Weiner Diagnosis?

 

In Shrink Rapper world, we get a lot of email from publicists about books, TV spots, upcoming events.  This was in my spam box today:

Rep Anthony Weiner is expected to resign today after weeks of scandal surrounding his lewd text messages, tweets and photos.  Even in his tearful media conference, Weiner could not explain why he participated in such behavior.  According to NYU Medical Professor and Internist, Dr. Marc Siegel, the congressman’s behavior is systemic of a larger psychological problem, which must be addressed before fixing the addiction to online sexual activities.  

 

Dr. Siegel says, “This seems to be an example of extreme narcissism, inflated self image, depersonalization, loss of contact with reality, addiction, and the power of the Internet as a medium (like the Wizard of Oz you feel you are hiding behind the curtain)”.

 

To discuss the dangers of addiction and steps to overcome the serious illness, Dr. Siegel is available to offer is medical knowledge.  As a medical practitioner and FOX’s House Doctor, Dr. Siegel has spent years diagnosing and treating people in the national media spotlight.

 

If you are interested in speaking with Dr. Siegel, please contact me at .

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

Oh my, I thought.  I read it twice. An internist is going to comment on Anthony Weiner's narcissism, motivations, sense of self, and contact with reality?   Sounds like a shrinky thing to me, but the Goldwater Rule prohibits psychiatrists from commenting on the mental state and diagnosis of someone they haven't personally examined.  Does that mean it's okay for other specialists to talk about the mental state of someone they don't know?  Hmmm...   I guess we'll see what he has to say, but I'm not so sure about this.

What's Holden Got?

There's a copy of the DSM-IV sitting on my coffee table. Not the usual, not even at a Shrink Rapper's house, but I'm trying to write the Shrink Rap book and, in theory, I may need to look something up.

So, kid looks at the DSM and informs me, "We read that in English class today." They read the DSM in English class? Hey in the good old days, we read Macbeth in English class. We didn't need psychiatric diagnostic manuals. "Oh, why?" So they're reading Catcher in the Rye and they decided to diagnose Holden Caufield. Interesting. What's he got? Oh, we shrinks don't do that. Until I personally examine Holden, I'm not venturing a guess as to his psychiatric diagnosis. The APA and the medblogging community would have me de-shrunked.

So what did the English class say? (They're kids, they can venture guesses if they like). One thought he had Borderline Personality Disorder, some thought he had Bipolar Disorder, and a few thought he had Schizophrenia.

Funny, I was writing today about how hard it is to diffentiate developmental issues, family complexities, and psychiatric illness in adolescence. Seems like a funny coincidence.
Well, what's Holden got?

To the Max--- Life With a Little Help

I'm back from my White Christmas, back to muddy Maryland. I'm trying to find something stimulating to blog about with my brain on psychiatric vacation. Judith Warner of the New York Times has been kind enough to help with her op-ed piece "Living the Off-Label Life." She talks about a Shrink Rap favorite topic: the line between distress and illness, the use of medication (or in this case, non-meds such as coffee ...Clink....diet, etc) to help people reach some idealized potential. Ms. Warner writes:

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What if you could just take a pill and all of a sudden remember to pay your bills on time? What if, thanks to modern neuroscience, you could, simultaneously, make New Year’s Eve plans, pay the mortgage, call the pediatrician, consolidate credit card debt and do your job — well — without forgetting dentist appointments or neglecting to pick up your children at school?

She goes on to discuss an article in Nature:

That’s why when Henry Greely, director of Stanford Law School’s Center for Law and the Biosciences, published an article, with a host of co-authors, in the science journal Nature earlier this month suggesting that we ought to rethink our gut reactions and “accept the benefits of enhancement,” he was deluged with irate responses from readers.

“There were three kinds of e-mail reactions,” he told me in a phone interview last week. “ ‘How much crack are you smoking? How much money did your friends in pharma give you? How much crack did you get from your friends in pharma?’

But Greely and his Nature co-authors suggest that such arguments are outdated and intellectually dishonest. We enhance our brain function all the time, they say — by drinking coffee, by eating nutritious food, by getting an education, even by getting a good night’s sleep. Taking brain-enhancing drugs should be viewed as just another step along that continuum, one that’s “morally equivalent” to such “other, more familiar, enhancements,” they write.
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Seems like something we struggle with over and over....

The Snake Trail Test

Psychiatrists have a way of assessing judgment during the mental status examination. Typically they'll ask a question like, "If you found an envelope lying on the sidewalk and it was addressed and stamped, what would you do with it?" The typical answer, the one that will get you a 'good' rating on the judgment line, is: "I'd mail it." Duh. There are other possible responses, some of them more interesting or creative than others, but that's the response you get most of the time.

I had a chance to come up with a new "judging judgment" type question this week. I call it the Snake Trail Test. Here's how I came up with it:

As coincidence would have it, one of the best local climbing spots near here also happens to be a repository for copperhead snakes. Since I've taken up climbing I've now seen more copperheads in the wild than I've ever seen in any zoo. Whenever I see a snake, I warn any hikers I happen to see in the area. Many hikers are parents with small children. It's been interesting to see the wide variety of responses.

One parent immediately grabbed the kid and said, "No no honey, don't go down that way. We'll go on this trail instead." Another parent still went down the trail, but cautioned the kids and made sure they stayed on the far side of the path, away from where the snake was spotted. The most interesting reaction came yesterday, from a young tattooed woman hiking with four kids under the age of ten. After I gave her the warning she shrugged, pointed back over her shoulder at the trail she had just come down, and said, "Yeah there's another one back there." Not a word to the kids and they all scrambled on without a care.

The psychiatrist within me thought: "Checkmark for 'poor' judgment." Then I thought again: "Maybe she's an herpetologist. Maybe she comes from a charismatic poisonous snake-handling cult. Maybe she's been hiking here for 20 years, has seen lots of snakes and never had a bad outcome." There were a lot of reasons why someone might not be freaked out by the idea of a poisonous snake in the trail.

My new Snake Trail Test has got me thinking about how we interpret judgment.

Judgment is formed through learning, experience, culture and a multitude of other personal idiosyncratic factors that a psychiatrist might or might not be aware of. The best way to sort out 'normal' and 'impaired' judgment is to ask followup questions. "Why would you do that?" is a good one. "Why not do this?" is another good followup question.

I didn't have a chance to ask the tattooed lady more questions, but I bet if I did she might have given me a good education about snakes.
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Note from Dinah: Here's a post from Edwin Leap about what Not to bring to the ER with you, and it includes the snake that bit you.

Everybody Lies

Back in the Dark Ages when I applied to medical school, all applicants were required to take the Minnesota Multiphasic Personality Inventory or MMPI. This is a personality test designed to identify psychopathology by examining the answers to literally hundreds of questions, many of them innocuous-sounding or not clearly related to any pathological answers. For example, one question that stood out in my mind was "I like to paint flowers." Now, I happen to like flowers and paintings of flowers but never in my life have I ever even tried to paint flowers. You're supposed to answer "true" or "false" to this question. Keep in mind that the answer to this question was going to have some bearing on whether or not I got accepted to medical school. OK, you make your best guess on the "right" (non-pathological) answer, whatever that's supposed to be, and then you run into this question:

"I always tell the truth."

Oy. Talk about your wife-beating question. (In other words, "Sir, when did you stop beating your wife?"). If you answer "yes" then you're obviously lying because everyone fibs now and then. If you answer "false" then you look like a dishonest person who couldn't be trusted to hold a friend's purse much less a scalpel.

So anyway, that brings up the issue of truth-telling in psychiatric treatment.

No patient ever tells the truth. Not the whole truth, not at first, and not in the way they want you to hear it. It's not a matter of intentional dishonesty or deception and it's not a character flaw, it's just being human. I've had friends (not my co-bloggers) who have told me, "Oh, only your patients lie." Well, as Dinah puts it, in my little bubble world it would be nice to believe that the only misleading people were the ones inside the prison walls.

There are many reasons not to tell the whole truth, or to tell it in a way that puts the best light on things. Self-deception (or therapist/psychiatrist) deception is a way to look your best to help the therapeutic relationship form. It's a defense mechanism for people who are feeling self-conscious about their problems or embarrassed about their background or humiliated by their real or self-perceived failures. In extreme cases, it's a way of protecting oneself from negative consequences (eg. "If I tell my doctor I'm suicidal, I'll get 'put away'.") For my patients inside the walls, it's the way they've found to cope with life and get their needs met because they learned early on that simple requests for help often didn't work.

The gradual unfolding of truth, the step-by-step admission of distortions, is part of the treatment process. It's a positive sign that trust is growing between patient and doctor. In psychiatric treatment, at least in my clinic, you don't get punished for admitting you lied.

So now in all honesty, I'll admit that I'd love to paint flowers.

(Wow, this is a first in the history of the blog---I've posted over myself!)