.com/2010/10/its-okay-to-laugh-at-jokes-your-career.html

And here's the ballot:

Pull & Pray - zDoggMD's Safe Sex Song

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

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

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

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

Straight to You From Broadway

Thanks to Dr. T for bringing this to my attention.

Too Chipper?

For those in need of a laugh:


FDA Approves Depressant Drug For The Annoyingly Cheerful

Cure for Fish Phobia?

Hmm, seems we zipped past our 800th post with Dinah's Dear Fat Doctor.  

So, you've heard of our Sex with Fish post.  And Sex with Fish, Revisited (of course).

Now comes Sex with Feet Feet with Fish. A Virginia salon is pioneering the use of little bitty carp to nibble away your worries... and your dry, flaking skin.

Just dip your tired dogs in the warm water and a hundred puny, puckering, piscine podiatrists suck your feet clean of dead skin.  AP writer Matthew Barakat writes about the tiny "doctor fish", also known as garra rufa, in the Baltimore Sun:

Customers were quickly hooked.

Tracy Roberts, 33, of Rockville, Md., heard about it on a local radio show. She said it was "the best pedicure I ever had" and has spread the word to friends and co-workers.

"I'd been an athlete all my life, so I've always had calluses on my feet. This was the first time somebody got rid of my calluses completely," she said.

First time customer KaNin Reese, 32, of Washington, described the tingling sensation created by the toothless fish: "It kind of feels like your foot's asleep," she said.

It seems that Turkey has used these dermophilic fish for some time to treat psoriasis. For those of you with fish phobias, this might be an excellent way to use exposure therapy ("immersion" therapy, even) to desensitize you to fish.  But can you charge it to your health savings account?

You Puzzle Me

Now that we have a couple years of blogging under our belts, I thought I'd do a little pop quiz for you folks who have stuck with us from the beginning. Click on the link below to go to the Shrink Rap Crossword to test your knowledge of Shrink Rap trivia. You can print out the web page and do the crossword at your leisure.

For people who want to brush up with a quick review first, I recommend these links:

Psych Notes For Smilies
My Planned Nervous Breakdown
True Confessions
Shrinks On Segs

Now get to it!

Click on the red link below for

Shrink Rap Puzzle

Note from Dinah: I love it!! Interactive silliness. You ate too many birthday mushrooms!! Also, please take our sidebar poll.

for me, back to coffee and the New York Times.

Shows I'd Like To See

Since there's been so much interest in HBO's new series "In Treatment", I thought I'd put up a post about the psychiatry-related dramas I'd like to see some network do someday. Let's face it, most television networks only think of psychiatry in terms of a private therapist's office. There's more to it than that, and I think the public has a right to know.

1. Mobile Treatment
A psychiatrist, nurse, social worker and psychologist team up to provide on-site mental health care to the chronically mentally ill, on the streets and in the community. They respond to police emergencies involving the mentally ill and showcase the problems in our current care delivery system. The show addesses ethical dilemmas, legal and financial barriers to care and how people living on the margins work around them.

2. Is There A Shrink In The House?
A spin-off from the series House, this psychiatrist starts out as a consult-liaison doc in the series House. (I know, Dinah hates House, but you have to start somewhere.) There are clashes and confrontations right off the bat as House's brash, sarcastic style comes up against the psychiatrist's more thoughtful, measured approach. The show addresses the intersection of psychiatry and medicine as the consult-liaison doc teaches House how the brain affects the body, and vice versa.

3. Emergency!
An ER doc and an on-call psychiatrist handle the quirky, spooky and overtly odd cases that only seem to come in after 3 am on a Friday night. The latest hit comedy series which will finally put an end to all the reality show shlock.

4. Pimp My Meds
An NIMH research pharmacologist presents a weekly review of psychopharmacology-in-development, with optional references to pharmacogenetics and neuroimaging.

5. Insurance Court
Judge Judy takes on the insurance industry as denied, delayed and neglected psychiatric cases appeal to the insurance commissioner. In lieu of payment, insurance companies found liable for care may choose from a variety of publicly humiliating punishments.

(By the way, the picture at the top of the post looks a lot like my actual TV, rabbit ears and all.)

You Eat Donuts Like A Psychiatrist

So I'm sitting in Dunkin Donuts having an apple fritter when this nice cleancut young guy walks up to me and says, "You should be eating a muffin."

I looked at him. He was nicely but casually dressed, in an Old Navy/Gap kind of way. I was sure I didn't know him. "Pardon?" I said.

"Dr. Ellen says you should be eating a muffin. She compared a bagel with cream cheese to an egg McMuffin, and said the muffin was better."

At this point I was rather intrigued. He engaged me in a long discussion of nutrition, exercise, the importance of balance in life. He was animated, gestured a bit, talked a lot but not too loud or fast.

"You're doctor, aren't you? You seem nice." he said.

OK, that spooked me a bit because I hadn't told him anything at all about myself. I admitted I was a doctor. Then he went on to tell me about his family (aging mother caring for father with Alzheimer's, multiple brothers and sisters overly involved in his life) and I began to catch the drift that he was having a bit of trouble breaking away from the conversation. I wasn't surprised when he mentioned he had bipolar disorder. By this time I was expecting it.

"You're a psychiatrist, aren't you?" he said.

OK, spooked again. I definitely didn't mention I was a psychiatrist. I know I've never seen this guy before.

"Uh, yeah," I said.

"I thought so. You seem nice."

He told me about his psychiatrist (someone I know, a non-Shrink Rap colleague of mine), his clinic (not too far away from my prison). He handed me a religious brochure, told me to "keep doing what you're doing, God bless you," and then left. He promised to say hi to his psychiatrist for me.

I still don't know how he pegged me as a psychiatrist. I guess I eat donuts like a psychiatrist.

Soylent Brown

Dinah wanted me to talk about the alleged Texas cannibal that PETA is using to promote vegetarianism.

I have to say, cannibalism is not nearly as interesting as what's being served on the prison menu these days.

I've eaten in the officer's dining room, and it's an experience. Most of the bugs stay on the walls but occasionally you see a little baby bug crawling along the edge of the salad bar. The inmate workers who serve the food all wear gloves and hair nets. I really don't notice the tattoos anymore. They're friendly and polite. They ask if you want the soggy vegetables or the dry white bread or they'll ladle a few scoops of thick sludgy soup into a styrofoam cup for you. On fried chicken days the line is always long, but they still ask if you want extra fries with that. There's always enough little ketchup packets to go with the fries. On non-chicken days, they have a brown square of some meat-type thingie. I'm still working on that one, trying to figure out if it's from the land, from the sea or from the air. At this point I just call it Soylent Brown.

One of the kitchen cadre workers told me that Soylent Brown is a staple of the inmate diet. It's from the food contractor, who I guess buys it by the truckload. For inmates who want a vegetarian diet I guess they can be reassured---my cadre worker tells me Soylent Brown is 90% soy and ten percent meat flavoring, according to what's listed on the box.

Several years ago there was a science fiction movie called Soylent Green. Like all great science fiction movies it starred Charlton Heston. It was set in the future when human overpopulation and global warming had killed off all the world's resources, and the entire human race was dependent on a type of food called Soylent Green. To make a very long story short, Heston played a detective who eventually discovered that Soylent Green was made out of recycled humans. I've included a UTube link to the crucial scene at the top of this post.

(Incidentally, when people talk about physician-assisted suicide I always free associate to the euthanasia scene from Soylent Green.)

So anyway, most of the civilian staff bring their lunches to work rather than risk the food in the officer's dining room. That worked fine until some unspecified employees (whether civilian or custody staff, I don't know) started smuggling contraband in inside their lunch bags. So then all the employees were required to bring their lunches in using clear plastic containers to make it easier to inspect the food on entry. So fine, everybody gets a clear plastic container.

Then more stuff gets smuggled in. Security rules change. There is a proposal to ban all outside food from coming in to the institution. The civilians are horrified that they might have to choose between starvation (only having a half hour for lunch means you can't really go out to eat) and eating Soylent Brown. We're talking Survivor-type reality show here. We're talking 'I may be forced to eat my co-worker' decisions. Fortunately, the no-outside-food rule gets voted down. Somehow the warden's office still gets to bring in catered food for special events; don't ask.

The bottom line is that news stories about cannibalism aren't nearly as interesting to me as the ever-changing security rules related to prison food. It's one of the things about my job that makes the work consistently challenging.

I Just Want To Talk

It's snowing here in Baltimore, it's kind of lovely. Victor, friend of our blog, told one of his classmates to sit down, it's only snow, and the boy told him he'd never seen snow before, they don't have it in his country of origin.

It's not 3:30 AM, but even in the daylight, I'm still worrying about my kid-- nothing awful, he had an issue at school and we feel he's gotten a bum rap at a time in his life when having a bum rap is hard, trying to rescue him from the unjust, and Roy is quick to tell me that life is unfair and it's a good lesson to learn early. I suppose. ClinkShrink and Roy both have things going on in their lives, Roy's working hard, I keep hoping he'll do the things I want him to do, but he's a guy who gets pulled in a lot of directions and judging by the long hours he tells me he's working, his hospital could use a few good shrinks. The blog is suffering a little, I hope not a lot. I haven't been visiting my usual blog friends and I hope everyone is well. I do peek at the results on our anti-psychotic poll and Seroquel is winning by a lot. If you haven't voted, please do.

Okay, so Roy did some Leopard thing this weekend. Yeah Leopard. Someday I'll be a Mac person, too. I'd kind of like an iTouch, but will I be able to get the information from my Palm Pilot over to it?? This story is for Roy: the psychiatrist across the hall from me also did tht iMac Leopard thing last week. Before he did, he backed stuff up, but still lost everything in his organizer-- he had to call 50 patients and ask them when their appointments were. Oh, and he did it twice.

With that thought, the judge in hair curlers sent me so cartoons that made me smile. I can share them with you?And finally, we three shrink rappers have been talking about distilling some stuff from the blog into a book. I suppose it would be for a different audience, one less likely to visit a blog, but perhaps a glimpse into How Shrinks Think? What do you think?

Writing Bad Prescriptions

OnthePharm has a good post about doctors with such bad handwriting that it is hard to make out their prescriptions.

Unfortunately, these are my "prescriptions" they are making fun of. But they weren't really prescriptions, they were notes from my Poetry Class, where I had to write haikus.

Here's the first haiku (above)... I hope you like it. To see the others, go here (comment #12 I think).

Scrooge 1 IQ say Lassie.
Yo, smile, Poog Pro.
And FIFO mail.

My Three Shrinks Podcast 14: No April Fool

[13] . . . [14] . . . [15] . . . [All]

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Hard to believe we went so long without a podcast. Sorry about that, folks, but life got too hectic for a spell. We didn't do anything special for April Fools Day (except some funny YouTube links), but we still think you'll like today's podcast.

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April 1, 2007:


Topics include:

• Q&A: Midwife with a Knife, an OB/GYN, asks us about whether pedophilia is a disease or something else, and what we think about civil (as opposed to criminal) commitment for it. Clink uses one of her 50-cent words on us (ephebophilia, a term that Clink says was coined by John Money in his book, Love Maps). See also The Last Psychiatrist's posts on this here and here.
  
• NYT article: "The Brain on the Stand", by Jeffrey Rosen. Clink talks about this article about brain diseases being put on trial to explain bad behavior.
• Q&A: Dr Anonymous wants us to say more about our recent posts (here and here) on humor and medicine. This whole discussion (and the numerous comments on the blog) was started by Roy's lyrics to "Walk Like a Psychiatrist."
  

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Find show notes with links at: http://mythreeshrinks.com. 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.

Laughter is a drug

This started out as a comment to respond to some comments in Your Doctor is Making Jokes About You, but it got so long that I thought I'd post it. Midwife's comments (dang, I see she removed them but they deserved to remain) about being able to laugh at tragic circumstances provoked some anonymous comments about insensitivity, which is the other side of the coin to humor (all humor has this Janus quality... it is insensitive to laugh at that poor chicken's difficulty getting to the other side of the street). Mid wife apologized for inciting a riot.

There's no riot. This is a healthy discussion about what it is like to work in a job where one deals with human tragedy on a daily basis.

The problem, I believe, that the anonymous poster has trouble getting his or her arms around, is that physicians (and here I mean all health care "professionals") are not perfect. We do not possess some unique ability that shields us from anger, fear, depression, loneliness, despair. Yet, for some reason, there is an expectation that we are somehow above these human foibles.

We are not.

In the past week, I have dealt with near-lethal suicide attempts, single women who have had their children taken away from them (probably forever) because their brain illnesses currently prevent them from providing adequate parenting, people who have recently lost a loved one, a home, a job, their freedom. I have also dealt with people making more incremental steps of improvement in their life (another week of sobriety, making it to their follow-up appointment, getting a job, making a new friend).

And, I'm afraid, this is a typical week.

Just writing this comment, I feel tears welling up. That's fine. I'm in touch with my pain. I'm down with that. Woo. But I cannot be in touch with it all the time. That may work for some, but for me it would impair my ability to be effective.

So humor is my way of managing these emotions, both in me and in others. And I use it like I use a medication... with a particular dose to achieve a desired outcome (that is, in my work with patients and staff... at home, my humor is much more random... in my posts, it is somewhere inbetween, depending on the topic). (Mind you, I am not talking about "humor" where one laughs at another's misfortune in a way that is intentionally harmful/evil/superior to that person... that is not what I am talking about here.)

My intent is to heal... both myself and others. Just like a drug may have unintended side effects and be harmful, so might humor. I choose medication which I think is uniquely appropriate for a given patient. My patients do not get angry and hurt when a drug makes them have a dystonic reaction. A shot of Cogentin makes it better, and I avoid that type of drug again. They know my intent was to help.

Similarly, I choose the words I use intentionally for a given patient because it is important to use language that they often use. It helps us understand each other. When my humor has an unintended side effect and is experienced as harmful, my patients also do not get angry and hurt. An Apology makes it better, and I avoid that type of humor again. They know my intent was to help.

On the internet, when one stumbles onto a near year-long, extended conversation about psychiatry, mental health, blogging, ducks and fish, it is all too easy to jump right in, read some comments that appear hurtful or mocking, and take offense. This casual blog observer does not know what the intent is, unless they take the time to understand. Similarly, in the hospital, it would be easy to judge me, for example, as insensitive if I am administering one of my therapeutic aphorisms and someone walks past the door, only to hear "You gotta cut this shit out, Joe," or "So your right arm became paralyzed just after your boss told you that you didn't do a good job on the report that you've spent all month working on? I tell ya, it's a good thing it happened when it did, because if that woulda happened to me, I would have wanted to punch him right in the nose."

My approach (in life, but especially on the net) is to assume benign intent. This takes work, because I am, deep down, somewhat suspicious. But at the end of the day, I am convinced that this way of viewing the world makes the world a better place.

Your Doctor Is Making Jokes About You

And Other Things You Don't Want to Know About Medicine

You deserve to know the truth. The truth is, your doctor may be telling jokes about you. Well OK, not necessarily about you, personally. But about medicine. About the experience of treating patients with common conditions in common circumstances. Stories about patients with unreasonable demands or unreasonable behaviors who come back repeatedly for repair after refusing to change the very things causing them problems. With regard to psychiatry, doctors who have been assaulted by a patient in seclusion may use humor to relieve the fear and anxiety associated with caring for a potentially violent person. In situations like this it's better to make a joke than to scream, throw up your hands and walk away.

Sometimes in psychiatry you work with patients who aren't very nice to you. They may be angry and they may say things that are hurtful. As professionals it is our responsibility to take this dispassionately and allow the patient to be honest about their feelings. We cannot snap back or be retributive or let this influence our judgement. Psychiatrists must be dispassionate, supportive, sensitive and empathic.

Frankly, that's hard work.

Humor is one way of dealing with this. People who read this blog know that we use humor a lot. We tell jokes about medications, about diseases, about the pitfalls of psychiatric practice and about each other. (Well OK, usually about Dinah but that's just because she leaves herself so gosh-darn open to it. And because she takes it so well. Believe me, she can give it as well as she takes it.) According to our readers' comments one of the things people like about this blog is that it gives them a behind-the-scenes glimpse of the human side of psychiatry. That may be disturbing to folks who don't want to think about their psychiatrists in that way.

Every physician at some point in time has used humor to mediate stress and vent frustration. Heck, even an entire television series was based on this premise. The legendary Hawkeye Pierce used humor and practical jokes to highlight the idiocy of military (and medical) bureacracy all the while giving terrific patient care. I imagine my opthalmologist, my dentist, my primary care doc and even my gynecologist have their own brand of behind-the-scenes humor that I as a patient have never heard. (I have to admit I've come up with a few thoughts on my own while straddling the stirrups. And here's an informal survey: how many of you have gynecologists who post cartoons on the ceiling above the exam table?)

Personally, if it keeps my dentist sane and available for me and helps him be more tolerant of me as a patient I'm all for it.

I'll bet he's laughing at how I walk.

**********

Warning: This blog features graphic scenes of psychiatric humor that may be disturbing to some readers. Reader discretion is advised.

Roy: Stopping the scourge of P.E.

You all remember Physical Education class (Phys Ed) back in school, right? I recall that it was always looked upon with great anxiety.

I see they now have a drug that helps with P.E. It's about time.

I think it was the performance anxiety... where you truly measured up next to the guy (or girl, I guess... wife tells me it was the same for her) next to you to compete on strength and endurance. Who can go farther, further? Who went the longest? Could I hold out 'til the end?

It wasn't easy. Your coach, with stopwatch in hand, would yell "Go!". You'd start the race, and before you knew it, it was all over. Those days in the gym were the worst hours of high school. It was so embarrassing. The apologies. The disappointment. And I know I wasn't alone. In fact, the article says that up to a third of men had this problem.

Globe&Mail: “We tend to think of this as, ‘Oh, it affects novices, the first time, and young people,' ” Dr. Pryor said Thursday from Minneapolis. “But no. There are some people who have this who are older, and oftentimes it affects them their entire lives.”

I hadn't thought that P.E. had such a prolonged effect on folks. I guess there's a kind of P.E. P.T.S.D. And this medicine helps. This drug, dapoxetine by ALZA, helped guys' stamina "last three, four times what they were before."

Just think of how that can relieve the anxiety of whether you can hold out long enough to go the distance. In football, you'd be able to finally score a touchdown. In baseball, you'd be able to steal third base and slide into home. Playing golf, you'd finally master your stroke and get a hole in one. In basketball, this drug would help you shoot the furthest. And surely, in cricket, you could manage the most sticky wicket.

Of course, we do have to temper our enthusiasm until further studies demonstrate the effectiveness of dapoxetine. Too often, the press goes off half-cocked about the latest fad drug. Let's not be too premature. However, I've already bought stock in ALZA, because when the FDA ...

...um... what's that?

It is?

Oh. Well, that's very different.

Never mind.

Roy: Psych Notes for Smilies

Inspired by Carrie's comments...
Carrie had wondered why her doc never put her on an antidepressant. She wrote: "God knows most days I wonder why not. LOL "
I replied: "It's because of the 'LOL'. If you couldn't LOL then maybe he would. Of course, if you were ROFLYAO, then he'd probably reach for the lithium."

This exchange got me thinking... hmm... how would a psychiatrist manage someone who could only communicate via emoticons? Below are the resulting progress notes...

:-)	stable. cont prozac 40mg. f/u 3 mos.
:-))	reduce prozac to 20mg. f/u 1mo.
:-))))	d/c prozac. add lithium 300 tid. check TSH, creat. f/u 1wk.
:-D	add depakote. check lithium level, LFTs, CBC. f/u 1wk.
:-|	stable. cont prozac 40 mg. f/u 1mo.
:-(	increase prozac to 60mg. f/u 2wk.
:'-(	add wellbutrin SR 150mg. f/u 1wk.
X-(	call 911. send to ER. check for OD.
:*}	check breathalyzer. refer to AA.
%-}	weekly tox screen. refer to AA/NA.
:-&@?	add haldol 2mg bid.
|-0	d/c ambien.
:-#	d/c elavil. use hard candies.
;-P	d/c haldol. add clozapine. AIMS exam. vitamin E 800 iu bid.
:-)~	reduce haldol. add cogentin to reduce sialorrhea.
8-~	reduce dose of seroquel.
(:-)	reduce depakote. add zinc, selenium.
;-)	establish boundaries. do not schedule at end of day.
;-x	see with chaperone only.
=^..^=	give Ativan 1mg IV to relieve catatonia. (thanks, ClinkShrink)
:-o	(on seeing the bill for 1st appt.)
>:-O	(on seeing the bill for missed appt.)

Roy @ Shrink Rap (http://psychiatrist-blog.blogspot.com) and mythreeshrinks.com

[thanks, SmiliesUnlimited, for the emoticons]

I Guess You Had To Be There

Every psychiatrist knows the DSM criteria for major depression: low mood, decreased self-attitude, changes in sleep, appetite, concentration, memory or sex drive, excessive or inappropriate guilt (and how do you judge that in a correctional facility?), anhedonia and suicidal ideation.

I would like to propose one small additional criteria:

Humor latency. Yes, a delayed or absent response to humor. Particularly my humor. Some people would claim that loss of humor falls under the anhedonia category, but I disagree. Anhedonia could mean almost anything: inability to enjoy knitting, exercise (but then almost everyone would meet criteria), coffee (never!) or Japanese existentialist literature. Humor is universal. Granted, some research suggests there may be gender differences in humor. Other research done on twins suggest that environmental factors play a role. (Where can I get in on a research gig that involves showing Far Side cartoons to twins?)

I'll grant the fact that men and women may appreciate different forms of humor. A male colleague of mine used to be prone to practical jokes---of the 'hide the rubber cockroach in the patient charts' kind of humor---and he referred to April Fool's Day as "Amateur Day". He had a problem with my puns. Or rather, he suffered from "humor latency". This is how he explained it: "I used to think I was just too stupid and didn't get your humor. But then I realized I did."

Now I know he was just meeting criteria.