Weiner Diagnosis?

 

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

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

 

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

 

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

 

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

 

Best,

Rena  

 

Rena Resnick

5W Public Relations

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

Calling All Would Be Forensic Psychiatrists...&...Wiki Your Diagnosis

Over on our Shrink Rap News blog, ClinkShrink has a post up on how to find the perfect Forensic Psychiatry Fellowship. She'll walk you through what to look for and how to apply. If you have the makings of an amazing forensic psychiatrist, please do apply to Clink's program.

_______________________
Over on Thought Broadcast, SteveMD has some ideas about how to improve on the process of creating DSM-5. He proposes a DSM-wiki. This one made me giggle out loud:

Patients could also upload their own experiences, in YouTube format. Their videos would be cross-referenced to the relevant diagnoses and/or medications. Videos with the most “hits” could win a prize. Maybe we can link terms to their Urban Dictionary entries.

We could add clips from Hollywood movies depicting particular disease presentations. We could add links to Amazon.com to purchase relevant books (and use the Amazon Associates revenue to help manage server costs). We could include a Skype plug-in that would allow users to chat with other people logged on at the same time. We could even sell space to advertisers like Groupon (“10 sessions of psychotherapy for the price of 5 in Chicago!!”) or, for those over 21, porn sites (targeted specifically to readers of the “Paraphilias” entry).

Social media is the future, and the APA really needs to get with the program! An animated GIF logo. An MP3 theme playing in the background of each page. A Flash-based interface (sorry, iPad users). The APA could even create new, edgy slogans for itself and for the DSM. For instance, it’s not DSM-5 anymore, it could be “D5M-ph!\/3″. It’s not just a “living document,” it can be the most 4w3soM3 social media psychiatry destination on the planet! OMG!!!!!!1!

________________

Finally, don't forget to submit your hot-to-trot Grand Rounds Submission with a pic. Roy's coals are hot and he's ready to cook!

Submissions are due on Sunday by Facebook on our Shrink Rap Book page, Tweet to ShrinkRapRoy, or email us at Shrinkrapblog at g mail dot com

"Hot" Grand Rounds Coming to Shrink Rap Next Week

Shrink Rap is hosting our third Grand Rounds on June 21, which is the first day of Summer. In keeping with the summer solstice, we will be accepting submissions that have a theme of "hot." Use your creativity to link your post with this theme. For example, "hot" can refer to temperature, spiciness, luck, passion, anger, popularity, etc.

Our first Grand Rounds in 2007 featured a clicky brain, and the second featured the then-new iPhone 3G, complete with clicky iPhone apps. This time, we will be using clicky pictures that exemplify the "hot" theme, so submissions must have a "hot" picture (keep it PG rated, folks ;-). If you don't feel hot looking at the picture, you might want to pick another one. (We don't want to ignore the southern hemisphere, so if you live where June 21 kicks off the winter solstice, feel free to use a "cold" theme and picture.)

Submit your post on our Facebook page or on Twitter to @shrinkraproy (or email if you must; it's in the sidebar). Deadline is Sunday night.

In the meantime, stay cool!

Guest Blogger Jesse: When Patients Don't Pay

Dinah asked that I “blog on what you do when patients don't pay.” I’ll try to put that question in a larger context. If a patient is seeing a physician for treatment of a mole, or of a fever, the treatment of those illnesses has no relation nor is affected by when or how the doctor is paid (other, of course, that the doctor might refuse to treat the patient). In psychodynamic therapy, where the therapist is helping the patient with relationships, anxieties, attitudes, and conflicts, everything that occurs is potentially helpful if it is understood. Observing and thinking about actions and feelings is a part of the treatment, as important a tool to the therapist as a stethoscope to a cardiologist.


Money is something loaded with meaning to most people. What does it mean that the patient forgets to pay? Does it mean “if you really cared about me you would not charge me”? Is it a reflection of anger for something that occurred in the last session? Is it a displacement of feelings from something else (“my boss didn’t give me the raise I expected”)? Is it completely inadvertent (Freud famously said “Sometimes a cigar is only a cigar”)?


There are so many possibilities, and the psychodynamic therapist wants to understand them. How the patient relates to the therapist is some part of how he relates to others. The patient hopefully starts to watch his own actions and attitudes, and also tries to understand them. A nonjudgmental stance helps the patient do this.


The therapist himself needs to be comfortable dealing with the subject of money. Sometimes beginning physicians fluctuate between feeling they are too inexperienced to be paid and feeling that they deserve anything they ask. We physicians might even (unfortunately) take on the attitudes of the insurance companies themselves (“Identification with the Aggressor”).


There are times when the treatment needs to be discontinued, or the patient referred for other care. Clearly, if the therapist has allowed a patient to go a long time without paying, without good reason thoughtfully discussed, both doctor and patient have unwittingly colluded in avoiding very important issues.


Many therapists believe it is important for the patient to pay something, regardless of his economic state. It is part of the patient’s self-esteem. It indicates a professional relationship, one in which the patient essentially is employing the therapist (physician, lawyer, accountant, et al) and in which the therapist has professional obligations to the patient. It is therefore part of the professional boundaries.


There is a curative aspect to the attitude I’m describing. To the extent that the patient can increase his ability to examine his own actions and feelings in a nonjudgmental manner he gains control over areas of life which may have been becoming increasingly difficult for him.


What have others experienced in this regard, and how do you think of these issues?

Of Course, Of Course

Perhaps you remember that line from Mr. Ed's theme song? A horse is a horse, of course, of course, he'll give you the answer that you endorse....I'm tired of talking about the same old things at Shrink Rap, so here's a horse of a different color. And you thought ClinkShrink did all the bad punning!

Over on the Clinical Psychiatry News website, there's an article by M. Alexander Otto about a study done in a state hospital in New Jersey on Horse Therapy. Otto writes:

In all, 32 patients worked with three specially trained therapy horses for 10 weeks in a corral built on campus for the purpose. They didn’t ride the horses, but instead saddled, brushed, and put them through various activities.

The weekly sessions lasted about an hour; the horses couldn’t tolerate much more. "It was hard work" for them, Dr. Schleifer said.

The project was part of a larger trial in which patients were randomized to either horse therapy, dog therapy, standard care, or off-ward group therapy, just in case the mere act of taking patients to a different part of campus – necessary for the dog and horse groups – made a difference in violence.

You can surf over there if you'd like to read more. I found it disturbing that this treatment was being tried if it bothered the horses.

Are We Not Thugs?

The voice at the other end of the line was angry and accusatory: "You didn't even talk to me! You never knew my son! You didn't talk to any of us!"

I explained to her that since she had never even met the defendant, there was no way she could have any information that would be relevant to the accused's state of mind at the time of the crime. The victim and the defendant were total strangers and there was no apparent reason for the killing, which made the crime even more tragic. Her son was dead in a random incident, in a crime that was unquestionably motivated only by the defendant's untreated psychiatric symptoms.

The defendant's family was equally shocked and horrified. They were all hardworking solid citizens, with no history of criminal contacts, substance abuse or mental illness. When their daughter started getting sick they knew something was wrong but didn't know what to do. They were all legal immigrants but because they were working at various temporary manual labor jobs they had no benefits and no insurance. They were still working to pay off the hospital bill from their daughter's childbirth, and they were worried about leaving their infant grandchild in her care while they worked. Their culture strongly discouraged discussion of emotional problems, and mental illness was considered a spiritual rather than a medical disorder. When their daughter started talking about spirits talking to her from the TV, they consulted a lay counsellor from their spiritual community rather than a doctor. She got worse, and started staying in her room laughing and talking back to the television. She stopped eating her usual foods, and said that she could only eat fruits because this was how God would turn her into a superhero. She lost thirty pounds and looked horrible. She stopped bathing or taking her antihypertensive medicine. In her eyes, the killing was a test to see if she had the strength to become one of God's warriors in order to save the world. She came across the victim, a ten year old boy, standing at a bus stop. Multiple witnesses were horrified to see the child stabbed to death in front of their eyes. When the police arrived she was still at the scene, holding the knife. At the police station the detective tried to interview her but was stymied by her illogical statements. She repeatedly made the sign of the cross over the detective's head and tried to bless him.

This is a confabulated story, but it's a typical scenario for a classic insanity case. We've talked a lot recently about involuntary treatment, civil rights issues and the anger people feel about being admitted to a hospital or given medications against their will. What we haven't heard about yet is the anger associated with a bad outcome---anger at losing a loved one to murder, anger at not being able to get the treatment you need for someone you love, anger at the unfairness of a society in which treatment can only be afforded to those with the education and financial means to obtain it.

This is where I come in. I have treated people involuntarily and testified at civil commitment hearings and requested emergency evaluations on people who needed care. Am I a thug? What alternatives would the psychiatrist in this scenario have, had the defendant been brought in for care against her will before the crime? If she was too disorganized to clean or feed herself, would she be safe to care for a newborn infant? What about her own medical needs? What would you say to the mother of the murdered child? And would should the psychiatrist in the forensic hospital do, knowing that the patient has just killed someone? Would involuntary medication be appropriate in this case? If not, what would you do?

I'm offering this story for discussion, please keep things civil.

Found on My Facebook Page

We talk about ducks here on Shrink Rap, but in my 'real' life, I like giraffes. I was very excited when today's American Journal of Psychiatry arrived in the mail and there were two giraffes on the cover! And if that wasn't wonderful enough, Henry put the cover up on my Facebook page with the cover of Shrink Rap in the background and mama giraffe saying to baby giraffe, " Because I'm your mother, no playtime until you finish reading!" How'd he do that? Well, I liked it, so I thought I would share it with you.

If you didn't catch it, our book was reviewed in The Johns Hopkins Magazine by Kristen Intlekopher. Three authors couldn't ask for a better review, so please do read it! You'll need to scroll past oysters, cell phone radiation, and political order, but this review made my day.

Someone asked if I would friend Jesus if he were on Facebook. I can't imagine I would ask to be his friend and I'm not sure what I would do if Jesus sent me a Friend request. Who thinks of these questions?

That's Entertainment???

I don't have time to clip my own coupons. Why would anyone ever want to watch someone else shop with coupons? There's a whole segment of life I just don't understand. Roy? Clink? Can someone explain this to me?

What's Really Insane

There's a great post up on Pete Earley's blog entitled "What's Really Insane? Our System" that outlines the conundrum of our mental health system from beginning to end. He starts out by discussing the Jared Loughner case and the difference between hospitalization for treatment versus hospitalization for restoration of competence. Among forensic psychiatrists we call this "clinical competence" (reduction of symptoms, restoration of function) versus "legal competence" (the mental capacity to participate in a legal proceeding). While he says these are two separate and distinct issues, in fact there is a correlation between mental capacity and symptomatology. I'm running late this morning and don't have time to post citations, but off the top of my head I remember reading some articles that correlate BPRS (a symptom scale) scores with evaluators' assessments of legal competency. In other words, treating someone's symptoms will improve and restore competency. That alone isn't always enough though, which is why forensic inpatients are also often involved in competency restoration groups to target that specific issue.

Earley does a nice job of outlining the problem of involuntary medication in some criminal defendants; in Maryland it's a particular problem due to a Court of Appeals decision that the person has to be dangerous in the hospital before they can be treated. Thus, someone could end up institutionalized for a very long time awaiting trial.

That's an incomplete summary of a very good post. Surf over to his site and read the full piece.

Shrink Rap News: Our Second Collateral Blog is Up!

We were invited to blog on the website of Clinical Psychiatry News, a print publication sent to psychiatrists around the country. They launched a website a few months ago and have made bloggers of some of their regular columnists. Shrink Rap, they thought, would having something to add (we hope so!) and we'll be doing a weekly column there.

The CPN website is specifically for psychiatrists and commenting there requires registration--- please do join if you're eligible. For those who aren't, we'll let you know here when we've put up a post and you're welcome to comment on the regular Shrink Rap.

Today's post is up on the CPN Website as an introduction called The Accessible Psychiatry Project.

Psychiatrists and Media Statistics

Thank you to Angela Wilson and her Twitter feed for pointing me in the direction of this story.

The Palm Beach Post News is covering an investigation of prescribing habits of psychiatrists working in the juvenile justice system. The implication is that doctors who receive Medicaid funding are overprescribing atypical antipsychotics for detained juveniles. While the data looks compelling at first glance, I agree with Angela that it is incomplete.

The article implies there is a correlation between the number of scripts written and the amount of money paid to the doctors. This may be true, but there are no correlation statistics in the article to support this conclusion. They list the doctor's name, how many scripts he writes and how much money he received from the pharmaceutical industry, but there are no correlation measurements whatsoever.

The other problem with the article is that the number of scripts written is not placed into any context: How many hours per week does each doc spend in a juvenile facility? How many patients is he seeing? Is there a difference in the diagnoses per patient group (some docs may be seeing sicker kids)?

I'm not saying that that the pharmaceutical industry doesn't influence prescribing habits, or that it's good to overmedicate kids. My complaint is with how this story is presented. It's incomplete, so obviously incomplete (and I'm NOT a statistics maven!) that even I can pick it up. Sloppy, inflammatory journalism won't help these kids.

Doctors Who Write

I can't find it now, but on one of our posts somewhere MovieDoc has stated that doctors can never ethically write about their patients since they are incapable of giving truly informed consent. Besides the obvious "huh?' response I have to the idea that patients aren't capable of making decisions like this, I question the basic assumption that this should never happen.

The medical literature is replete with published anonymized case studies of patients with various maladies. For psychiatry in particular, early psychiatric classification was based on longitudinal descriptions of diseases. If it weren't for the early case descriptions of Kaposi's sarcoma in gay men published in the 1980's, AIDS would not have been identified as a new disease. Case studies can and should be published to advance medical science.

Some medical schools are requiring medical students to write essays about their patient encounters, to build communication and empathy skills and to get them thinking about patients as whole people rather than a single organ system. This is a good thing, and as several commenters on this blog have noted some doctors really need work on this. Patient narratives force doctors to seriously think about personal aspects of medical care, and from a patient perspective they may help people understand how doctors think and what they feel about providing care. Improved mutual understanding and communication is a good thing.

Andrea Crawford wrote a very nice piece about this entitled "For Writers, The Doctor's Definitely In" for the Poets and Writers web site. In this article she lists numerous physicians who have written about their experiences and the unique position physicians have to write about human suffering. Physician memoirs may educate other doctors about work in underserved settings or places: Paul Linde has written two books about his work in Africa and as an emergency room psychiatrist (I'm reading it now, it's good.). Inspiring doctors to provide care to the underserved is a good thing.

So that's at least three or four reasons why medical writing should happen. The real question is, what's the best way to do it?

There seems to be four general mechanisms: completely fictionalized vignettes, as we did in our book; anonymized real cases stripped of identifying details; completely factual cases written with the consent of the patient, as done in the New York Times, or the "literary non-fiction" approach of medical writers like Linde. In the literary non-fiction genre doctors write anonymized case composites based upon actual experiences. The "patient" in these publications are not a specific real person, but are build out of various aspects of real cases.

There are problems and limitations with all these approaches and I don't have a strong opinion about the "best" way to deal with this issue. Factual cases written with patient consent is the ideal, but this is not always possible if the writing is done years after the event when the patient can no longer be located or may be deceased. Fictionalized vignettes are probably the best ethically, but from a reader is then left wondering how much---if any---of the story is real versus written for dramatic effect.

I've done some searching in this area and we Shrinkrappers obsessed quite a bit about it when writing our book, but I haven't seen any guidelines about it anywhere. If I'm missing something, speak up.

Happy Birthday in the Weird World of Social Media

I remember when birthdays were a quiet thing. A few phone calls from first degree relatives. A couple of cards from extended family members. A special meal with family, and a couple of gifts.

Now there's Facebook.

Birthdays are have become a multi-media event. The phone rings, repeatedly, a friend drops by with a giraffe toilet paper holder, there are text messages from ....my cousin, my kid, my kid's girlfriend, a friend of my other kid, and yes, a text message from the Vision Care place where I get my contact lenses. My father-in-law sends an e-card with music. Forty of my closest friends, including people I haven't talked to since elementary school, and my prom date, wish me the best. The request to serve on yet another committee comes in an email and notes "Happy Birthday." And yes, the Vision Care place also sent a happy birthday email, complete with animated balloons. For the first time ever, my beloved sibling seems to think that writing on my Wall suffices and I don't warrant a phone call, and this year, I did not get a greeting card from the Toyota dealer.

As long as the roses and chocolate continue IRL (in real life), then count me in! When the cake turns virtual, I'm signing off.

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of psychiatrists as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:

STORY HIGHLIGHTS

• Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
• But antipsychotics are most effective drug for calming agitation in dementia, he writes
• Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

Right About Now, We Need A Duck Break

I showed up at my community's organic vegetable garden to work yesterday morning. I was a little late and people had begun to disperse. A neighbor tossed some spinach my way. Another said, "Larry says we need ducks."

We need ducks? We have a patch of land by some athletic fields. No pond. Are we going to eat the ducks? No, they are going to eat the bugs off the vegetables. Interesting. I'd never heard of this. Larry's raised ducks before? Last week he was talking about chickens. It's all so confusing.
Apparently Larry wants us to research ducks, and so here is what I found:

http://www.grit.com/Livestock/Raising-Ducks-Helps-Your-Garden-Patch.aspx

The photo above, by the way is a picture of ClinkShrink and I together in Hawaii. I'm the duckier duck.