musings of a psychiatrist in the pacific northwest
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With apologies to vegetarians everywhere, I have to say that I can't get enough of that mini-burger stuff. I eat them so infrequently (for obvious reasons) that when I finally do get my hands on one (or six) I find myself overcome with a joy that can best be expressed through the power of The Dance.Joyful, indeed. Thanks to Geeknurse, who reports that MissB's video helps him cope. But note:
...if you eat six cheeseburgers while dancing in your living room, you may later experience a severe form of gastric distress. Please don't try this at home.
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One of the key questions—going straight to the heart of the Enlightenment ambition for us to be happy here and now, in this life—is whether happiness is a default setting of the brain. That is to say, are we, left to our own devices, and provided with sufficient food and freedom and control over our circumstances, naturally happy?
The answer proposed by positive psychology seems to be: It depends. The simplest kind of unhappiness is that caused by poverty. People living in poverty become happier if they become richer—but the effect of increased wealth cuts off at a surprisingly low figure. The British economist Richard Layard, in his stimulating book “Happiness: Lessons from a New Science,” puts that figure at fifteen thousand dollars, and leaves little doubt that being richer does not make people happier. Americans are about twice as rich as they were in the nineteen-seventies but report not being any happier; the Japanese are six times as rich as they were in 1950 and aren’t any happier, either. Looking at the data from all over the world, it is clear that, instead of getting happier as they become better off, people get stuck on a “hedonic treadmill”: their expectations rise at the same pace as their incomes, and the happiness they seek remains constantly just out of reach.
According to positive psychologists, once we’re out of poverty the most important determinant of happiness is our “set point,” a natural level of happiness that is (and this is one of the movement’s most controversial claims) largely inherited. We adapt to our circumstances; we don’t, or can’t, adapt our genes. The evidence for this set point, and the phrase itself, came from a study of identical twins by the behavioral geneticist David Lykken, which concluded that “trying to be happier is like trying to be taller.” Contrary to everything you might think, “in the long run, it doesn’t much matter what happens to you,” Haidt writes. Consider the opposing examples of winning the lottery or of losing the use of your limbs. According to Haidt, “It’s better to win the lottery than to break your neck, but not by as much as you’d think. . . . Within a year, lottery winners and paraplegics have both (on average) returned most of the way to their baseline levels of happiness.”
Can that possibly be true? Here we run into one of the biggest problems with the study of happiness, which is that it relies heavily on what people tell us about themselves. The paraplegics in these studies may well report regaining their previous levels of happiness, but how can we know whether these levels really are the same?
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Alexandria, Va.: Not only has there been a rise in children diagnosed with Bipolar but also with ADHD. I'm not sure I understand why there has been an increase? Were these same behaviors not present 30 years ago and now are all of a sudden rearing its ugly head and if so, what type of environmental, social, emotional changes are causing such behavior? I believe the majority of the children are misdiagnosed and it is really just big pharmacutical businesses getting big bucks at the expense of our children.Here is Dr. Nancy Andreasen, no less, telling New Scientist:
Jon McClellan: This is a very good question, but complicated. In part I think our culture has changed about how we view mental illness, and in some ways the definition of what is normal has narrowed. Expectations for kids has increased. In a world dominated by technology and computers, being able to pay attention and focus is a much more necessary trait. Some of this shift is not necessarily bad. For example, it used to be more acceptable for kids to be physically aggressive, bullies were considered part of life, etc. What used to be "boys will be boys", in many ways is now recognized as a problem because of the impact such behaviors might have on others. However, that doesn't mean such behaviors are the same as having a mental illness.
I don't think this is an organized plot by the drug companies, yet they clearly benefit. Their marketing reflects what we want as a society; better moods, better sex, better social functioning, etc. The difference between treating an illness versus enhancing skills or quality of life has become blurry.
In the US, at least, we have had some serious over-prescribing for conditions such as attention deficit disorders...Dr. Gelwan, in his excellent blog, notes:
Stimulants, on the other hand, are superfluously prescribed for a condition that is vastly, epidemically, overdiagnosed in a loosey-goosey, unsystematic, irresponsible way. Unlike antidepressants,I'm no ADHD expert. My attentionally-challenged patients tend to have diagnoses like depression, dementia or delirium. Do any child psychiatrists blog...or read blogs? They seem far too busy for such things. Their attention is focused on issues like this and this, as well as ADHD (and much more: see here).anyonealmost anyone prescribed a stimulant like Ritalin or Adderall, ADHD or not, will feel better and the shoddy diagnosis becomes a self-fulfilling prophecy because a medication is seen to have caused improvement. Again, unlike antidepressants, the drugs have enormous potential for abuse, diversion to the street trade, and addictiveness, because they feel so good to use. Tolerance accelerates use and creates escalating need for higher and higher doses over time. And the cardiovascular consequences, including sudden death, are far from trivial risks.
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"Tough problems best left to the unconscious mind"We aren't told enough about this research to evaluate it. I know lots of people who stop thinking about things. I can't say that I'm always impressed with the results...
Here's a suggestion for the next time you need to make a complicated decision: stop thinking. According to a new study, thinking too hard about a problem leads to poor choices - difficult decisions are best handled by our unconscious minds. While most people are happy to buy a new set of towels without much thought, they are unlikely to buy a new car or house without some serious thought. But Ap Dijksterhuis, a psychologist at the University of Amsterdam, argues that we might be getting these methods of decision-making the wrong way around...
He asked volunteers to pick their favourite car from a list of four based on a set of four attributes including fuel consumption and passenger leg room. He gave them four minutes to think about their decision and most people chose the car with the most plus points. When Dr Dijksterhuis made the experiment more complex - 12 attributes rather than four - people could only identify the best car a quarter of the time. This result was no better than choosing at random.
However, when the researchers distracted the participants after showing them the cars (by giving them puzzles to do before asking participants to make their choices), more than half picked the best car. "Conscious thinkers were better able to make the best choice among simple products, whereas unconscious thinkers were better able to make the best choice among complex products," wrote Dr Dijksterhuis in a paper, published today in Science.
(Er, weren't the distracted participants making the "best" choices? Is distraction a good thing?)
The problem with thinking about things consciously is that you can only focus on a few things at once. In the face of a complex decision this can lead to giving certain factors undue importance. Thinking about something several times is also likely to produce slightly different evaluations, highlighting inconsistencies...
He added that unconscious thinking does not seem to suffer the capacity limit: "It has been shown that during unconscious thought large amounts of information can be integrated into a evaluative summary judgment."
Jonathan Schooler of the University of British Columbia in Vancouver told Science that, while the new study builds on evidence that too much reflection is detrimental in some situations, he is not yet ready to dispense with conscious thought when it comes to complex decisions. "What I think may be really critical is to engage in [conscious] reflection but not make a decision right away," he said.
Dr Dijksterhuis said that when an important decision comes up he gathers together the relevant facts and gives it all of his attention at first. Then, he told Science: "I sit on things and rely on my gut."
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Patients often bring Dr Crippen articles from newspapers or from the 'Daily Mail'. He just doesn’t know how he would manage without them. He only spent six years at medical school with four years post-graduate training and then another twenty years in practice, so obviously he cannot be expected to know everything.Addendum: One commenter is very angry about this post (see below). What do you think?
It so refreshing therefore that helpful patients never cease to remind him how many areas of undiscovered ignorance he still has, and can back this up with newspapers cuttings not just from England but from all over the world.
It really helps.
If any patients are reticent about proffering advice to their doctor, and wonder how best to approach him, Dr Crippen always advises trying to help a pilot first. Be guided by his reaction in making your decision as how best to help your doctor...
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"I hold the viewpoint that the concept of sexual addiction was created by factions of the mental health community who were personally uncomfortable with robust sexuality and who possibly also wanted to create a new way of attracting therapy clients. The problem is, those who 'treat' sexual addiction, by their own admission, are treating something that is 'untreatable.' Read any of the literature from the sex addiction field and one finds that it cannot be 'cured.' That's a nice way to keep a full therapy practice..."
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It is not easy to delineate the characteristics that make a patient difficult. First, different physicians have different reactions to various types of behavior. In other words, behavior that one physician might find annoying, another might find to be particularly challenging or even endearing. Second, the characteristics of a physician may contribute to what he or she perceives as a difficult physician-patient relationship. Thus, a physician might perceive a patient as excessively demanding when, in fact, the physician or the medical profession may be at fault...Difficult Patient says: "While I can't imagine caring for a difficult patient being a rewarding experience, I think that finding a way to help them so that they aren't difficult anymore (maybe it isn't their underlying nature!) would be very rewarding..."
One study found that the most common responses by physicians to difficult patients were feelings of anger and insecurity. What is it about the encounter, the physician should ask, that is engendering these feelings? Assuming that the physician concludes that the problem stems from the patient's personality, it is useful to try and ascertain which of the patient's behaviors are so upsetting. This task is not performed in order to give the patient a derogatory label, but rather to initiate a diagnostic (and hopefully therapeutic) process. Thus, a patient might be characterized as overly demanding, a chronic complainer, or noncompliant.
At this point, it is important to assess the patient's psychiatric status. Does the patient's behavior stem from an underlying psychiatric problem? Important things to rule out immediately are clinical depression or an anxiety disorder, both of which are treatable. Underlying personality disorders, while less amenable to therapy, are nonetheless important to identify. Such patients may be referred for psychiatric consultation. Detection of a psychiatric problem, however, should not be a mechanism for "turfing" the patient to psychiatry. Rather, psychiatric intervention - by the primary physician or the consultant - should comprise one part of the overall therapeutic strategy and most often can be done in the primary care setting...
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I mean, it's happened before, when we were students in our med rotations, and certainly when I was doing palliative care, but this is the first that I've had a hand in arranging things for, following up, that I saw almost every day.. Heck, he'd been in this hospital longer than I had. He was quite young too, hadn't even made 50 years old. He always had a smile for when we came around, even on his not-so-good days. It wasn't entirely unexpected...
It's strange not seeing his name on the list, and not seeing him on the round..but we don't have time to stop. No such thing. It all goes on. There will always be people in the beds. The hospital never stops. And neither can we.
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I cleverly bought some flowers a day early in order to beat the Valentines Day rush, and also so I could get the “good stuff” before it was gone. What I learned is that smarter guys bought all of the “good stuff” at least TWO days ago. I couldn’t go home empty handed, so I picked the best of what was left. It was grim.
I’m no flowerologist, so I can’t identify all of the flowers in this arrangement. But I’m reasonably sure that two of them are dryer lint and at least one is a used hanky on a coat hanger. The rest of them are either dead or at least hunting quail with the Vice President if you catch my drift...
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Welcome to the personal ads of Grand Rounds. It’s Valentine’s Day and you’re looking for that special someone—or just some stimulating entertainment. Skim the personals below and if any tickle your fancy, don’t be shy—that click could be the sound of a love connection.
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The truth is, health and appearance are absolutely, 100%, forever intertwined. How many of us have looked in the mirror and felt 'depressed?' How many of us have avoided working out because we worry about what we'll look like at the gym? How many of us stay in unhealthy relationships because we worry that we have no options?
Ask a thin and athletic but homely woman if she would prefer to be pretty. Would it make her life easier? Yes. Would it improve her self-confidence? Yes. Would she have made different choices in her personal and professioanl life? Probably. Would junior high and high school have been more pleasant? Most definitely. Ask an intelligent, perfectly healthy man who is unfortunately unattractive if he would have an easier time getting that promotion or asking that woman on a date if he met the socially accepted standards of attractiveness.
We work with what we've got because we're survivors and many of us have no options. But if we had been given choices when we lined up at the gene pool, I bet we know which noses and bodies and hair we would have chosen. Pretty people have it easier. That's all there is to it.
Now, the fat acceptance folks do wonderful work. Because a good part of mental health is social interaction, it is super that fat people have support networks that help them get out there and get active. And nobody I've read has ever suggested that being psychotic is better than being fat. But my prediction is, once that patient leaves the supportive confines of her hospital and enters the real world, she will feel the stares, the contempt and the repulsion that we fat people have tolerated forever. The question is, does her not recognizing her weight problem indicate that she's still crazy? In my opinion, no. It just means she hasn't had a chance to get back to a regular life where her obesity will be pointed out to her every minute of every day. And yes, that is sad.
It all boils down to this: We need better drugs. Or maybe as a society we need better values. Better drugs are probably easier to accomplish.
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The weight gain associated with psychiatric meds sucks. It's a pain in the butt...and the hips, and the knees and the back. But the reality is that the giant spiders that used to hang out on my ceiling, the strange buzzing that I would hear coming from the television and the fixation on the Golden Gate Bridge (which is far to close to my home for comfort), suck more. The diabetes is definitely an unreasonable risk, but unfortunately, I started the anti-psychotics before the diabetes risk was widely known. Although I would gladly not have diabetes, because of it, I am being forced to slowly (very, very slowly) lose the weight that I have gained. I MUST exercise, I MUST NOT eat that cheesecake no matter how much I crave it.
I will never be thin...that's a fact. My body isn't made that way. My goal is to be healthy...at whatever weight that means for me...
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"Still Doing It tackles the stereoptypes and preconceived notions about sex (or the lack of it) and aging. The women profiled are thoughtful, insightful and brutally honest as they talk about their aging bodies, their needs for intimacy, what they are still doing and what they wish they could do...
"My favorite character was Frances, the 87-year old blind, wheelchair-bound woman who found her soulmate in the nursing home. And yes, they had sex. "Aware that many people see her as "nothing, but an old woman in a wheel chair," she is defiant in living her life on her own terms. 'When I'm having sex nobody matters. I'm in my own world, David is in his own world and we don't give a damn...'
"Fishel takes on the nursing home, health care and retirement community industries and challenges them to recognize that sexuality is a lifelong issue for their clients...Still Doing It is a great vehicle for opening up the dialogue around sexuality and age. I encourage you to see this important documentary if you are afforded the opportunity."
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...one morning, Nia was transformed. She left her bedroom, came to meals, had normal conversations with staff. Her face filled out with ordinary human expressions. A day later she was even laughing. A young woman, an intelligent teenager, had reappeared; the psychosis seemed to have left her. To see a patient respond to a drug in this way made the young psychiatrist feel like a real doctor. Almost ashamed of himself for feeling this, he noticed that he felt grateful towards Nia—for getting better.An alternate med is tried, with poor results.
What the staff didn’t pick up immediately was Nia’s hunger. The nurses were so encouraged by her regular appearance in the dining room that they didn’t question the heap of beans and potatoes. But soon it became apparent that insanity had been replaced by appetite. Within three weeks she put on three stone. Now, for the first time, Nia’s features were being corrupted. She started to take on the shape of many of the chronically mentally ill. Her jawline collapsed below puffed-out cheeks. Her stomach sagged above her jeans. Even the consultant found the contrast alarming...
The young psychiatrist’s early optimism collapsed under the grinding reality of Nia’s dilemma. The first drug had worked. But the change in her appearance seemed intolerable—and potentially devastating for the self-esteem of a 17-year-old girl. The second drug hadn’t made her fat, but nor had it treated her illness. The consultant felt there was no option but to put her back on the Olanzapine. Again, it worked. The terrors of persecution vanished, the voices quietened down. Even her parents said that this was the old Nia. They cried over her.Thanks to Mindhacks for pointing to this excellent article.
The desire to experiment further with her medication left the consultant and the young psychiatrist. It was likely that the weight gain associated with Olanzapine would be very difficult to treat and that Nia would be fat, if not obese. But more disconcerting to the young psychiatrist was Nia’s apparent indifference to her predicament. While those around her worried about the beauty she had lost, she seemed unconcerned. Was she really as well as her family suggested? Had she really rejoined the image-conscious world of her peers?
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...This brings us into sci-fi territory, into the realm of mind reading. When Vendemia has a subject in an E.R.P. cap, she can detect the first brain-wave changes within 240 to 260 milliseconds after a true-false statement appears on a computer screen. But these changes are an indication of intention, not action; it can take 400 to 600 milliseconds for a person to decide whether to respond with 'true' or 'false.' 'With E.R.P., I've taken away your right to make a decision about your response,' Vendemia said. 'It's the ultimate invasion.' If someone knows before you do what your brain is indicating as your intention, is there any room left, in that window of a few hundred milliseconds, for the exercise of free will? Or have you already been labeled a liar by your spontaneous brain waves, without your having a chance to override them and choose a different path?
Lies make secrets possible; they let us carve out a private territory that no one, not even those closest to us, can enter without our permission. Without lies, there can be no such sanctuary, no interior life that is completely and inviolably ours. Do we want to allow anyone, whether a government interrogator or a beloved spouse, unfettered access to that interior life?"
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"The motion to be debated at the RCN (Royal College of Nursing) Congress has been put forward by the mental health nursing forum, an RCN division. It states: “Safe self-harm — is it possible? That this meeting of the RCN Congress discusses the nurse’s role in enabling safe self-harm.”
According to proposers of the motion, some nurses already stay with patients while they harm themselves to ensure they do so as safely as possible. One, who declined to be named ahead of the debate, said: “There are some areas of Britain where they have already explored safe self-harm. We may not like someone self-harming, but they are going to do it whether we like it or not and we will need to deal with the problems afterwards.”
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The biggest relationship mistake you can make is to assume that because you have some special training or knowledge on a topic, that your opinion should be extra important. You could be the world’s most respected expert on insects, for example, but if your mate insists that caterpillars grow into chipmunks, there will be no talking him or her out of it...(This works well if one partner doesn't care much...)
So forget about how much you know, or how smart you think you are, or how much extra information you might have recently collected. That will not help you. Instead, I offer you the only solution: The WCM Method.
WCM stands for Who Cares Most. If you want your relationship to have a chance, defer all decisions and interpretations of fact to the person who cares the most...
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"This first Carnival of the Bipolars is my take on the electronic ties that dissolve the isolation that many bipolars feel from spending their lives in their living rooms, terrified of going out while in episode, scared of the “normals” who mock them and make sport of their fast-talking, their racing thoughts, the shaking that ripples from the tops of their heads to the soles of their feet and back again. Inside this disease at its worst is a continual soliloquy...
"Most of the people who appear on this page suffer from my disorder. Others have similar problems for which my sympathy is deep. Of they live with someone like me. It’s hard enough being human. To have any disease or any order of pain, I think, is the profoundest expression of a large part of what our constantly growing and failing chemical reactions must be about. Choosing who to include and for what was hard. The arms of bipolar stardust stretch well beyond these representatives. I hope we’ll draw in more of our kind because no matter how distant we are, this Internet helps us to step out, to find others like us, and develop a new language that describes what our living is about."
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My desk and my office took on 8 feet of water after Hurricane Katrina, so I only have my memory of it; but my memory in this rare case is perfect: It was a 5-inch tall gray ceramic skull, a Halloween trinket, glazed to a high gloss...It was, in a word, tacky. I kept it to remind me that I could never get a worse gift. My little Yorick humored me.
As with any gift, its value was derived not simply from the value of the object itself but also from the circumstances of the giving, which I will now relate...
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People are complex. When you schedule a woman for a routine pap smear, this is what you are planning to do. However, when you enter the room, you are faced with a crying, depressed individual in a paper gown. Clearly, a pap smear is not her main issue today. You patiently listen to her version of the divorce and custody issues, and what a bastard her husband is, or how she may lose her job. You wait and you listen. Tactfully, you try and look at your watch, but you always get caught. Sometimes, you will decide to triage - take care of the situational depression first, rescheduled the pap. Sometimes, and more likely, you do both. This is a 45 minute visit (at least).(Don't miss the comment thread.)
Out in your waiting room, people are stirring. They are making quick arrangements for people to pick up their kids at school, or cancelling other appointments. They are waiting and people HATE to wait (even though we call it a WAITING ROOM!). And, I understand that they are ticked. I hate to wait, too.
My next patient has been waiting a nearly an hour in the room. I don't want to go in there, but this is my job. My first goal is to defuse the angry. I apologize for the wait, acknowledge their anger for being inconvenienced. 'I am sorry that you had to wait today. I had an unanticipated medical crisis that took more of my time than anticipated. Sometimes, people's medical problems take more than just 15 minutes. I hope that you understand. Someday, YOU will need more time, and I hope the people that have to wait for YOU will be understanding as well. So, how can I help you today?' We both smile, tensions have released, and we complete the visit. As I exit the door, I hear, 'Oh, by the way...'"
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All clinical details on this site are modified and obscured to protect confidentiality. No medical advice is given on this site, except "Talk to your doctor."
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