I Am Not 'One Of Them'

Since the Fort Hood shooting I've been hearing and reading a lot in the media about 'compassion fatigue' and 'vicarious trauma'. I feel compelled to blog after reading yesterday's New York Times article on the topic, which I'm sure won't be the last.

The idea is that any mental health professional who spends their days listening to patients tell their stories of traumatic events will eventually end up having emotional difficulties from it as well. The other term for this is 'compassion fatigue', in other words losing the ability to empathize with others or becoming numb to trauma due to exposure to patients' traumatic stories. The Times article is careful to point out that vicarious trauma and compassion fatigue will not automatically lead one to become a killer.

Well, I'm relieved to hear that.

Over the years as both a forensic and correctional psychiatrist I've heard plenty of trauma-related stories. I've reviewed autopsy photos and crime scene photos and read police reports of violent offenses and watched videotapes of violent offenses. I've heard people talk about
their crimes and talked to victims of violent crimes (if they survived). People who have read my "What I Learned" posts know that the annual conference of the American Academy of Psychiatry and Law regularly features presentations about serial murderers, psychotic killers, crime scene investigation techniques and other topics that can be a bit gruesome.

If all 1700 forensic psychiatrists in this country are exposed to this regularly that's a whole lot of vicarious trauma. It's good to know I won't automatically become a spree killer.

Frankly, I wasn't worried.

Ch-Ch-Ch-Changes!

The times they are a-changing....

Next year, the new parity laws for mental health will go into effect: health insurance must cover mental disorders the same when it covers other medical illnesses, without limits on visits, or higher co-pays. It remains to be seen how this will play out-- my fear has been that the response might be to simply eliminate mental health benefits from insurance policies. From the American Psychological Association (sorry, it was a pdf file so there is not a direct link) on the Wellstone-Domenici Parity Act of 2008 :

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (The “Wellstone-Domenici Parity Act”) will end health insurance benefits inequity between mental health/substance use disorders and medical/surgical benefits for group health plans with more than 50 employees. Under this new law a group health plan of 50 or more employees that provides both physical and mental health/ substance use benefits must ensure that all financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than those requirements and limitations placed on physical benefits. This means that equity in coverage will apply to all financial requirements, including lifetime and annual dollar limits, deductibles, copayments, coinsurance, and out-of-pocket expenses, and to all treatment limitations, including frequency of treatment, number of visits, days of coverage and other similar limits.

We don't know yet how this will play out...I hate that little clause "...that provides both physical and mental health/substance use benefits..." because it's left as an option. Would we tolerate a health insurance plan that excluded pneumonia or cancer? And it would be so nice if one could see a psychiatrist without pre-authorization (do you need pre-authorization to go to the doctor for your back pain or headaches or fever?) but my guess is that won't play out, since surgeries require pre-approval in many plans.

The New York Times has an optimistic piece on upcoming parity. Leslie Alderman writes in "In Anxious Times: Help for the Mind as Well as the Body:" Alderman writes:

The law’s changes can be good and not so good. Good, because you might have access to more care. Not so good if there are new requirements, like getting precertification for coverage, that place additional barriers to getting treatment, says Kaye Pestaina, vice president of health care compliance for the Segal Company, a benefits consulting firm.

“Employees should make sure their employer provides information to them about any new medical management rules,” Ms. Pestaina said.

Okay, so the House just passed the President's Health Care Reform bill (all 1,990 pages of it). What might this mean for psychiatry and how will parity play out in a newly-insured American?

One Of Us: Physicians Who Kill

"I have already said that if you kill a doctor, all the doctors are instantly on your neck. But what if the man who does the killing is a physician himself? That complicates the situation most damnably..."

---Foursquare: The Story of a Fourfold Life by John Oliver

I've been reading, along with everybody else, the story of the Army major and psychiatrist Dr. Nidal Hasan who killed thirteen people in a spree shooting at Fort Hood yesterday. Let me say first that I've never met Dr. Hasan and know nothing about him; I have no particular information or insights about this offense beyond what I've read in the media.

The CNN article today interviewed two of Dr. Hasan's patients, who both said nothing but glowing things about him and his care. I've blogged about spree killers before ("Shooter Psychology") but this case is different. It got my thinking about the general issue of physicians who kill.

Physician killers are certainly a relative rarity, but they are not unknown. Dr. Jack Kevorkian is probably the most famous here in the United States, but in the United Kingdom there was the case of Dr. Harold Shipman. Dr. Shipman forged the will of, and then killed, several elderly female patients. Then there was Michael Swango, a serial poisoner who killed his patients specifically so that he could take credit for his heroic "resuscitation" efforts. As far back as 1920 Dr. John Oliver wrote about an anonymous psychiatrist colleague who killed another physician and was found legally insane. The quote at the start of this post is from Dr. Oliver's autobiography were he discussed the case. For anyone really fascinated by the topic, I refer you to the book Demon Doctors: Physician Serial Killers. I haven't read it myself so I can't vouch for it; feel free to write in reviews.

But I digress. Getting back to what happened at Fort Hood, the news reports don't indicate anything to suggest that Dr. Hasan was psychotic, motivated by greed or financial gain or out of a need to be a hero. He wasn't an infantryman who had been exposed to combat and who might have been terrified of going back to a traumatic environment. He was educated and presumably in a better financial and social situation than most of the patients he treated, unlike many of my murderer patients who have burned multiple social bridges prior to the killing.

Regardless, a killing by a physician---particularly by a psychiatrist---creates a bizarre aftermath. The military is sending mental health professionals to counsel the victims and witnesses; I'd be willing to bet those military mental health professionals will be required to check their weapons at the door.

Here is an excellent article about preparing for testimony, for anyone
who has to testify at civil commitment hearings:

http://www.currentpsychiatry.com/article_pages.asp?AID=8091

One Offender's Story: Not Sick Enough

I don't blog about patients, so I was pleased to find this excellent story about one mentally ill offender covered by American RadioWorks. I don't know and have never met this prisoner, but his story is similar to many of those I evaluate and treat.

 

http://americanradioworks.publicradio.org/features/mentally_ill/stories/notsick1.html

Too Interesting For Twitter

I had to put this up on the blog because it was just too quirky to Tweet. A prisoner in the U.K. filed suit to request visitation rights for his cat:

Cat Banned From Visiting

The Accessible Psychiatry Project

We've decided we could use an umbrella organization to explain what we do in a more official capacity. What do you think? And yes, the podcast will be back, we're just trying to keep our heads above water with getting the manuscript done for the book, blogging, and the rest of life!
----------------------

The Accessible Psychiatry Project

Encouraging dialogue about psychiatry across media.

Mission Statement:

The Accessible Psychiatry Project strives to encourage dialogue about psychiatric disorders and their treatment in order to explore issues of controversy and misunderstanding in our field. Through open dialogue, in both new media and old, we hope to foster awareness about the work psychiatrists do, and to decrease stigma associated with the treatment of mental disorders.

Components of The Accessible Psychiatry Project include:

Shrink Rap: a blog by psychiatrists, for psychiatrists. April, 2006- present—currently over 1100 posts on a wide variety of mental health topics.

Shrink Rap: http://psychiatrist-blog.blogspot.com/

Shrink Rap gets approximately 2,000 unique visitors per week. Readers are not limited to psychiatrists

My Three Shrinks podcast: a regularly aired show featuring 3 psychiatrists. Other mental health professionals have made guest appearances.

My Three Shrinks: http://MyThreeShrinks.com/

November, 2006- present, 48 episodes aired,

10,000 downloads/month

Featured on the Itunes Medical Podcasts Webpage

ShrinkRapRoy Twitters about technology and healthcare.

ClinkShrink Twitters about issues related to psychiatry and the law.

Off the Couch: Three Psychiatrists Discuss Their Work. In process, to be published by Johns Hopkins University Press, 2011.

What I Learned Part 4

I attended a great lecture on the history of forensic psychiatry.
Prior to 1825 most forensic experts were providing testimony on
relatives or former patients. There was a woman who tried to kill King
George III and was found insane. Benjamin Rush promoted the use of the
"tranquilizing chair".

Homeland Security is moving into the old St. Elizabeth's Hospital.
There's something weirdly appropriate about them being in a
psychiatric facility. James Hadfield killed another patient and later
escaped but was recaptured. Edward Oxford tried to kill Queen Victoria
and was found insane. He was ultimately discharged from the hospital
and immigrated to Australia.

It's estimated that there are150 victims of Munchausen's by proxy
every year. Most victims are under the age of five.

A surprising number of surgeons have performed their own procedures
including appendectomies and herniorhaphies.

Rethinking Antidepressants

Thanks to Henry for sending this link.

On cnet news, Elizabeth Armstrong Moore writes about research presented at this month's Neuroscience conference in Chicago:

Depression researcher Eva Redei presented research at the Neuroscience 2009 conference in Chicago this week that calls into question two tenets of depression science: that stressful life events are a major cause of depression, and that an imbalance in neurotransmitters triggers depressive symptoms.

Armstrong goes on to report that the research looks at the overlap of genes in RATS (not peeps) and notes that antidepressants work better for stress then depression and the genetic overlap between the two is minimal (--oh, why isn't Roy writing this, he's so much more eloquent than I am about the genetic stuff).
Armstrong goes on to say:

To test the long-held belief that stress is a major cause of depression, Redei looked for similarities between these two sets of genes. Out of more than 30,000 genes on the microarray, 254 were related to stress and 1,275 to depression. Only 5 were found in both samples.

"This finding is clear evidence that at least in an animal model, chronic stress does not cause the same molecular changes that depression does," Redei says. She is now looking at the genes that differ in the depressed rats so that she can narrow down targets for drug development.

Antidepressants are also often ineffective, Redei says, because they aim to boost the neurotransmitters serotonin, norepinephrine, and dopamine, whose reduced levels have been associated with depression. But this strategy is now also being called into question.

It's sort of news to me that we thought stress "causes" depression. I guess I thought extreme stressors (as opposed to general 'stress') can precipitate depression in those inclined to become depressed. Many people suffer extreme distress without getting major depression and many people with histories of major depression weather severe storms without a recurrence. What is nice about this research is that it challenges us to think in new ways, and I think sometimes research gets hooked around theories that aren't definitely proven and creativity gets stifled. Anything that nudges that can't be bad....

What I Learned Part 3

Psychiatric evaluations were done on all homicide defendants over five
years in one Pennsylvania county. Forty-three percent of defendants
had no Axis I disorder.

One 300 mg pill of Wellbutrin sold in the underground economy of the
South Dakota state prison system is worth the equivalent of one week
of inmate wages.

Male and female homicide offenders are exposed to physical abuse and
traumatic events at equal rates in childhood, but women are less
likely to exhibit antisocial and aggressive behavior in childhood.

In California, the law allows jails to be considered "treatment
facilities" for the purposes of involuntary medication.

Reed Elsevier owns Lexis Nexis and ChoicePoint, the two biggest
information databases in the country. In Australia lawyers are able to
serve subpoenas through Facebook.

Twenty-two states have laws allowing for psychiatric advanced
directives.

A one year followup study of offenders under community supervision
showed that about half were on prescribed medication. A quarter of the
prescriptions were for controlled substances, generally Xanax or
Klonopin prescribed by a family physician or an ER. Intravenous drug
use was rare. This study was done on 336 offenders in Iowa, where 98%
of citizens have a high school diploma. Their offenders are more
educated than the average Baltimore citizen. The average offender IQ
was 108.

Univ of Conn did a study of psychiatry residents rotating at a prison
outpatient clinic and compared their ratings of the rotation to
rotations at free society sites. The prison clinic had higher ratings
on all measures---patient diversity, case load, safety and other
factors. Half of the students went on to work in the public sector.

(The pumpkin was added by Dinah, but it was carved by ClinkShrink...
Happy Halloween from the Shrink Rappers!)

What I Learned Part 2

Notes from the second day of the American Academy of Psychiatry and Law.

The only psychiatric diagnosis not related to an increased risk of
suicide is mental retardation. Poor David Carradine got a mention
during the lecture on autoerotic asphyxia. Menninger talked about the
"three wishes" of suicide: to escape pain, to express rage, and to be
martyred (when provoking others to kill him). Five percent of all
suicides happen in the hospital. The legal idea of "proximate cause"
consists of the "cause in fact" (the poor treatment) and the issue of
foreseeability. HIPAA allows disclosure of information without consent
for purposes of treatment (like to do a risk assessment). HIPAA was
amended in 2002 to allow this. Many states allow disclosure without
consent in emergencies.

Humans and functional MRI are equally poor at predicting human
deception in an experimental poker bluff paradigm.

Georgetown medical school requires all their students to have an
iTouch or iPhone. Dang, that's progress!

The best predictor of competency restoration is the cumulative days of
length of stay. (Longer LOS means less restorable.) Predictors of non-
restorability are older age, mental retardation and a diagnosis of
schizophrenia.

The forensic sciences sampler is always the most fun and interesting
presentation for me. This year's topic was the investigtion of fires
and bombing. There is a local company, Combustion Science and
Engineering, which does computer modelling of these incidents.
Psychiatrists use psychodynamics, fire investigators use "fire
dynamics" or fire behavior. They consider witness reports, burn
patterns and electrical arc patterns to determine an origin and cause
of the fire. People who die within the compartment of origin tend to
die of heat injuries while outside the compartment they die of carbon
monoxide poisoning. Dr. Doug Ubelaker, a forensic anthropologist from
the Smithsonian Museum of Natural History, talked about human
identification of fire victims. When dry bones burn they get
longitudinal fractures, when flesh-covered bones burn they get
transverse fractures.

In the early days of the FBI the Smithsonian scientists were routinely
"loaned out" to help investigators.

Fetal kidnapping is when pregnant women are killed for their babies.
Out of 18 reported cases, only one defendant was legally insane.

It's never a good idea for your mistress to die under mysterious
circumstances even if you didn't kill her.

Kierkegaard today....

I'm trying to schedule my posts around ClinkShrink's AAPL updates.

From the NYTimes, here's a piece by Gordon Marino on....What if Kierkegaard were alive today? Would he YouTube, Facebook, Twitter, take Prozac and be done with it?

Marino writes:

Each of us is subject to the weather of our own moods. Clearly, Kierkegaard thought that the darkling sky of his inner life was very much due to his father’s morbidity. But the issue of spiritual health looms up with regard to the way that we relate to our emotional lives. Again, for Kierkegaard, despair is not a feeling, but an attitude, a posture towards ourselves. The man who did not become Caesar, the applicant refused by medical school, all experience profound disappointment. But the spiritual travails only begin when that chagrin consumes the awareness that we are something more than our emotions and projects. Does the depressive identify himself completely with his melancholy? Has the never ending blizzard of inexplicable sad thoughts caused him to give up on himself, and to see his suffering as a kind of fever without significance?

If so, Kierkegaard would bid him to consider a spiritual consultation on his despair, to go along with his trip to the mental health clinic.

What I Learned Part 1

Here's a brief summary of tidbits from the first day of the American
Academy of Psychiatry and Law conference.

First, there was an interesting keynote by Dr. Pat Recupero regarding
how to incorporate questions about the use of the Internet into the
mental status examination and the ethics of googling patients. (Shrink
Rap reader?)

The Indiana v Edwards case is a popular topic for presentation.
Defendants who represent themselves at trial are more likely to be
convicted of misdemeanors than felonies. Lots of discussion about how
pro se competence should be assessed and what the standard should be.

Got to meet and listen to Dr. Steve Morse, doing some of the most
fascinating research in forensic neuroscience. He stated functional
MRI will likely never be determinative of any legal issue. Favorite
quote: "Brains don't kill people, people kill people." Followed by:
"The only thing we know for sure about the mind and the brain is that
when the brain is dead, the mind is gone."

Six Federal jurisdictions have case law to bar third party observers
(ie lawyers) from forensic evaluations.

There are still people writing books about ritual cult abuse. They are
still not acknowledging that some claims may not be true, not even
after multimillion dollar malpractice actions for implantation of
false memories and exoneration of alleged perpetrators.

There was a presentation about expert witnesses' transference
reactions to attorneys and defendants. I think this is a pretty broad
stretch of the term.

Interesting historical overview of multiple personality disorder. The
patient Sybil had her sessions recorded. Her psychiatrist, Dr. Wilbur,
can be heard invoking and assigning names to her alters. The patient
Eve, Chris Sizemore, later wrote an autobiography repudiating her
diagnosis. Fifty-seven percent of audience (forensic psychiatrists)
did not believe in the disorder. Fifteen percent of surveyed general
psychiatrists think dissociative identity disorder should be removed
from the DSM. There was discussion of the role of the media and the
book Courage to Heal in precipitating the DID epidemic. DID experts
themselves disagree about the literal reality of satanic ritual abuse.
Some say this is a metaphor for severe psychological trauma. The FBI
division for offenses against children has never found evidence of
such cults.

Burgus v Braun is a landmark case for anyone working with trauma
patients. It resulted in a 10.3 million dollar settlement against
therapists for malpractice and Dr. Braun was expelled from the APA.

The Goat Story

There are some tales that will only live in infamy, to be told only after generations have passed...

Sent from my iPod

Let Me Tell You About My Days

By last night, I felt like I was supposed to blog about this. Several people mentioned a book to me that was written by a Bellevue psychiatrist-- Julie Holland-- and an NPR Interview they'd heard. One pretty much convinced me I might want to actually read the book (reading about psychiatry isn't quite my idea of a leisure activity). So I get home and check my email: there's a link to the NPR page and interview about this book. There's an e-mail from Clink about how this is stuff kind of looks like the stuff from the book we're in the process of writing. I read a little of the Fresh Air piece and think, wow, this does sound kind of like our stuff. Sort of.
So go for it: Dr. Julie Holland writes about her work as an ER psychiatrist.
Okay, I only read a few paragraphs, and there was more of an edge to it than I want for our book.

For nine years, psychiatrist Julie Holland ran the psychiatric emergency room at Bellevue Hospital in New York City on Saturday and Sunday nights. Along with treating patients, she served as liaison to the medical ER and the toxicology department.

Holland says one of the hardest parts of her job was figuring out which patients were manic or schizophrenic and which were high on cocaine or methamphetamines. An expert on street drugs, Holland spent her college years researching and writing Ecstasy: The Complete Guide. Her new memoir is called Weekends at Bellevue: Nine Years on the Night Shift at the psych ER.

See what you think.