I Feel Your Pain

The relationship between physical and emotional illnesses is a really complex one. There's nothing easy about this, and there are psychiatrists who specialize (like Roy) in consultation-liason psychiatry: the interface where psychiatrists deal with psychiatric issues in patients who are hospitalized on med/surg units. There are psychiatrists and neurologists who specialize in pain management.

It's probably no surprise that people with known psychiatric disorders are more easily dismissed by their primary care docs-- their chest pain is assumed to be 'anxiety' and their GI symptoms are due to "stress." It drives me nuts.

This shrink's rule of thumb for medical workups [I hope Dinah doesn't mind me sticking in my 2 cents :-Roy] :

• All symptoms which may be indicative of medical illness should be assumed to be so until proven otherwise. I don't want to see a patient for "panic attacks" until after a thorough work up to rule out cardiovascular or pulmonary disease. What's the work up? Well, it's one thing for an 18 year old girl with no risk factors and a primary complaint of "I feel panicky" and another work-up for a 55 year old smoker with hypertension and a father who died at 54 of an MI who presents with chest pain and shortness of breath on exertion. Don't send the 55 year old smoker with chest pain to see a psychiatrist until after he has a cardiac catheterization! [It's not uncommon to get a consult request to "rule out" conversion disorder when they cannot find a cause for symptoms. Sometimes it is appropriate; others I tell to keep looking.]
  
  
• Elusive symptoms are elusive symptoms and should be worked up completely, even if the patient has a psych history.
  
  
• Bizarre, non-biologically founded symptoms may require less of a work up--- the classic being "My hair hurts when I pee" or "the machine the aliens inplanted in me is squeezing my thighs." [Though this last example reminds me that people with psychosis get sick, and sometimes interpret their symptoms in a psychotic manner. Don't blow off the alien machine guy's complaint until you've ruled out a blood clot, fracture, or compartment syndrome.]
  
  
• Pain syndromes often respond to psychiatric treatments: it doesn't mean the pain wasn't real. Unfortunately, people take this to mean "it was all in your head," and who ever came up with that phrase is not my friend. You can have back pain. It can be real pain and it can really be in your back. Psychiatric treatments may make your pain go away. It was still real pain and it was still in your back. [e.g., tricyclic antidepressants reduce sensitivity to visceral pain]
  
  
• Some people have known medical/anatomical reasons for their symptoms and adding psychiatric treatment to the medical regimen helps.
  
  
• Some people have extensive workups for an assortment of symptoms: pain, weight loss, diarrhea, migraines, you name it. These can be really extensive work ups running tens of thousands of dollars (or more) with many invasive procedures and nothing is revealed that explains the symptoms. These patients become depressed (this is a very frustrating scenario), and sometimes when the depression is treated, the rest of the symptoms go away. Yes, this really happens, it's profound and it's remarkable. How do you explain this, given that the physical symptoms preceded the depression? I'm left to say that in some people, their stress gets funneled into their body, it's just how they're wired. It doesn't mean their symptoms weren't real, it doesn't mean they are crazy, it doesn't mean it was all in their head, it just means that for them, Depression starts with physical symptoms. Some of these patients do amazingly well, get off their narcotics, and resume normal lives that are no longer controlled by pain/medication regimens/doctor's appointments and tests. If you can't figure out the physical causes for an illness, there should be no shame to looking for a psychological cause. It's sad that there is.
  

Midwife With A Knife: Infertility, Stress, and Psychotherapy

Okay, so I'm behind the times, here's a cool post from Midwife With A Knife from 2 months ago-- an interesting post on fertility, stress, and psychotherapy. Oh, and lemurs and monkeys and all kinds of critters, fertile and otherwise. I'm even stealing her lemur photos. I can't quite get the link right but it's the post called "Are you reading my blog?"

MWAK asks how to tell stress-susceptible people they may benefit from psychotherapy without making it sound like you think they are wusses (her word, isn't it great?!). What do you think?

I've never seen anyone for a primary complaint of "I can't conceive" but I face this problem regularly with pain patients. I'm left to say that some people's depression gets funneled into their body as pain or physical symptoms, and it's remarkable how treating the depression can alleviate the other symptoms. I could have sworn I once wrote a post called "You Need a Psychiatrist" about how to talk to people about getting care without sounding judgmental, but I can't seem to find it---must have been a dream.

So for tags we have pregnant pigs, bears, turtles, vultures, fish, glow in the dark cats, but no lemurs or monkeys. What kind of blog is this anyway?

In Treatment: Season 2 Oliver,Walter, and Gina: RAGE!

Poor little Oliver: his mom wants to move to upstate NY to take a teaching position. She wants to leave him with his dad. Dad says they'll kill each other, so okay, mom will take Oliver. Paul thinks this is a bad idea. Everyone is mad and Oliver doesn't want to move with his mom. He runs off and all three adults chase him to a playground. Oliver asks Paul if he can come live with him. This is pretty sad. Paul feels badly saying no, Oliver really has no one who really wants him. He leaves Paul feeling sad and rejected, and saying he'll never see him again.

Paul can't take Oliver, it's just a big therapeutic boundary violation to let your patients come live with you. Paul feels the boy's anguish-- sadness about leaving his own children, perhaps, or angst about his own inadequate and abandoning parents. But he tells Oliver he will always be his friend; oh, we grown up shrinks don't talk to our patients this way and I don't see kids, so I don't know what to say here. Paul tries to spare Oliver's feelings, he tells him they have fun together, but his reasons why he can't keep him feel inadequate: you have your own parents who want you---hmmm, this isn't really true, they might be thrilled to give Oliver to Paul. Oh, it's just sad.
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Cashmere Walter is on a pass from the inpatient unit-- he hates it there. Nothing to do, everyone is beneath him, no one is as good as Paul. Paul sees through the flattery and he doesn't mince words: "Why are you sucking up to me?" He tells Walter to stop bullshitting him. They talk about the personas of Walter--the busy CEO who needs to be important, the small child who lost his brother and can no longer play, which one crumpled, will he try to kill himself again. Walter sobs. I'm not sure I got all this, it was a bit heavy on the hypothetical constructs and I wasn't so sure what exactly made Walter sob so. Maybe it was supposed to be Walter's breakthrough and catharsis.
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Paul is angry and agitated and he rants at Gina. He's decided that therapy doesn't work, "Absolutely I want to make them happy, what do you want to do, F*** them up even more?"
Now Paul wants to be a Life Coach and tell his patients to go live in Napa Valley in the sunshine, get dogs, and bike (not bad suggestions, if you ask me). Paul screams at Gina, he calls Gina a coward and he's vaguely threatening. "Unlike you, I actually give a s*** about my patients!"
It's one hell of a therapy session. Okay, I'm ready to give Paul some medication here. If I were Gina, I'd ask him to leave. He asks Gina what she really thinks and she screams at him that he's acting like an a**hole and he has remarkably little insight, is self-absorbed, and she's furious. "You got me to play the role you cherish." I have to give it to Gina, she thinks quickly when on the spot-- I want her script writer. They walk, they pace, they curse, someone please tell these people to sit down. "Somehow you have to tolerate that we don't save people." They sit down finally, and talk about Walter's suicide attempt. Paul sounds dismal and Gina wonders if Paul is suicidal. Somehow they've gone from a place of rage to a place of poignant sadness, they both talk about their grief, their dark moments. Paul apologizes for not coming to Gina's husband's funeral, maybe he apologizes for a multitude of sins. Gina ends the session by doing what Paul wants her to do: she offers to have coffee with him, and she tells him exactly what to do next.

Stuff. Like iPhones. For Peacocks.

It made me think about Roy, this article I read today in The New York Times. Roy is at APA in San Francisco. I miss him. My inbox is practically empty. He texts, and he left me a voicemail, but it's not the same. I want him to come home to be with me and ClinkShrink.

Okay, so the article, it was about stuff, and why we buy it and why we care about brands. Stuff, like iPhones. Roy loves his iPhone. He can talk about "apps" for hours.

In Message in What We Buy But No One's Listening, John Tierney writes:
Instead of running focus groups and spinning theories, he says, marketers could learn more by administering scientifically calibrated tests of intelligence and personality traits. If marketers (or their customers) understood biologists’ new calculations about animals’ “costly signaling,” Dr. Miller says, they’d see that Harvard diplomas and iPhones send the same kind of signal as the ornate tail of a peacock.

In Treatment: Rethinking Family

Mia is no longer pregnant (oh, soon we find out she never was). She's tired and she wants to go home or maybe have the session in the waiting room. This troubles Paul, but he sits down anyway.

Mia's mom came to visit her when she thought she was miscarrying--- suddenly mom is repainted in a more sympathetic light. She feeds Mia and she tells her about her own severe post-partum depression after Mia's birth. The events of the family's past-- where mom was always horrible and dad was always wonderful-- are now cast differently. Mia is angry-- her mom is just re-writing history in a way that makes her look better and makes her idealized father villainous. But Paul-- coming from his own father's funeral where he learned that his own evil, abandoning, philandering father had some virtues-- encourages Mia to be open to the possibility that mom wasn't all bad.
Paul tells Mia he knows from experience.

So what did I think? I often feel that when people paint another person as all evil with evil motives, that they may be missing something--- most people don't seem to want to willfully injure others. So I understood that Paul jumped on the opportunity to point out that some of Mia's mother's persona may have been something other than all bad---here she's the sympathetic mom with a tray full of food, confessing all sorts of family secrets, taking her daughter to the doctor. But when Mia doesn't want to see it all this way, Paul pushes the reinterpretation on her a little more strongly than I'm comfortable with. It's as though he's talking to himself, and not considering his patient's story.
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April is angry with Paul. She was feverish and delerious and he called her mother and had mom come to the hospital. Paul points out to April that she has high standards and people let her down. She's quick to write them off for a single mistake, Paul included, even though his intent was for her wellbeing. They bicker. April talks about her childhood, about being the perfect child, about hiding her accomplishments from her mother. Paul wonders if she's repeating a pattern with him. She doesn't like this, but somehow, they come to a place of peace. The session ends and he helps her up. There's something vaguely tragic about it all.

You Have To Try This First!

The patient is agitated and intrusive. He shows up without an appointment, and when I say I'll see him, but he'll have to wait, he is not pleased. He knocks on the door while I'm with another patient. He's been off his medicines, and he's decided he felt better with them. I think we both felt better when he was on them. Oh, but he didn't like those medicines. He wants something else. He needs something else. Maybe he needs to be in the hospital? He won't hear of it.

Okay, go back on Old Medicine you've been on before.

No.

How about Medicine X?

No. That stuff made his see dead bodies floating in space.

How Medicine Y?

No. Friend is on that stuff and it's awful.

How about Medicine Z?

No. Oh, you think that will help? Okay, he'll take that.

I think it will help. Oh, but then I remember that the state requires pre-authorization forms and I'm already behind here and there's all sorts of other issues, this patient isn't really in a great place for a detailed risk/benefit discussion, he's demanding something that will make him feel better now and I'm starting to feel his pain.

How about Medicine ZZ? I suggest a similar medicine.

Okay, he'll take that. In fact, he likes the name.

I write a prescription, he leaves and I resume my regularly scheduled clinic morning.

And then there's yet another knock at the door.

"But if you think that other medicine is better, I'll pay for it."

No, no, it costs hundreds of dollars, Just take the other stuff. Really, he's so bouncing off the walls that anything will take the edge off. The morning goes on. Yup, another knock at the door. The pharmacy couldn't fill the medication, not sure why. I've now drowned. I don't have pharmacies and calls to the state, and finding the right form, and pre-authorization phone calls and faxes...and whatever else it might take, in me right now and oh, he's not sure his insurance is even active. I surrender and grab samples (in the clinics, we save these for patients who have no other means of getting meds). He takes them and he actually leaves.

Next clinic day: Thank you, that medicine helped. The patient is much calmer, I don't once utter a word about hospitals. No side effects. And his insurance is now active. I write a prescription.

Fast forward to the next day. My cell phone rings, it's the pharmacy--- remember that patient (I do, but I see him at a clinic and I don't have access to his chart and why are you calling this number?). His insurance requires documentation that he's failed two other medications in the same class (and yes, those two medications both cost a small fortune as well, they aren't even asking if he's failed cheap meds!). I don't have a chart, but I think one of those meds made him see dead bodies floating in the air.

So let me get this right, I have a patient who was really sick, who's been in the hospital before, who is now better, and I'm supposed to take him off that medicine that's causing no side effects and put him on another, equally expensive medication---actually two-- and watch him maybe get sick twice, before I can put him back on the medication that is currently working just fine?

And how was your day?

Music is Good Stuff...

Here's a story about a cardiologist who says music does good things for us....helps your heart, helps your mood, slows the aging process (really?). Roy likes music and he's young at heart. I like music, especially when I exercise--the boppy stuff that keeps me from falling asleep in my tracks. CNN's Val Wilmingham writes:
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"If you didn't catch the white coat and the stethoscope, you might take Dr. Mike Miller for a middle-aged rocker, roaming the halls of the University of Maryland Medical Center in Baltimore.

Playing or listening to music can create a feeling of well being, which affects the vascular system.

For years, Miller, a research cardiologist, has been studying the effects of happiness -- or things that make people happy -- on our hearts. He began his research with laughter, and found watching funny movies and laughing at them could actually open up blood vessels, allowing blood to circulate more freely.

Miller thought, if laughter can do that, why not music? So, he tested the effects of music on the cardiovascular system. "Turns out music may be one of the best de-stressors -- either by playing or even listening to music," said Miller.

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Oh, so Dr. Miller's real claim to fame is that I'm Facebook (and real life, too) friends with his wife and she linked to this story, so here's my Shrink Rap plug!

Wash Those Paws!

Oh where oh where can my co-bloggers be? Can someone send a Tweet to Roy and see if he's still alive? And you'll need a search team and a helicopter to fetch ClinkShrink these days.

Well, you know how I love those Support Pet stories? Bad news: according to the New York Times Well blog, it seems Therapy Dogs can bring germs from one person to the next while bringing good cheer. Wash those paws!

Going Public With the Private

In the past week, I've heard Kay Jamison and Judith Werner speak, and yesterday I read the preview of a New York Times Magazine article by Daphne Merkin-- it will be published on Sunday. So I'm trying to figure out what draws these three events together, and all these people talk about there personal feelings in a public forum.

Kay Redfield Jamison is a scholar of bipolar disorder--- she co-authored the textbook on it. She moved from the academic world to the popular world when her memoir, An Unquiet Mind, was published in 1995-- with this she described her personal struggles with bipolar disorder. Dr. Jamison spoke on "Uses of Adversity" and part of her talk included mention of her personal struggles-- the idea that personal suffering can be the fuel for creative endeavors.

Yesterday, I heard New York Times blogger, Judith Warner, speak. Ms. Warner writes Domestic Disturbances, a blog about family life, and is the author of Perfect Madness: Parenting in the Age of Anxiety. Ms. Warner talks about the differences she noted in parenting when she moved from France to the United States, and talks quiet openly about what it's like to be the mother of two pre-teen daughters. She talks about the loneliness and isolation of being an American mom, of the crazy busy lives we struggle with. And she talks about her relationships with her daughters and with her own mother.

Both women are captivating speakers, and there is something very compelling about someone who talks openly about their own struggles.

So I didn't hear Daphne Merkin speak)....but do check out her on-line, to-be-published account of her episode of major depression in A Journey Through Darkness. Everything about Merkin's writing is hard-- she has an edge to her, one I don't always find to be sympathetic, but in this piece she simply oozes pain.

In Treatment: Oliver/Luke, Cashmere Walter, & Gina

Oliver shows up early, a runaway from school. His dad comes in and talks about his frustration with parenting and the fears that he's repeating his own father's sins. What timing, now that Paul has closed the circle on his father's mistakes and he's still grieving the death last week-- sounds like Paul is lecturing to himself when he tells Luke he has a choice to be a better father. Oliver may be the saddest looking child actor I've ever seen.
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Walter is in the hospital with "food poisoning." Or rather, for a suicide attempt by overdose. Paul comes to assess him, and while he denies the overdose at first, he soon gives details, and it's clear he wanted to die. Paul will have him committed, and Walter is angry. The pilot who died comes up, and Paul is clear that he can't take a chance like that. Walter is angry and tells him to leave, which Paul does. Paul mentions that Walter can have a hearing before a judge if he's still in the hospital in 2 weeks---hmmmm, in Maryland it's usually less than one week. Clink will know exactly how long.

There are continued family parallels----Walter's daughter looks strangely like Paul's daughter. Walter is laid out in the hospital bed just like Paul's father was and Paul reaches for his arm in the same motion that he reached for his father's hand.

I was surprised when Paul left and shut the door, leaving the potentially suicidal Walter alone. He's on 15 minute checks, and someone who wants to commit a desperate final act can do it in less than that. Why would Paul close the door--- why isn't Walter under constant observation? Ah, TV....
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Paul has a rather intense session with Gina the week after his father's funeral. He thanks Gina for the orchid she sent, and says he wishes she'd come to the funeral. She says it wasn't her place. She pushes Paul to talk about the funeral and his father, and redirects him from discussing other things he wants to discuss. Interesting....I might have let a distressed patient do what they wanted with the session, but Paul is surprisingly agreeable about going where Gina directs him.

After the session, Paul goes to meet with Alex's father, the man suing him. People don't usually go to restaurants to meet people they are engaged in litigation with, and for a moment, I wondered if the furious father might kill Paul (oh, the season has more episodes, so we need Paul to remain alive). My guess is that Paul's attorney wouldn't be happy about diner negotiations, and the waitress if strangely agreeable to letting the men stay there without placing an order. Alex's father says he will drop the lawsuit if Paul gives him a letter accepting full responsibility for Alex's death. He doesn't just want to believe Paul was negligent and should have done more to prevent Alex's death; he believes Paul killed Alex. Seems a bit of a stretch from negligence to murder.

Add it to the Drinking Water

So Roy sent me the link, but he couldn't post it?
Mind Hacks tells us that where there are higher levels of naturally occurring lithium levels, the suicide rate is lower. Referring to a study in the British Journal of Psychiatry, Mind Hacks states:

"This new study suggests that even trace amounts might have an influence on the whole population level, and this is not the first time this link has been made."

What do you say, should it be pumped in?

With Love to ClinkShrink: More In Treatment: Mia & April

Paul is a wreck--he's unshaven, uncombed, and his eyes sink deeper in his head than ever before. Mia is intrusive (so what else is new?) and grills him on how much he must be distressed--she's talked to his lawyer and knows his father died. She repeatedly asks him how he's doing? Is he lonely? And she speculates on aspects of his personal life and tells him it shows in his eyes that he's lonely. Oh, and she's pregnant by an unknown man. She asks Paul to celebrate with her, asks him if sex with his wife was as good after she gave birth, fantasizes about meeting Paul in a bar and running off to Las Vegas with him to get married. She wants to know if he'll be there for her, as she debates the pros and cons of becoming a mother.

Mia is cloying. I want to go home. Paul is good about distancing himself from her intrusions, but she is right that he's not ready to be back at work, and I can't help but wonder if he should continue treating her (or if he ever should have re-started after their first meeting in her legal office). She would be devastated if he refused to treat her, and her devastation would be understandable. But, is he safe with a patient who is asking questions of his lawyer, fantasizing marriage, and repeatedly asking if he'll be there for her in a way that sounds like she wants so much more than a therapist? And is he safe with such a patient, given that he's already professed his love for another patient last season, and admitted to his therapist that he could see himself with a woman like Mia? Not sure where the plot is taking us, but if this were real life, it would be going no where good.
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April is now getting chemo and she tells Paul she loves his eyes and they are "bottomless." What a life, women falling all over him. Apparently Paul was in the OR when they put in April's port. I don't think they let visitors in the OR in real life. They smile at each other a lot and the session has a flirtatious edge--- is this my imagination>? April falls apart when she hears that Paul doesn't plan to keep taking her to chemo-- one more patient he isn't there enough for-- and she puts it back together when he tells her his father died last week. Enough, it's bedtime.

Unusual Treatment Settings

A psychiatrist colleague is learning to do Cognitive Behavioral Therapy. He's treating a patient with agoraphobia, and goes to the patient's home to work with the patient on slowly coming out of his comfort zone.

It got me thinking about treating patients in their homes, or in places other than the office.

I've been to the homes of patients a few times-- none were my on-going therapy patients. As a resident, I rotated through an Outreach Team. These teams provide treatment to people with severe and persistent mental illnesses who have a history of non-compliance-- these patients don't keep their appointments, and they repeatedly get sick and end up in the hospital, sometimes many, many times. As the doctor on the team, I never went alone, always with a nurse or social worker who knew the patient, and mostly I was an observer. It was a great experience. As a clinic medical director, I went with our case manager a few times to see patients she was worried about.

So I'm thinking about the colleague who visits the patient in his home to help him negotiate the world. Is this a feasible way of treating people? The psychiatrist stays for an hour, and there's transportation time (I don't know how long that takes)....so financially, this could be an expensive endeavor. In this case, I believe the doc is salaried, and the patient is being seen pro bono as part of the learning experience. And what about the boundary issues involved in being in a patient's home?

I'm writing without really having a point I want to make. Does anyone else do Home Visit Psychiatry and what thoughts can you share?

In Treatment: Season 2, The Rest of Week 3

Oliver shows up with his mom. She thanks Paul for miracles he's worked. She talks about how she and her husband got together. Bess talks about all her insecurities about entering the world of work. Bess gets angry at Paul-- she's anxious about leaving Oliver to go off with a friend, she can't find a balance between smothering him and letting him go. Bess leaves Oliver with Paul and goes on vacation.

Oliver tells us he's fine but he doesn't look so hot. He talks about his friend who brings him chocolate every day. I'm jealous. Then Oliver tells us he's stopped eating because he's tired of being fat. Paul tells him he can't do it alone. I can see Paul encouraging Oliver to eat healthy, but telling him he can't lose weight on his own? How does he know? Oliver wishes he was adopted. Paul says he also felt this way as a kid-- is this good self-disclosure, kind of like announcing he had an unhappy childhood? Oliver is waiting for his Dad and offers to leave, but Paul tells him he had a cancellation and he can hang out-- they can talk (haven't they been doing that?) or play blackjack, and then Paul brings Oliver into the kitchen (isn't this the poor-boundaries room?) and makes him a sandwich. It's like Paul is borrowing a son and Oliver is borrowing a dad.
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Walter has lost his job, his blackberries, and now there's no point to talking. Then he talks. "I'm in a bunker with a remote control and pills." Paul assesses Walter for suicidal thoughts. Walter talks about how he can't stand people who live fake lives. He talks about a friend who lost his job and started taking photographs, "He's outlived his usefulness." Walter talks about his relationship with his employer, the old man, and how the old man's son died. "We would build something special and we did." Paul responds, "After 35 years all he said was 'Good luck?'" Funny, that when the episode started, Paul was on the phone with his brother talking about his father's problems-- Paul didn't know his dad was in the hospital, he promised to pay more attention to him. More father-son themes and questions of guilt and perception-- Walter's daughter blames him for his role in his corporate fiasco. His product killed babies, and he's struggling with trying to figure out what his role was, in all his relationships. "It was my fault," Walter announces. And now we find out that Walter knew his brother was going swimming and didn't stop him the night he drowned. Destroyed families, a theme both men know all too well.
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Paul's life is a mess: he's being diposed in a lawsuit, he's already arguing with his new/old lover, Tammy Kent, he misses his daughter, "I hate my life." He's intensely lonely. "Do you have any water, you're so convinced I don't have water, you don't see it, it's sitting right there." He looks so vulnerable, and he picks at Gina. He misses his family life. He goes to bars at night and watches soccer and watches the women with bracelets that jingle. Paul tells Gina that Mia could be right for him if she worked through her issues, he's drawn to her, but no more falling in love with patients "for a while." Oy. Gina asks if Mia is in love with him. Funny between two therapists...to refer to a patient's feelings so casually as 'is she in love?' Gina and Paul spend the session at odds. She gets in his face, "All you can do now is hope to heal this wound so you can move on."

He's handsome, he's compelling, he's charismatic, he's so insightful with other peoples' problems. Why is he so lonely? He has so little, he's chased away everyone important in his oh-so-empty life. Pathetic and fixated.

Paul goes to visit his long lost dying father in hospital. The conversation he has with his non-responsive father feels desperate, and way too late.

Zen and The Art of The Psychoanalyst's Couch

This weekend's Sunday New York Times Magazine featured a piece by Chip Brown titled Enlightenment Therapy where Brown discusses the coming together of psychoanalysis and Zen Buddism. It's a long piece, and I looked at it several times. I read for a while, but it was long and I can't say it held my attention well. I went back several times. I'm missing something here: Why is this a featured article? What's said that's worth taking pages to say? What am I missing here? Someone want to enlighten me?