What's A Sociopath?

As my fourth and final post for Clink Week here at Shrink Rap, I have been inspired by Roy (again). I was curious about our different reactions to the character Tippi Hedron played in the Alfred Hitchcock movie Marnie. Roy pointed to different aspects of her personality to say that she wasn't a sociopath, so it got me thinking about why I reacted so differently. We've already speculated about whether or not Darth Vader had borderline personality disorder, so lets progress to another Cluster B disorder by talking about Marnie.

First of all, sociopathy per se does not exist in the Diagnostic and Statistical Manual. It was originally conceived in the mid-nineteenth century as "moral insanity", in other words a defect in moral reasoning. Even then there was argument about whether or not this constituted a "real" mental disorder.

Later in the Twentieth Century sociopathy was further refined by Hervey Cleckley's book The Mask of Sanity. His series of case reports of psychopaths formed the basis for Robert Hare's later Hare Psychopathy Checklist, a tool that is in common use in forensic settings. Both of these sources describe several core features of psychopathy:

• a parasitic lifestyle, the ability to control or manipulate others
• superficial charm, glibness, pathological lying
• criminal versatility
• lack of remorse, inability to empathize or lack of regard for impact on others
• shallow or feigned emotions
• early behavior problems, impulsive or unstable adult behavior
  

The descriptions go on and on, but those are some of the main aspects. So, that being said, how does Marnie stack up?

Well, what struck me at first was her level of ease and comfort while committing her crimes. She took her time, observed her workplace surroundings, kept her cool and escaped without breaking a sweat. She readily used aliases and multiple false identities, and her facile lying ability allowed her to quickly gain the confidence of the employers who later became her victims. Many people commented on her confidence, poise, intelligence and charm. She showed no apparent remorse nor did she ever even comment upon the damage her crimes inflicted on others. It's true that she was committing crimes to buy the love of her mother, as Roy suggests, but she showed a startling level of callousness to a young girl in her mother's care who also needed attention. She loved her horse, an attachment that seemed to be her only genuine emotion. Although she agreed to marry Connery, her love for him is closely tied to his willingness to help her as he made restitution for her crimes and took steps to help her avoid prosecution. As far as the impulsive or unstable lifestyle goes, one of the most intense scenes in the movie took place after she shot her horse (her only strong consistent relationship) when it seemed she might shoot Connery as well.

And for the last criteria---the early childhood behavior problems---well, you'll have to watch the movie to find out what that was. Let's just say it's not the behavior of a typical child. (I'm amazed she was so strong for such a little kid!)

So that's why I thought Marnie was a sociopath, for those who are interested in them.

I'm going to let Dinah out from under the floorboards now.

Leave Me Alone: Does SHU Syndrome Exist?

[Note: This is the second in a two part series discussing the effects of longterm segregation. The first part in the series can be read here.]

When you read legal opinions or listen to professionals talk about the psychiatric effects of longterm segregation you will sometimes hear them refer to something called the "SHU syndrome". The "SHU" stands for Special Housing Unit, another name for a control unit prison or a tier in a regular prison where inmates are kept in longterm segregation.

The commonly accepted definition of "syndrome" is a constellation of signs and symptoms that are common to all sufferers of a disease. Syndromes are validated by showing that the particular syndrome can distinguish between people who have the disease versus those who don't, and can distinguish one disease from others.

The SHU syndrome has had a variety of symptoms attributed to it, but they generally include some type of altered mental state, specifically changes in mood and cognition or orientation. It is presumed to be caused by the conditions of confinement in segregation. One of the earliest descriptions, and the one that probably gets cited most often by correctional experts and the judiciary, is in a 1983 article by Grassian, The psychopathological effects of solitary confinement. He interviewed fourteen segregation inmates who had been confined from eleven days to ten months. These inmates reported heightened sensory acuity, affective disturbance (particularly anxiety), difficulty with concentration and memory, as well as illusions and misperceptions. All symptoms reportedly resolved within hours of release from segregated confinement. It should be noted however that all the subjects in this study were inmates who had filed a class action Eighth Amendment suit based upon their condition of solitary confinement. The author himself noted that he was required to “actively encourage disclosure of information” in order to obtain symptom reports, because the subjects initially denied problems. This aspect of the study is rarely (make that never) cited in legal opinions.

I could post a series of studies, using small sample sizes of actual prisoners, to detail things people have done to see if segregation actually does cause physiologic changes or changes in psychiatric symptoms, but that would basically end up being a tedious listing of article summaries (a big reason why my book chapter on the effects of segregation was never finished---I even bored myself!). The bottom line is that studies using control groups showed either no significant differences with controls, or only minor differences that disappeared quickly after removal from segregation.

If anyone really really wants me to post the draft of a book chapter I could but I'm not sure my co-bloggers would forgive me.

**********

Grassian, Psychopathological effects of solitary confinement, American Journal of Psychiatry 140: 1450-1454, 1983.

Marnie: A Movie Review

Alfred Hitchock's film "Marnie" is both a romance and a pop psychology study of sociopathy. Sean Connery, playing an amatuer jaguarundi-taming zoologist, traps and marries Tippi Hedron, a compulsive liar and thief who represents the ultimate challenge for him, taming the predatory American female. Hedron is also suffering from erythrophobia (fear of the color red), which drives her sociopathic behavior. Connery feels compelled to cure his wife of the early childhood trauma which lead her in adulthood to commit a series of robberies.

Apart from the questionable wisdom of trying to analyze your wife, his "treatment" tactics are also dubious from my prospective. He attempts to cure his wife through bibliotherapy---titles such as "The Sexual Deviations Of The Female Criminal" and Jung's "The Undiscovered Self", word association and abreaction. Unfortunately, none of this prevents her from shooting her horse, attempting to rob Connery's father, attempting suicide by drowning on her honeymoon and banning her husband from their honeymoon suite.

In true pop psychology form, he ultimately learns that she committed the robberies and used the loot in an attempt to buy the love of her mother. Wow! What a film. Hitchcock takes us from the horseracing track to the brothels of 1960's Baltimore to the estate of Connery's blueblood father. Along the way Hedron reveals clues to her early trauma---she freaks out at any sight of the color red and at the sound of thunder.

Since all criminal behavior is caused by an early childhood trauma, Hedron's secret is of course eventually revealed in a massive regression scene involving Connery and her creepy mother. In the final scene we find her turning gratefully to Connery to say:

"Mark...I won't go to jail for this, will I?"

He answers: "Not after what I have to tell them."

I silently answered: "You may or may not go to prison, Marnie, but you do need a good forensic psychiatrist."

*********

This is the movie I went to in order to escape my lack of air conditioning this past weekend. Dinah wanted a review, so here it is. It was fun.

Apple Releases New Medical iPhone 3G Device: the iShrink

Steve Jobs today unveiled Apple's latest cool new device, the iShrink.  The handheld device is the latest Cupertino offering for its e-health initiative, following in the steps of its highly successful iKG for monitoring the heart, and the iXRay Nano.

The iShrink follows the iPhone form factor, while adding an alcohol breathalyzer to detect the user's alcohol level.  Initially aimed at the emergency psychiatry market, the electronic psychiatric aide also capitalizes on its camera, microphone, and accelerometer.  The accelerometer is usually used to detect screen orientation, but new software can analyze rapid changes, resulting in the ability to distinguish among a Parkinsonian tremor, a lithium tremor, and EPS.  It can even detect objective akathisia, according to Apple's Chief Medical Officer, Dr. Benjamin Rush.  "This does not replace the psychiatrist, but helps busy E.D. physicians get a better assessment before deciding to order a psych consult."

The camera's facial recognition software can detect the amount of lid lag, helpful in assessing for thyroid conditions and also intoxication, while also looking for tardive dyskinesia movements.  The microphone can assess for slurred speech, and uses the Dragon Dictate engine for speech recognition.  Software written by psychiatrists and programmers at the University of Maryland provides cognitive behavioral therapy, and the software can be updated via iTunes in response to the most up-to-date evidence-based medicine findings.  If a psychiatrist is  recommended, the iShrink can also be used to contact a telemedicine psychiatrist, who can interact with the E.D. physician and with the patient in real-time.

"It can even be used to listen to our podcasts on My Three Shrinks," notes psychiatrist Dr. Roy.  His colleague, Dr. Clink Shrink, noted "What I like best about it is that you can use it to go to iTunes and write a review."

While the price of the iShrink is a steep USD$599 (much more than the iPhone 3G at USD$199), many groups feel it is worth the expense.  But not everyone feels the hot new device is worth all the attention.  Dr. Dinah from the Shrink Rap blog said, "I can't even figure out how to use the darn thing, and if I got one I'd surely spend all my time on it, so forget it."

The iShrink will be available on July 11 in 62 countries.

Leave Me Alone: The Science Of Solitary Confinement

Solitary confinement, or segregation, is used for several reasons. Inmates are put into segregation as a disciplinary measure for doing things like threatening or fighting with officers, escaping, destroying state property or setting fires. Segregation is used for medical reasons for inmates who may have infectious diseases (like tuberculosis) or who are refusing evaluation for infectious diseases. Segregation is used for protective custody if the inmate is a juvenile or if there are reasons to believe the inmate's safety might be at risk in regular housing (also called general population). Finally, there are also mental health reasons for putting someone in segregation. Inmates who are new to the facility, who are frightened and need time to adjust, or who have had a recent trauma or loss may temporarily be put by themselves to give them a quiet place to deal with whatever is going on.

In free society segregation is used for therapeutic reasons too, although the terminology changes. On an inpatient unit "segregation" becomes "seclusion" even though the physical conditions may be identical, or very similar to, the physical environment in a prison. Seclusion rooms and segregation cells are usually bare with minimal comforts. The patient (or inmate) is deprived of access to outside resources and supports, with no regular recreation or entertainment. The food is, well, institutional food is institutional food.

The only real difference is that in free society when someone is put in seclusion there must be a clinical evaluation that finds an indication for using this intervention, usually unpredictability or evidence that the patient may be a danger to himself or others. The indication is documented and the patient is usually also observed at regular intervals. The order for seclusion must be rewritten at regular intervals and the basis for continued seclusion documented in the patient's chart. The patient must be allowed periodic freedom from restraint (if physically restrained) and access to hygiene and toileting facilities. Seclusion must end when the clinical indication for it is over.

In a correctional facility segregation does not have to be based on clinical need, and most often it's not used for mental health reasons. Segregation is usually used for security and disciplinary reasons, in which case it's called "disciplinary lockdown". The length of confinement is predetermined, usually a few days to a few weeks. If the inmate is really really bad (has killed other inmates or correctional officers) or presents an extreme security risk (repeated escapes or organizing riots) the segregation may last for months or even years. Inmates have a lot to lose by being placed in lockdown for this long, so correctional facilities have due process protections in place to provide them with a chance to challenge their confinement. The legal steps used to place an inmate in lockdown are very similar to the process used for civil commitment in free society: the inmate is given a notice that documents the alleged behavior leading to the lockdown, he is given a hearing before an independent factfinder with a chance to present evidence and confront witnesses, and he's given an opportunity to appeal the results of the disciplinary hearing. He is also allowed to be given less restrictive sanctions, like loss of privileges or cell restriction in general population. If all else fails, the inmate has the right to appeal the administrative hearing officer's decision to a court in free society.

So, now that you have this background I'll come to the real reason I want to talk about longterm segregation:

Inmate advocates allege that longterm segregation drives prisoners crazy. Whether you know it or not, millions of taxpayer dollars are spent every year litigating the use of longterm segregation. Specialized correctional facilities, known as control unit prisons, were invented specifically for inmates who require segregation for months or years. Class action suits filed by the American Civil Liberties Union and other advocacy organizations allege that this causes psychiatric deterioration and psychosis, with some groups calling for closure of all control unit prisons.

But is this true?

The fact of the matter is that despite all the money we've spent regulating the use of control unit prisons and monitoring inmates who are on segregation, the data are sketchy. Epidemiologic studies have shown that the prevalence of psychiatric disorders among prisoners increases with each increase in security level---in other words you find more psychiatric patients in maximum security than in minimum security---but this does not prove that high security causes psychiatric disorder. In all likelihood, inmates with aggressive or disruptive behavior, such as those found in maximum security, are more likely to be diagnosed with a psychiatric illness. Aggressive antisocial or borderline inmates often are also concurrently diagnosed with bipolar disorder. Conversely, inmates with psychiatric disorders are less likely to be classified to lower security levels where on-site psychiatry services may not be available. The epidemiologic findings are an artifact of the classification process and a reflection of our limited diagnostic schema.

I did a PubMed search (I'm big on these lately for some reason) using the terms "administrative segregation", "longterm segregation", "control unit prison" and "solitary confinement". There are only about 20 significant articles on this topic going back 45 years---not exactly an overwhelming body of literature. Only four of the nineteen are controlled studies with data, while the majority are descriptive, theoretical or speculative in nature.

Contrast this with the court's view of the psychological effects of control unit prisons, as outlined in David Fahti's law review article "The Common Law of Supermax Litigation" (Pace Law Review Vol. 24:675, 2005):

"Federal courts continue to recognize as established fact that isolated confinement inflicts serious psychological harm on many prisoners."

And in one case cited in the article:

"The effect of prolonged isolation on inmates has been repeatedly confirmed in medical and scientific studies".

The medical articles cited in these legal cases are few, and are usually 20 years or more out of date. They point to the effects of social isolation and sensory deprivation, a line of research popular in the 1960's when research into brainwashing was de rigueur for psychologists. Unfortunately, because most of these cases are settled by consent decree and rarely go to trial, this lack of scientific scrutiny is left unchallenged. The result is that courts are mandating that certain inmates be removed from segregation based on the presence or abscence of an Axis I DSM diagnosis, disregarding the inmate's behavior and adjustment in previous facilities. In one case a court mandated that any inmate with a "serious personality disorder" be removed from a control unit prison---I imagine that must have pretty much emptied out the place.

I agree with the courts that control unit prisons should practice humane care under safe and reasonably comfortable conditions. It should be done because it's the right thing to do but you shouldn't misrepresent or distort scientific evidence to justify it.

*********

I had trouble saving the link to the combined search, so I'll just post the references:

1: Arrigo BA, Bullock JL.
The Psychological Effects of Solitary Confinement on Prisoners in Supermax Units:
Reviewing What We Know and Recommending What Should Change.
Int J Offender Ther Comp Criminol. 2007 Nov 19. [Epub ahead of print]
PMID: 18025074 [PubMed - as supplied by publisher]

2: Cloyes KG.
Prisoners signify: a political discourse analysis of mental illness in a prison
control unit.
Nurs Inq. 2007 Sep;14(3):202-11.
PMID: 17718746 [PubMed - indexed for MEDLINE]

3: Doncliff B.
Solitary confinement in mental health nursing.
Qld Nurse. 2007 Jun;26(3):7. No abstract available.
PMID: 17624037 [PubMed - indexed for MEDLINE]

4: Way BB, Sawyer DA, Barboza S, Nash R.
Inmate suicide and time spent in special disciplinary housing in New York State
prison.
Psychiatr Serv. 2007 Apr;58(4):558-60.
PMID: 17412861 [PubMed - indexed for MEDLINE]

5: Andersen HS.
Mental health in prison populations. A review--with special emphasis on a study
of Danish prisoners on remand.
Acta Psychiatr Scand Suppl. 2004;(424):5-59. Review.
PMID: 15447785 [PubMed - indexed for MEDLINE]

6: Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, Hemmingsen R.
A longitudinal study of prisoners on remand: repeated measures of psychopathology
in the initial phase of solitary versus nonsolitary confinement.
Int J Law Psychiatry. 2003 Mar-Apr;26(2):165-77. No abstract available.
PMID: 12581753 [PubMed - indexed for MEDLINE]

7: Andersen HS, Sestoft D, Lillebaek T.
Ganser syndrome after solitary confinement in prison: a short review and a case
report.
Nord J Psychiatry. 2001;55(3):199-201.
PMID: 11827615 [PubMed - indexed for MEDLINE]

8: Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, Hemmingsen R, Kramp P.
A longitudinal study of prisoners on remand: psychiatric prevalence, incidence
and psychopathology in solitary vs. non-solitary confinement.
Acta Psychiatr Scand. 2000 Jul;102(1):19-25.
PMID: 10892605 [PubMed - indexed for MEDLINE]

9: Gore SM.
Suicide in prisons. Reflection of the communities served, or exacerbated risk?
Br J Psychiatry. 1999 Jul;175:50-5.
PMID: 10621768 [PubMed - indexed for MEDLINE]

10: Sestoft DM, Andersen HS, Lillebaek T, Gabrielsen G.
Impact of solitary confinement on hospitalization among Danish prisoners in
custody.
Int J Law Psychiatry. 1998 Winter;21(1):99-108. No abstract available.
PMID: 9526719 [PubMed - indexed for MEDLINE]

11: Farrell GA, Dares G.
Seclusion or solitary confinement: therapeutic or punitive treatment?
Aust N Z J Ment Health Nurs. 1996 Dec;5(4):171-9. Review.
PMID: 9079314 [PubMed - indexed for MEDLINE]

12: Grassian S, Friedman N.
Effects of sensory deprivation in psychiatric seclusion and solitary confinement.
Int J Law Psychiatry. 1986;8(1):49-65. No abstract available.
PMID: 3940165 [PubMed - indexed for MEDLINE]

13: Suedfeld P.
Measuring the effects of solitary confinement.
Am J Psychiatry. 1984 Oct;141(10):1306-8. No abstract available.
PMID: 6486277 [PubMed - indexed for MEDLINE]

14: Grassian S.
Psychopathological effects of solitary confinement.
Am J Psychiatry. 1983 Nov;140(11):1450-4.
PMID: 6624990 [PubMed - indexed for MEDLINE]

15: Volkart R, Rothenfluh T, Kobelt W, Dittrich A, Ernst K.
[Solitary confinement as risk factor for psychiatric hospitalization]
Psychiatr Clin (Basel). 1983;16(5-6):365-77. German.
PMID: 6647886 [PubMed - indexed for MEDLINE]

16: Kaufman E.
The violation of psychiatric standards of care in prisons.
Am J Psychiatry. 1980 May;137(5):566-70.
PMID: 7369400 [PubMed - indexed for MEDLINE]

17: Maclay DT.
Letter: Solitary confinement in control units.
Lancet. 1975 Aug 30;2(7931):408. No abstract available.
PMID: 51211 [PubMed - indexed for MEDLINE]

18: Gendreau P, Freedman NL, Wilde GJ, Scott GD.
Changes in EEG alpha frequency and evoked response latency during solitary
confinement.
J Abnorm Psychol. 1972 Feb;79(1):54-9. No abstract available.
PMID: 5060981 [PubMed - indexed for MEDLINE]

19: WALTERS RH, CALLAGAN JE, NEWMAN AF.
Effect of solitary confinement on prisoners.
Am J Psychiatry. 1963 Feb;119:771-3. No abstract available.
PMID: 13998703 [PubMed - indexed for MEDLINE]

20: van WULFFTEN PALTHE P.
Fluctuations in level of consciousness caused by reduced sensorial stimulation
and by limited motility in solitary confinement.
Psychiatr Neurol Neurochir. 1962 Nov-Dec;65:377-401. No abstract available.
PMID: 14002046 [PubMed - indexed for MEDLINE]

Street Value of Psychiatric Medications

StevebMD asked: "Is there a way to find out the "street value" of various psych meds in different cities? We know that benzos and opioids are highly valued, but I'm curious about other things like antipsychotics and sleep meds."

So I did some googling and did not find much. I even went on erowid.com, but couldn't find much there, either. So, I thought I'd set up a little database for people to enter what they know about the street value of, say, a 100mg pill of Seroquel.


Now, I am NOT trying to encourage these sorts of illicit transactions (you do know that it is a federal offense to sell a controlled prescription drug, right?). Indeed, the more we become aware of the potential for diversion of the drugs we prescribe, the more we can guard against it.


So, please complete the following form for any medications you may have knowledge of (either from asking your patients or from your own personal knowledge). Include your zip code so that I can set up a Google Map of all the entries. Once we have a number of datapoints, I will add the map to this post.

---

[View Database]

Grand Rounds Coming to Shrink Rap June 24

Hey, folks.  Thought I'd just give y'all a heads up that we will be hosting Grand Rounds on Tuesday, June 24, 2008.  So, if you are a blogger and want to submit something, stay tuned to this space.

We are planning something special again for Grand Rounds this year (if you don't know what this is, here is the one from this past week).  Last year, Clink designed a Clicky Brain, so that one could go to different categories of posts by clicking on a map or the brain.  We hadn't seen an image map used like this on Blogger until then, so it was the cat's meow... "the bee's knees", as my resident colleague, David Rosenberg, would say.

So, we have to come up with something unique again, of course.  I will keep that a surprise until June 24 (clue: "one more thing").  But I will leave you with one tidbit.  We will do an entire podcast about the Grand Rounds submissions.  Yep, each of the submitted posts will get some air time.  

So stay tuned.

Until then, check out John Crippen's NHS Blog Doc on June 10 and Mariana's Eye Blog on June 17.

I Didn't Hurt Anybody

I am not a happy ClinkShrink right now. I'm a bit hot under the collar. In fact, I'm a bit hot everywhere right now.

I have no air conditioner. I know, I know, I should be used to this by now. I don't have a phone, I don't have a desk, I have to hunt for chairs to sit on every day. I should be used to this.

I am, I'm just not used to this at home.

This isn't something I typically blog about. I generally keep my personal life off the Internet and stick to mainly professional-type topics, but I promise I will make this relevant to psychiatry.

I called up the local heating and air conditioning guy, who took one look and pointed out what was wrong. He saw it immediately, and I can't believe I didn't.

Someone stole my copper freon pipe. It was four or five feet long, leading from the external pump up into the side of my house. It had been clipped off neatly at either end, so neatly I didn't even notice it was gone. I'm told it's going to take four hours of labor (at an hourly rate nearly 50% higher than what I make as a physician) and four gallons of freon (at $60 per gallon) to fix and there is no guarantee it will work. Depending on how long the pipe was gone, both my external compressor and internal unit may be toast. Replacing both units is ridiculously expensive, not to mention time lost from work and loads of inmates who aren't going to get psychiatric care while I'm out.

I'm going to think about this incident the next time I hear someone say drugs should be decriminalized because drug addicts are only hurting themselves. I will think about this the next time a non-violent substance abuser says, "I'm an addict but I never hurt anybody."

Horse hockey.

Like most people who live in big cities, I've been a victim of crime before. I've also had my car window smashed in by someone looking to steal a bag of used spark plugs (long story). Again, metal recycling is used to support drug addiction. (Maybe we need a registry of people selling metal like we do for pawn shops??) Once upon a time, someone even stole the brass doors off of our circuit court house (200 pounds apiece, metal value estimated at a quarter of a million). Drug addicts don't only hurt themselves and the most hardcore addicts need to be picked up involuntarily and taken off the streets to make them stop using.

So anybody who really wants to debate this is welcome to come over to my place this weekend. The forecast is for a hundred degree heat index.

Bring ice.

*********

For more on the scrap metal theft epidemic, see also:

How hot are metals?

---
Note from Dinah: my guest room has a window unit. You're always welcome

But I Do Want To Talk

First, Roy wants your opinion about Online Access to Prescription History, so if you haven't chimed in, please do.

This post was inspired by ClinkShrink's post, I Don't Want To Talk, where she discusses mandated debriefing after trauma and what role that might have in either preventing or causing mental illness (Roy: which is what we spent all of podcast #46 talking about).

Disaster Psychiatry is a field that it still defining itself. It's a close-to-home issue for me because Shrink Rap was started as a way for me to deal with some residual angst I had after returning from a couple of weeks in Louisiana where I worked on the Katrina Assistance Project. Roy & Clink got sucked in, but what can I say? At that time, I wrote a piece about my experiences and posted on it's own blog link. I talked a bit about the stuff ClinkShrink discusses-- some history of the Mitchell Model of Critical Incident Stress Debriefing, as well as Sally Satel's paper on how the mental health industry exploited the terrorist attacks of September 11th. You can click HERE to link to my Katrina Reflections.

Since ClinkShrink wants to talk about mandatory debriefing and whether talking about a trauma lessens it's impact and prevents the development of future psychopathology, I'll talk about my own thoughts about the role of psychiatry in the aftermath of a community trauma.You can define community in a big or small way, but I mean a shared experience as opposed to a traumatic act to a single individual .

There are five concerns from a shrink's point of view. There may be more, but these are my random thoughts and it's our blog. Do chime in on the comment section.

• There are people with psychiatric disorders who may no longer have access to treatment-- perhaps because they need to relocate, because their doctor &/or records have been obliterated, their pharmacy closed down-- and they are at risk for a relapse of a pre-existing illness.
  
• There are people who develop psychiatric disorders as a direct result of stress-- it's not unheard of for people to become manic after the death of a relative, to become anxious or depressed, and so if psychiatric symptoms are precipitated without disasters, it's safe to assume they can be precipitated by trauma. Certainly, some of these people may have underlying disorders that would eventually be unmasked anyway.
• There are people who develop psychiatric disorders as a direct result of the specific trauma who may not have ever required the services of the mental health profession if such an event didn't occur. The question here, and the one that ClinkShrink addressed, is whether early interventions to the entire population alter the likelihood that someone will develop a psychiatric illness. Who to target, what to target them with, and if it will matter are all questions to address
  
• There are people who are distressed by an objectively distressing event but who don't (and hopefully won't) develop a psychiatric condition. These people often feel a need to talk and are well-served by friends, family, and religious leaders. The role for psychiatrists here is one that should be taken only if the trauma victim identifies himself as a patient and requests treatment. There seems to be a statement in our society that it's bad to not talk about troubling things-- this is true for some people who feel a need to talk, but it's a blanket statement that often crosses the line into being judgmental.
• Lastly, there is question as to the role mental health professionals should take with disaster workers who go to the aid of the victims. We're back to the Critical Incident Stress Debriefing and I wonder if the issues are different for those who are in the position of being helpers voluntarily (Red Cross workers and assorted humanitarians) versus those who go as a job requirement-- fire fighters and the like. I'm not sure what to say here. Again, this speaks to the issue of interventions to prevent the development of disorder in a population that might remain healthy without intervention.

Ugh, I can't get a picture in. Open all those alligator mouths and yap it up for me.

Online Access to Prescription Medication History

I saw a headline this morning that the California attorney general is moving to provide instant access to a patient's prescription history for doctors and pharmacists (regulatory boards and law enforcement organizations currently have ready access to this info).  

State Atty. Gen. Jerry Brown unveiled a plan Wednesday to provide doctors and pharmacists with almost instant Internet

 access to patient prescription drug histories to help prevent so-called doctor shopping and other abuses of pharmaceuticals.

Brown told a Los Angeles news conference that the state's prescription monitoring is a "horse-and-buggy" system that needs significant improvements because it now can take healthcare professionals weeks to obtain information on drug use by patients. That delay can allow some patients to get large quantities of drugs from multiple doctors for personal use or sale.

"If California puts this on real-time access, it will give doctors and pharmacies the technology they need to fight prescription drug abuse, which is burdening our healthcare system," Brown said.

The database, known as the Controlled Substance Utilization Review and Evaluation System, contains 86 million entries for prescription drugs dispensed in California.

I have mixed feelings about this issue.  Maryland passed a similar bill this past session to study such a program.  There is a very serious problem with abuse and diversion of controlled medications, such as Percocet, OxyContin, Lortab, and Xanax.  It is indeed very easy to get scripts from duped physicians and nurse practitioners and PAs, get it filled, and then sell it on the street for a 1000-5000% profit.  We need methods to control this.

The flip side is the risk of privacy violation.  Patients could have their privacy breached.  So, how much are we as a society willing to give up to combat this problem?

My suggestion:  Build in banking-level protections, provide patients access to their own histories, provide patients the ability to permit or deny access on an individual basis (so that they have control over access), and permit patients to see who has accessed their records.  Also, provide protections to prescribers and pharmacists which allow them to not prescribe or fill a medication if the patient refuses access to their history.

This provides a greater amount of control over access to personal info, while still providing the ability of prescribers and pharmacists to exercise careful judgment about the medications they write or fill.

I'm not totally sold on this solution, but it does seem to be a better compromise than the big brother approach.  I'd like to hear your thoughts on this difficult problem.  Please add your comment below.

Normal People

I was talking to my med school roommate last night. She's a regular doctor, and she was talking about how they need more psychiatrists where she works. They're getting a new one soon, but he scratches his chin and he sounds a little twitchy. Someone said something about psychiatrists being weird. My friend said, "I know a normal psychiatrist." I asked her who, and she said "You" meaning me. I'm normal? Roy likes that people say we sound like "normal people" when they listen to our My Three Shrinks podcast. Roy actually looks like a normal person. ClinkShrink looks like a nun. I don't want to know what I look like. There are moments when I think I'm normal. When patients ask me if they're normal, I generally respond "What's normal?" Actually, I think I equate Normal with Boring. Maybe Normal people equate Normal with Sane? Most days, I'm pretty sure I'm sane, I'm positive that ClinkShrink is sane, and Roy...oh, Roy is sane and he even looks like a normal person.

So does psychiatry make people abnormal or are abnormal people attracted to psychiatry?

Let's try a few, feel free to add some of your own thoughts:

--People are often attracted to fields relevant to their own lives, so they are more likely to be interested in psychiatry if they have a mental illness or know someone with a mental illness. With the lifetime incidence of mental illness above 50%, I'm not sure this accounts for "weird." And many of my patients easily meet criteria for "Normal Person." This is the obvious response to why shrinks are weird, so it's where I started.

---One gets a little bonkers listening to people's problems all day. Maybe. I still enjoy it.

---Everyone knows shrinks are weird, so weird people join the club. I'm not sure how this explains the nun amongst us.

---Psychiatrists analyze everything and all that introspection makes you relate strangely to other people. There are probably some variants on this theme. It may account for unusual interpersonal styles, but not for chin scratching and twitchy-ness.

---Twitchy people can't hold scalpels steadily so they have to be psychiatrists. Good point.

So do 'normal people' have blogs?
And I still have to comment on ClinkShrink's last post Coming soon.

I Don't Need To Talk

Roy is the blogger who inspired me today. I recently posted about the use of medication to prevent depression, and Roy followed this up with a comment on our Podcast #46 post about willingness to talk and prevention of trauma-related psych problems. He referenced a University at Buffalo study of 3000 9/11 survivors who were asked to respond to an online survey immediately following the 9/11 attack. The survey asked questions about their willingness or need to talk about the event, and followed their adjustment for two years after the initial survey. The study found that those who were unwilling to talk about the event actually fared better over time than those who wanted to talk.

Now, there are a lot of obvious limitations here---and I don't have the actual published article to analyze the news releases' interpretation of the study---but those who responded to the study had not lost any loved ones or known anyone who died in the attack, and it doesn't say whether or not the respondents themselves had direct experience of the event. For all I know, they could have been people living on the other side of the country. Personally, I doubt that people who were really upset and had direct experience of the 9/11 attack would have much interest in responding to an online survey at the time. It also doesn't mention whether or not the people who wanted to talk about their feelings ever actually had the opportunity to do so or received therapy following the event. All of this would obviously make a difference on the outcome.

Nevertheless, I think it says something relevant about an area in which there is a significant body of published data, which is the issue of crisis debriefing counseling. Crisis debriefing is something that's being used for a lot yet it's controversial because its efficacy hasn't been proven and there are some studies suggesting it could harm people.

Critical incident stress debriefing (CISD) was developed with the idea that providing rapid intervention to people exposed to trauma would prevent the development of PTSD. It was used following events like hostage-takings, natural disasters, plane crashes or other mass casualty accidents. CISD uses peer facilitators and mental health professionals in a time-limited, single session group setting to provide peer support and to allow people to talk about their feelings about the event. They also talk about the impact of the event on their relationships or day-to-day functioning as well as coping techniques. In addition to providing an emotional outlet, CISD typically also involves education about stress-related symptoms and stress management.

A PubMed search of the term "crisis debriefing outcome" brings up 33 studies on the outcomes of crisis debriefing counseling. Once you eliminate the studies with no controls and no data, you find that CISD studies have been done on a huge mixed bag of subjects: children, crime victims, soldiers, anesthesia residents, post-partum inpatients, burn victims and emergency service workers. The good news is that the majority of the subjects got better over time, even if nothing was done. The interesting news is that participant satisfaction surveys showed that patients frequently reported satisfaction with CISD, found it helpful and would recommend it to others even though there was no measurable reduction in symptoms. In other words, they felt it was helpful even when there was no objective evidence it helped.

Out of all the studies that reported outcome data in a group-controlled fashion, three found CISD led to improved symptoms. Seven studies showed there was no significant difference between CISD and a control group---neither benefit nor harm. Three studies showed worsened symptoms following crisis debriefing. A couple review articles in the Pub Med search as well as one meta-analysis also showed mixed results, with most showing no clear benefit and a few documenting aggravation of symptoms.

In all, the main conclusion I could come up with from this is that CISD probably should not be mandatory for everyone following a trauma (eg. an employer probably shouldn't mandate that all employees must attend CISD following an episode of workplace violence). It might help some people, and will probably not harm the majority, but a few will be hurt by it. The trick is, you don't know in advance who will fall into which group.

My Three Shrinks Podcast 46: Fugetaboutit!

[45] . . . [46] . . . [47] . . . [All]

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Whoa!  Sorry about the long delay, folks.  In case you missed Podcast #45, with Ray DePaulo, the Chair of Psychiatry at Johns Hopkins, we talked about cosmetic psychopharmacology -- taking psychotropic medications to improve one's mental performance better than one's normal baseline. We then had two related posts, I Forgot (what happens when memory does not work well) and Now I Remember (when people remember too well, such as traumatic memories and PTSD).

The current podcast takes off from there, so you may want to review the above links for, as Paul Harvey would say, "the rest of the story."

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June 1, 2008: #46 Fugetaboutit!

Topics include:

• PTSD. A Psychiatrist Who Learned From Veterans commented that "A really towering paper in the Posttraumatic Stress Disorder literature deals with the excessive stickiness of memory in PTSD. The data comprises case reports of the month long use of Cortisol (Cortef) 10 mg a day, this is a low dose of glucocorticoid, by Amanda Aerni. R Greene at the Dallas VA has a nice paper using rats in a related paper; impressive statistics in the latter." These papers are discussed in the podcast, and mentioned in more detail below.
  
• Cortisol for PTSD.  Amanda Aerni, et al., published "Low-Dose Cortisol for Symptoms of Posttraumatic Stress Disorder" in the August 2004 American Journal of Psychiatry. This was a 3-month observation study on three people with chronic PTSD, using a low-dose of cortisol in a double-blind, placebo-controlled manner. They found "cortisol-related reductions of at least 38% in one of the daily rated symptoms of traumatic memories, as assessed by self-administered rating scales."
• Memory "Erasure".  Wen-Hui Cai, et al., published "Postreactivation Glucocorticoids Impair Recall of Established Fear Memory" in the September 2006 Journal of Neuroscience.  This study exposed mice to a trauma (loud noise).  After developing mousie PTSD, exposure to glucocorticoids at some later time after the traumatic memory is being triggered caused the fear response to be much less.
• More PTSD Talk.  Pink Freud commented that "On the surface, I find the thought of preventing the formation of memories (traumatic or otherwise) to be repugnant. It's experiencing, working through, and ultimately making meaning of what life deals us that defines the human condition."  Here follows lots of discussion about what is a "trauma" (such as being hit by a flying, flaming toilet seat [Youtube] from the space shuttle as in the show Dead Like Me, or being tasered at a political event [Don't tase me, bro]) and how some people are at increased risk for developing PTSD given similar traumas.  Also, discussion about reducing the strength of the connection between a traumatic memory and a pathologic fear response.

• Dinah's Flomax (tamulosin).  Dinah discusses the discrepancy between the focus on benign prostate conditions and other more serious ones.

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

Shrink Rap Meets Shrink Rap Radio

Dr Dave from Shrink Rap Radio interviewed us last week and posted it to his interview site, Shrink Rap Radio.  He asks us lots of questions, and we (characteristically) wander off topic.  There may even be a shocker in his podcast (no, just kidding).  [EDIT: Susan Argyelan has graciously transcribed the podcast for all to read (a pdf).]

Check out his extensive list of interviews, with many giants in the field (yes, that is a play on "shrinks").  We plan to have him on as a guest soon.  (And, yes, I am FINALLY getting our own podcast #46 to you today!  Sorry for the delay.)

Check it Out

Psychiatry 101 is a blog about psychiatry by a mom who was once treated for post-partum depression. She has been a welcome commenter on Shrink Rap with some great comments.

So most recently, Psychiatry 101 sent us a link to Tony White's blog. Tony is a therapist in Australia, he has a blog, and his patients and supervisees read it. He writes HERE about what his patients say about his blog.

Several people have suggested to me that my patients read Shrink Rap and don't tell me. I find that perplexing--- why wouldn't a patient just say "Hey, I came across your blog..." ? In real life, I'm not a particularly intimidating person. At least I don't think so.