Tuesday, November 29, 2011

Does Your Psychiatrist Respect You?

My biggest surprise since becoming a mental health blogger -- how little self-reflection psychiatrists do.

Healer, Know Thyself

Clinical education for clergy usually happens in a hospital.  For every patient contact hour, we would spend another hour writing verbatims (one third what the patient and the chaplain said, one third what the chaplain was thinking, one third what the chaplain was feeling), and then another hour discussing what we were thinking and feeling in group or individual supervision.

Continuing education for clergy includes more large doses of self-reflection.  I don't know how many times I have created my genogram, a family tree that includes the dynamics of relationships: alliances, roles, conflicts, secrets, patterns... for my first family counseling course, for a seminar on family systems in congregations, for doctoral work in congregational development, while training congregational leaders to show them how to do their own.  I once even made a genogram of a congregation and key diocesan figures when I took a situation to a consultant.

In this example, Sarah is extremely focused on her son, while Abraham and Isaac are distant; the brothers are in conflict.  The pattern repeats in the next generation.

Clergy groups do critical incident reports in support groups.  Similar reflection.  What is my part in this mess?  How do my needs and fears interact with somebody else's needs and fears?  How do I get out of the blame game?  How can I tap into my sources of strength (faith, friends, scripture, sacraments, grace, knowledge...) to get myself unstuck?

The point is to figure out how my issues interact with anybody else's.  If I can sort out my own stuff, I can be a healthier presence in my relationships with others, less bound by unhealthy patterns, more able to find creative solutions.

The two most helpful discoveries I have made from these exercises: sometimes my troubles at work have come from my repeating a script from my childhood, a conflict or alliance with a person who is no longer in the room; sometimes my troubles at work have come from inadvertently stumbling into a power struggle, when my first-born status runs into somebody else's position of power.

When I discover what is going on in me, and hence what is going on in the relationship, I can change my own behavior to defy the script.  I can do something unexpected that helps me and maybe even the other person break out of his/her script.  It works best if this unexpected behavior is funny.

Psychopharmacologists Don't Do Self-Reflection

It used to be that people training to be psychiatrists did psychoanalysis.  Then the mind was replaced by the medical model of mental illness, and this requirement went by the board.  Now it's all about the meds.

But we don't take the meds.  We don't.  The numbers differ for a variety of meds.  In one study, three months out from the original prescription for antidepressants, 72% of us have quit.

Psychiatrists call this noncompliance.   They write myriads of articles to explain the numbers, saying about us, they miss their highs or they lack insight.  These articles make no reference to what patients say about why we quit our meds, the meds make us sick and the meds don't work.  [That last link is to a rare exception.]

Systems theory would call these articles evidence of a power struggle.  Psychotherapy might recognize counter-transference, the feelings, in this case very negative feelings psychiatrists have toward patients who do not do what we are told or, even if we do comply, refuse to get better anyway.


My therapist was surprised when I commented on how little self-reflection psychiatrists do.  Her field, psychotherapy is all over the counter-transference-type issues.  And there still are a few psychiatrists who follow the old model.  At the Gabbard Center, two of the three who interviewed me even had couches, not living room-type, but New Yorker-cartoon-psychiatrist-type couches.  I had never seen one before!

So I have to qualify my comment.  My reading has primarily been in the field of psychopharmacology, as in, the psychiatrist who told me, I don't do relationships.  I treat psychological illness with pharmacology.

It occurs to me that patients might be better off if this kind of psychiatrist skipped medical school and went to pharmacy school instead, with a specialty in psychopharmacology.  There they might learn about adverse effects and the consequences of adding one med on top of the other, to make it work better or to counteract its adverse effects, resulting in iatrogenic disease, the disease that is caused by the treatment itself.

You know, that overweight zombie you became, stuck on the sofa, unable to complete a sentence, until you die 10-25 years before your time on account of complications from liver disease, diabetes, and cardiovascular disease, on account of you actually took the meds that were prescribed..  Death by medical treatment.

The Power Struggle

The thing is, in this particular power struggle over medication, while psychiatrists think they have more education, more knowledge, more insight, more prestige, more standing, while they think they are the parent in this relationship and the patient is the child (yes, they do think this, they really do, they betray it in every printed word), all these things that make psychiatrists think they know best and should have more say matters not when it comes to whether that pill will go into the patient's mouth and down the patient's throat.  Short of physical restraints and a hypodermic needle (which every parent of a toddler in a grocery store has had occasion to covet), the patient is going to win this power struggle.

So why not recognize the power struggle for what it is, and give it up?  As long as you are bound to lose it, why not do something else instead?

I Trust My Psychiatrist

If, after all that, you still remember how I got onto this topic last week, and where I said I was going, then your cognitive functioning is not as bad as you thought.

I said when I feel respected by my psychiatrist, I am more willing to trust her with my body.  I promised I would name some behaviors that she exhibits that build the therapeutic alliance, notwithstanding the lack of respect that I find in vast numbers of articles by psychiatrists who write about why patients don't take our meds.


She asks me, What do you want to do?

When we have a med check, we exchange information.  She listens to my report about what I am doing with my meds, how they are helping and hurting my life, and what kind of life I hope to live.  Then I listen while she gives me information about how the things work, why I might be having certain problems, what might be possible.  I tell her my concerns, she tells me hers.

I know that she won't prescribe things that she thinks will be harmful, because she remembers how sensitive my body seems to be to these things, and prescribes accordingly.  She knows that I won't take things that I think will be harmful, because, well, nobody does, not for long.  She expects that I will do my own research and make my own decision, because she remembers that I know my stuff.

When I am not in good shape, she does not confuse a current cognitive deficit with lack of intelligence.  So she makes lists, writes down the major points.  I am still in charge.  She asks, What do you want to do?  I sometimes say, I don't know.  What do you recommend?  But she always asks, What do you want to do?

As it happens, I don't take antidepressants, antipsychotics or mood stabilizers anymore, because I never found one that worked and was tolerable.  But we worked together to reach that decision and to develop an alternative plan.

With my previous psychiatrists, I just stopped.  I made the follow-up appointment, then called the machine after hours to cancel, and stopped.  In a sense, that was childish, not to confront the doctor directly.  But honestly, when I did confront the doctor directly, I got treated like a child.

My current psychiatrist continues to participate in my decisions, and I continue to rely on her for help managing symptoms with rescue meds, because we are partners.

What About Lack Of Insight, Denial, and Stupidity?

So, I am on top of this.  I am motivated and informed.  I have lots of resources that support my recovery and carry me when I flag.  I have good insurance and get more than ten minutes for a med check.  I am not the typical patient in the typical setting.  I can imagine a psychiatrist reading this and saying, Collaboration just won't work in my setting.

So, does what you are doing work?

Follow up question: does blaming your patient work?

What About Frustration, Worry, Disappointment?

What if psychopharmacologists spent more time acknowledging that their work conditions are lousy, they are anxious for their patients, and they know they can't deliver on the promises of these miracle meds?  What if they wrote articles that addressed these issues, and how their frustration, worry and disappointment get taken out on their patients?

Maybe they could discover their patients share these frustrations, worries, and disappointments. with them.  Maybe they could figure out something new to do.


Examining ones own stuff takes work, and is not pretty.  Coming up with new behaviors that display respect and build a therapeutic alliance, experimenting, trying to change habits -- all of it is hard work.  And it might not make a difference anyway, if it's just behavior.  Even if it's respectful behavior.  If we can tell that the psychiatrist is faking it, is parroting a line.

Coming soon -- I will up the ante and write about:


genogram of my own creation, please give attribution
flair from facebook.com
photo of mirror by Jurii and used under the Creative Commons Attribution 3.0 Unported license
clip art of tug of war by Microsoft Office
illustration of A Zombie, at twilight, in a field of cane sugar of Haïti by Jean-Noël Lafargue used under the Free Art License
sketch of hands shaking by Danieldnm and in the public domain

Wednesday, November 23, 2011

Holiday Shopping for True Happiness

A friend of mine reports for work at Target on Thanksgiving, 11:30 PM.  They are ready with extra security.  Only thirty people can enter the store at a time.  There are even line judges, to prevent jumping.  Oh, the humanity!

Me, I will do my shopping right here in the very chair in which I am writing this post.  Save your hippocampal glial cells damage from your overactive HPA axis!  Save your toes!  Internet!

Oh, and because this year's flu shot missed, this week's blog post is a rerun, dedicated to the topic of shopping for, of all things, meaning. 

From Friday, December 17, 2010,

Holiday Shopping for Loonies and Normals Alike


Last year I got an earlier start with my efforts to help you purchase the perfect Chanukah/Kwanzaa/Christmas present.  Here are the links, one for your favorite loonie, the other your favorite normal.  The first is even diagnosis specific.  The most popular pick turned out to be a bluetooth phone for the one who talks back to his/her voices, but is trying to pass.

This year, regular readers know that I have been living and breathing gingerbread.  So this post, like my own shopping, comes late in the season -- Chanukah has passed us by.

Internet.  God bless the internet.

And what with last week's post on happiness fresh in my mind, this year's holiday shopping picks combine the two issues -- where to get what makes for true happiness on the internet.  No, really!

The Sources Of Happiness

Martin Seligman's Authentic Happiness identifies three major sources of happiness, pleasure, engagement and meaningfulness.  So here are suggestions to enhance all three for your favorite loonie or normal.

Let's address one issue first.  Life circumstances, beyond having the essentials, are not really that important an influence on the measure of ones happiness.  But poverty does matter.  If the one you love lives in poverty, go to Amazon.com's gift card section, where you can find gift cards for clothing stores, restaurants, general retail, entertainment and more.  Give us bread, but give us roses are lyrics of a working women's song from the early 20th century.  It's nice, when you are poor, to have the opportunity to choose which is the higher priority this week.


Well, yes.  Feeling good makes you feel good. 

On the other hand, have you seen that bumper sticker, The one who dies with the most toys wins?  That bumper sticker is an example of irony.  I hope it is an example of irony.  I am sure the person who came up with it meant it ironically.  It is possible that the person on whose Lexus SUV you saw the bumper sticker might have missed the point.  That would be sad.

Irony means that the bumper sticker is not true.  The one who dies with the most toys does not win.  I just wanted to make that clear.  Of the three top sources of happiness, pleasure, engagement and meaningfulness, pleasure ranks lowest on the list, happiness producing-wise.  Our mindless pursuit of it notwithstanding.

Nevertheless, perhaps the heart's desire of the person for whom you are shopping is toys.  There are all kinds of toys out there.  Almost all of them, you can find, again, at Amazon.com.  I thought they were a book store.  No, from Automotive to Watches, with books, electronics, movies and even musical instruments between.  If you know what that heart's desire is, you can probably find it there.  If you don't know what that heart's desire is -- are you noticing a theme developing here? -- gift card.

Yes, I know.  This reads like an infomercial for one particular corporate giant that is destroying local businesses across America.  But give me a break.  And give yourself a break.  Your Chanukah presents are already late.  Christmas and Kwanzaa are bearing down like a runaway train.  I don't have time to look up a bunch of choices for you.  I have my own shopping to do.  Internet.

Who am I kidding?  I can't go into stores anyway unless medicated.  Maybe you can relate.  At least I have the Rx!


Engagement means being absorbed in the here and now, whether in family, romance, work or hobbies.  That being absorbed is the key, because the wandering mind is an unhappy mind.  Gifts that bring the family together, or send your recipient out on a date or relate to his/her interests can enhance that person's happiness.  And you can find just the gift or gift card at... what has evidently become the Shameless Commerce Division of Prozac Monologues.


Okay, all the above is filler.  Here is what I really want to sell this season.  Making a difference.  What makes for meaning is using one's personal strengths to serve some larger end (Seligman's definition.)

One kind of strength is passion.  So let's start with a question.  What is the passion of your gift recipient?

I knew an old lady once who absolutely would not deal with that word passion.  It's a wonder she reproduced.  Like Queen Victoria, she probably closed her eyes and thought about England.  Or, being American (and Episcopalian), she probably thought about The Book Of Common Prayer.

So here is an alternative for Thelma, God rest her soul, and for you if you can't relate to the word passion.  Determination.  What is the determination of your gift recipient.  What is he/she determined to support/challenge/change/make possible in the world?

Now let's go shopping for meaning.

Clean Water For Africa

Here is my passion/determination story.  The Episcopal Diocese of Iowa has a companion relationship with the Diocese of Swaziland.  Swaziland has had a drought for a decade or so.  There are things that could be done.  But the king has about a hundred wives, and he can't play favorites, can he?  If one has a Mercedes Benz, then each have to have her own Mercedes Benz...  So who can afford to dig wells?

But then this guy in Southeast Iowa developed this technology that turns table salt into chlorine.  For $150, we could get this thing called a chlorinator that produces enough chlorine to give clean water to an entire village[Here is an update from the original article about how the system works.]

Well, heck.  I'll buy two!

We took a lot of them over.  Now the Swazis are making them in country.  One year a mission team came back from Swaziland with the story.  An elder from one village had told them, 

Since we got the chlorinator, not one child died last year.

Not one child died last year.

I have never spent any amount of money that has ever given me and will forever give me as much happiness as those six words.

Not one child died last year.

Give your mother or your father this story and clean water for a whole village in Africa right here.  Now we are doing Haiti, too.

NEWS FLASH November 26, 2011 -- This just in from Earl Ratcliff, the inventor:

As you noted the cost of our CPU WAS $150.  The Lord has been good to us.  We've been able to reduce the cost to $50.  Assembly time went from 1 1/2 hours to 10 minutes and from 20 pieces to 6.  Plus overall quality has improved.

So that is how this year's holiday gift-giving guide is going to work, using one's personal strengths/passions/determinations to serve some larger end.

Shopping To Serve A Larger End


So look again, more deeply this time at those pleasures.  Do you have a friend who loves camping?  Insecticide treated mosquito nets are a bargain for $18.57, delivery included to places in Africa where one person dies of malaria every 30 seconds.

How about a friend who bakes?  High energy biscuits will feed young children in disaster sites, 600 for a mere $24.98, again, delivery included.

You can find these and a whole assortment of Inspired Gifts for the health, water, nutrition, education and emergency needs of children around the world at unicef.org.

Heifer International

How about a gift that keeps on giving?  Heifer International provides livestock and training to improve nutrition and generate income, lifting families out of poverty.  Recipients share the offspring with others in the community, multiplying the impact of each gift.

So do you have a friend who wants a pet but is allergic?  Three rabbits, $60.  Aaahh, aren't they sweet?!  We bought bunnies for China one year.  Hunger has been wiped out in China.  Heifer International has moved on to another country.

Do you know a cowboy wannabe?  One heifer, $500.

How about a whole ark with two cows delivered to a Russian village, two sheep to Arizona, two camels to Tanzania, two oxen to Uganda, two water buffalo to Cambodia...  There are fifteen pairs in all for $5000.  For your friend who is delusional?  (Noah/end of the world/delusional -- get it?)

We are just getting started.  Knitters, a knitting basket (llama, alpaca, sheep, angora rabbit) -- $480.  Gourmet, cheeses of the world (how cool is that! heifer, goat, sheep and water buffalo) -- $990.  Homesick Iowan, pig -- $120.  Let's not neglect our vegan friends, trees -- $60.

If you are shopping for me, I have long had my eye on that water buffalo, a mere $250.

All of these are available in shares, by the way, if that fits your budget better.

Seriously.  Water buffalo. 

Habitat For Humanity

Now let's return to where this series started and my life for that last two months, Habitat for Humanity, building affordable housing by using volunteers, including those who will own - and pay for - the houses.  Whether your designated gift recipient is Martha Stewart or Frank Lloyd Wright, Habitat has its own gift catalog with everything from light switches to flooring.  One year my sister-in-law gave me a kitchen sink. 


If I haven't hit a bulls eye yet, one.org is the meaningfulness equivalent of amazon.com.  This one may appeal to the rockers in the crowd.  Cofounded by Bono, Bob Geldof, et al, one.org created a partnership of all sorts of groups working to eliminate world poverty by 2015 -- the Millenium Development Goals.

Here you will find more about one.org.  Here you will find the partners (Bread for the World, Oxfam, Bill and Melinda Gates Foundation, various churches, etc.)  Each one has its own focus, allowing you to find your perfect match.

And since this is my blog, after all, I will put a word in for Episcopal Relief and Development, ER-D.  When earthquake or hurricane strikes, ER-D listens to local people to determine how best to help.  Then they stay with it after the cameras move on.  For example, ER-D is still working on economic redevelopment in New Orleans.  And this is one church organization you can support that will NOT ask potential recipients where they go to church.

Joy That Lasts

So there you have it.  Without leaving the comfort of home, without even having to change out of your jammies, you can find the perfect gift, one that will give joy beyond the end of the year.

Not one child died last year.

photo of Hindenburg in the public domain
clipart from Microsoft
cotton candy photo by Maggie D'Urbano,
used under the Creative Commons License (cropped)
child with unsafe water by Pierre Holtz - UNICEF, licensed under Creative Commons
child drinking well water by Scott Harrison licensed under Creative Commons
mosquito netting by Tjeerd wiersma, licensed under the Creative Commons Attribution 2.0 Generic license
photo of rabbits by Kessa Ligerro and made available under the GNU Free Documentation License 
Entrada dos animais na arca de Noé by Giovanni Benedetto Castiglioni, public domain
photo of water buffalo by Da and made available under the GNU Free Documentation License
GNU -- somehow seems appropriate, doncha think?  

Friday, November 18, 2011

Narrative and the DSM

My therapist once picked up the DSM and said, This could be called The Book of Behaviors That Make Therapists Nervous.

An apt description.  It is filled with descriptors: adjectives, behaviors, impulses, thoughts, feelings that are all human adjectives, behaviors, impulses, thoughts and feelings.  Almost none of them are strange in and of themselves.  Almost all of them are familiar to all of us.

It's just that at some point, when these descriptors add up, somebody starts to get nervous.

Diagnosis -- Recognizing Deviation From The Norm

Well, our brains are wired that way, to recognize patterns and deviations from what we expected, and to discern the potential consequences of the deviations.  If the deviations are sufficiently nervous-making (and are not caused by organic disease), then we have what is called a mental illness.

That is diagnosis.  That is how the Diagnostic and Statistical Manual, DSM works.

At that point, evidence-based medicine steps up to the plate.  What are the medications and other interventions that have demonstrated the potential to reduce these descriptors to levels that are not so nervous making?

Inevitably, certain symptoms get more attention than others.  Psychiatrists are not concerned when patients sleep too much, do an astounding amount of work in three days or die twenty-five years before our natural lifespan due to complications of obesity, as long as we don't have hallucinations or delusions or try to end our misery by self-harm.

It's all about the descriptors, and how nervous they make people.

DSM V - Passé Before Published

I think the real reason the DSM V is years behind its publication schedule is that it just doesn't make sense anymore.  Two glaring flaws come to mind.

First, the people it purports to describe are dissatisfied with the treatments that it supports.  Well, it's not that anybody actually consults us.  They call us consumers.  But the focus groups and satisfaction surveys are conspicuously absent.  When we vote with our feet (become non-compliant), they simply diagnose that, as well.

Second, and more telling, Nature has not read the DSM.  -- That is the epigram of the Wasn't-that-book-supposed-to-publish-last-year? season.  In other words, there is not good correspondence between the sorting the DSM does by symptom and the sorting that researchers are more and more able to do by brain dysfunction.  A disregulated HPA Axis can manifest the symptoms of Major Depression in one person and PTSD in another.  The same gene configuration manifests as schizophrenia in one and OCD in another.

It's like, the DSM tells you what color the car is and how many cup holders it has.  Big Pharma has made a lot of money tinkering with the placement of the cup holders.  Meanwhile, what patients want to know and what scientists actually are working on nowadays is, what's under the hood?  [John McManamy gets credit for the metaphor and his persistent question.]

What To Do With The DSM?

Meanwhile, there is another strand running through these journals and debates.  Trauma-informed care is shifting the nature of the conversation.

The Substance Abuse and Mental Health Services Administration (SAMHSA), among others, sponsored a report on trauma informed behavioral health systems by Ann Jennings.  The following summarizes the basic principles:

The new system will be characterized by safety from physical harm and re-traumatization; an understanding of clients and their symptoms in the context of their life experiences and history, cultures, and their society; open and genuine collaboration between provider and consumer at all phases of the service delivery; an emphasis on skill building and acquisition rather than symptom management; an understanding of symptoms as attempts to cope; a view of trauma as a defining and organizing experience that forms the core of an individual’s identity rather than a single discrete event; and by a focus on what has happened to the person rather than what is wrong with the person (Saakvitne, 2000; Harris & Fallot, 2001). Without such a shift in the culture of an organization or service system, even the most “evidence-based” treatment approaches may be compromised.

What Happened To This Person?

If any consensus about mental illness exists among scientists, it is that it results from interplay of genetics and experience.  Genes provide the backdrop of strengths and vulnerabilities.  The brain itself is plastic -- it wires itself in response to what happens to it.  Sometimes the same gene provides both strengths and vulnerabilities -- See a recent post from John McManamy at Knowledge Is Necessity.

Meanwhile there is growing awareness that the vast majority of people with mental illness have experienced trauma of one sort or another (or many).  Well, maybe the vast majority of all of us has.  But those with mental illness have genetic predispositions to problems processing the trauma.  Then the brain rewires itself in response to the trauma.  And there you have the root of the problem.

The DSM does not address the root of the problem.  It asks, What is wrong with this person?  Yet even beneath its endless lists, there lurks another issue.  You could call it the counter narrative.  Or simply, the narrative.  What happened to this person? 

Narrative In DSM Categories

Let's imagine the DSM as a book of short stories, and ooh, ooh, give the stories some alternative titles. 

Hotel Rwanda: The first, least fun and most obvious example-- a diagnosis of PTSD has behind it a traumatic event.  The sufferer nearly died or watched somebody die or nearly die. 

Ferris Bueller's Month Off:  Moving on to mood disorders.  You sold your house and went out to save the world -- the story behind Bipolar I.  You stopped sleeping, ignored your grandmother you hadn't seen in seven years, never went to the beach, and instead wrote a book during your tropical vacation.  But (very important for differential diagnosis) you didn't get arrested! -- Bipolar II.

Alexander and the Terrible, Horrible, No Good, Very Bad Day:  So what about Major Depression?  Here a story can even negate the diagnosis.  Sure, you haven't eaten or slept in a couple weeks, you have lost all will to live, you can't make decisions and feel hopeless.  On the other hand, your spouse was inside the house when the tornado blew it away.  That's not MDD.

Here is my favorite.  The aforementioned therapist said the chapter on personality disorders could be used for examination of conscience.  (She can speak fluent Catholic and knows I can, too.)  But I like the title Why Your Wife Divorced You, Your Boss Fired You, And Your Therapist Doesn't Much Like You Either.  See, if your therapist says you believe you are "special" - quotes added by the therapist - require excessive admiration, have a sense of entitlement, lack empathy, and take advantage of people, then you know there is a story, probably several, behind that little list of "symptoms."  Or in Catholic-speak, sins.  (The stories about people with that particular list of symptoms usually are told in third person, by the ex-wife to her therapist.)

Any readers have other chapter titles to suggest?

Listen To The Story To Get The Diagnosis Right

Remember, I have two new diagnoses?  When I originally complained of the symptoms of PTSD, my own psychiatrist asked me the cause.  What do I know about cause?  I told her the story that triggered the symptoms.  And frankly, that story just didn't measure up to the diagnosis.  So she called it Anxiety NOS (not otherwise specified.)

But the Gabbard Center asked me straight out about traumas in my life.  I have a list.  Boy, do I have a list.  They heard the triggers in the context of the original events that wired the brain.  So they say I have PTSD.

On the other hand, they were so determined to hear this trauma story nobody else had been hearing that they didn't have time for the rest of the story.  They didn't hear the bit about the book, or the seasons I would spend building a dozen gingerbread houses in two weeks, each unique in materials and design, or the paint job I did on our rental house that I still say was not excessive, though my friends and family insist it was and were quite worried about my behavior...  So the Gabbard Center says I have MDD, not Bipolar II after all.

Listen To The Story Because The Listening Itself Is Healing

Each time a long term memory is repeated, it moves temporarily into short term memory.  From that position, new meaning gets added.  It can be the meaning of being dismissed once again (retraumatized).  Or it can be the meaning of an encounter with somebody who respects the teller, who recognizes the person, not the list of symptoms.

Psychotherapy works because the brain is plastic.  When the long term memory moves into short term, has value (the experience of somebody listening to it) added, and returns to long term memory, its meaning is transformed.  The wiring changes.  Maybe a little, maybe a lot.  It takes longer to work than a pill.  But it lasts longer, too.

The Rest Of The Story

Prozac Monologues is all over the power of language.  There is power in these labels given us by the DSM.  The person who suffers is affirmed when the suffering is recognized.  It's real; it's not just in my head.  The family's anxiety is reduced once the pattern is recognized and named.  They knew something was wrong.  The therapist's anxiety is reduced, as well.  S/he is empowered, knows what to do.

It's just not enough.

Peer to Peer devotes two of its ten weeks to the DSM.  Often participants don't know why they were given the particular label they have.  Often the opening of this magic book gives us power, too, to name ourselves.

And then we spend the other eight weeks deconstructing the labels.  Because whatever our diagnoses, we discover that we travel similar paths.  Not identical, but similar.  The labels help us find each other.  When we get to the specifics behind the labels, then we begin to help each other.

The DSM As Literature

What if we thought about diagnoses as genres in literature, rather than scientific categories?  What if we used it to describe the arc of the story, to guide the way forward?

So the guy was walking down a street one night and fell into some dark hole you can find described on page xxx.  He yelled for help.  A psychiatrist walking by threw a scrip into the hole and said, Call me in three months to set up a med check.  The guy yelled for help.  The spiritual person said, Sending positive energy! :-)  He yelled for help.  The therapist said, Tell me about another time you found yourself in this hole.  He yelled for help.  And the next passerby jumped down into the hole with him.  What did you do that for?  Now we're both in the hole.

Yes, but I have been here before.  I know the way out.

See, it's all about what happens next.

Photo of Bible be Walter J. Pilsak, permission  to copy under the terms of the GNU Free Documentation License
Sketch of anterior cingulate cortex from NIMH and in the public domain
Photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
Queen from Disney's Snow White -- I think this is in the public domain

Thursday, November 10, 2011

I Told Them I Was Sick - DSM Revisited

Have you heard about the man whose tombstone read, "I told them I was sick"?

A New Diagnosis Or Two

So, the docs earned their big fee and the Pension Fund got its money's worth out of this three-day psychiatric evaluation.  I have a couple new diagnoses.

That is really not so remarkable.  If you attend a Peer to Peer course, NAMI's signature ten-week self-help program for loonies, you know this.  One week, the participants go round the circle and tell their diagnoses, or rather, their history of diagnoses.  Most trace a whole tour through the DSM, the Diagnostic and Statistical Manual.

Where Diagnoses Come From

The DSM originally was intended to give a common language, distinguishing one sort of loony from another, so that scientists could compare their research results and build up a common body of knowledge.  Then came insurance codes...

We are sorted by symptoms and severity: delusions, irritability, instability in relationships, difficulty concentrating, intrusive and persistent thoughts...  I am sampling here from different chapters.  Each diagnosis has its own profile of a minimum number of symptoms from a particular list, with a certain level of life dysfunction resulting from the symptoms.

There is overlap in these lists.  Irritability and insomnia, for example show up in a number of them.  Some lists define their own diagnosis (like depression) and then become subsets of another (like bipolar).  Then there are a few that include life events as criteria, like getting arrested or hit by a bus, as well as symptoms.

The system is a bit unwieldy.  Researchers never rely on somebody else's diagnosis, and often write articles about how many people are diagnosed with depression who actually have bipolar, bipolar who actually have a personality disorder.

DSM Revision

So they keep trying to rework the DSM.  The current rewrite is a couple years off its original publication date, as scientists debate the number of angels on the head of a pin, claiming they will get better results if they distinguish between people whose hypomanic symptoms last at least four days from those whose episodes last only three, while others plead the case of those who go untreated because they don't make the cut.

Doctors mostly just want to know which diagnosis the insurance company will pay for.  They have to fudge sometimes when, whatever the label, the person in their office should not be let out on the street.

Therapists say it doesn't matter what the label is, as long as you get the right treatment.

Patients' Perspective On Diagnosis

Then there are patients, who do not have a voice in these debates.  Well, we do have our blogs.  We have discovered it does matter what the diagnosis is.  The doc may say you have bipolar, because that is the only way s/he can get you a bed.  But once tagged by the ER doc, the next doc prescribes those meds.  And if they are the wrong meds... well, you end up in a Peer to Peer course years later, telling a tale of woe that everybody in the room already knows.

Then there is that pesky issue, even if the diagnosis is correct according to the strictest application of DSM criteria, the "right" treatment might be wrong anyway.  Suddenly, once your mind has gone south, the doctors who originally prescribed the med, assuring you that they are scientists, unlike the commentators you read on message boards, turn around and remind you that medicine is an art.

Mental Illness Is Physical Illness

The whole thing is a peculiar way of going about it.  Everybody has figured out that mental illnesses are physical illnesses, that there are biological differences inside the brains and in the processes of the brains of those who have a mental illness and those who do not.  They have taken pictures, both brain structures (MRIs) and brain functioning (fMRIs).  They have sampled neurotransmitter and hormone levels.  They have found genetic variations.

None of this verifiable information has any place in the DSM.  None of it is used in the exam, not even if the exam goes on for three days.  They examine our heads, not our brains.  They consider their prescriptions a success when symptoms (and only certain symptoms, at that) go away, not when the dysfunctions that caused them are repaired, and not when we actually get well.

What If Cardiology Worked  Like Psychiatry?

Okay, so imagine you went to your doc complaining of tightness in your chest.  Let's call this Tight Chest Syndrome.  Big Pharma has spent years developing remedies for tight chest syndrome.  Each company runs its research, comparing its remedy with the other companys' remedies and suppressing the publication of studies in which the other company came out looking better.

Great news!  Your doctor has a whole cupboard of things to try for your tight chest.  Ben Gay, antibiotics, beta-blockers, Valium -- just the beginning.  If one doesn't work, keep trying!!!

GABA And Glutamate

So once upon a time I met the diagnostic criteria for Major Depressive Disorder, and was given Prozac, the starter drug from the doctor's cupboard.  Prozac, like most of the antidepressants that 11 out of every 100 people in the United States are currently taking, is a stimulant.  It perks up glutamate, the neurotransmitter that tells the brain cells to go.

The go message from Prozac and every other SSRI and SNRI I took said go to my anxiety and suicidal thoughts.  Not a good idea.  The fact that they made me so much worse was part of the evidence that maybe my glutamate didn't need perking up after all.

The results of that chemistry experiment is the most common path by which a diagnosis of MDD is changed to bipolar.

So then I started taking a med to increase my GABA, the neurotransmitter that tells the brain to slow.  And that does help with the anxiety, though it has its own drawbacks, chief among them that it doesn't cut the depression and could become addictive, a new problem I don't need.

So which is it?  Too much glutamate/not enough GABA, or the other way round?

Biological Markers

They spent a whole lot of money on research in heart disease, found biological markers, and use them to make a better diagnosis.  Like, your doctor checks whether your cholesterol or blood pressure are out of whack, if things are firing as they are supposed to, if your arteries are blocked.  They listen to your chest to find out if maybe your tight chest is from pneumonia.  They ask if you just joined a gym and overdid the bench presses.

Then they prescribe meds on the basis of measurable results.  As a consequence, the death rate from heart disease is dropping.

Over in psych, we are still guessing.  These people in Houston question the bipolar diagnosis, went back to MDD.  But at least they paid attention to what happens when I take the meds for MDD, so did not recommend I try the newest one out.

Wouldn't it be nice to take a test before taking a pill that could kill me? 

HPA Axis, Other Neurotransmitters, Genetics

Well, there are lots of options here for the source of the problem.  Many are interconnected.  We have the research tools today to make the breakthroughs.  We don't have the research dollars.  We don't have the political will.

Patrick Kennedy is putting his name behind the Moonshot to the Mind, an effort to generate that will and to replicate the successes we have achieved in curing heart disease and cancer.  We'll see.

The Power Of Story

Meanwhile, what do I do with my set of diagnoses, the work of one family practitioner, one psychologist and three psychiatrists, now superseded by another three psychiatrists?

I plan to tell a different story about mental illness, mine and yours.  It is the power of story.  This critique of the DSM continues next week through the lens of story.

Photo of Bible be Walter J. Pilsak, permission  to copy under the terms of the GNU Free Documentation License
MRI of corpus callosum by Frank Gaillard and shared under the Creative Commons Attribution-Share Alike 3.0 Unported license
schemata of GABA/glutamate/dopamine transmission in public domain
flair by facebook.com

Tuesday, November 1, 2011

Support the Troops - Stop Shopping

So I am back from getting my head examined, that three day intensive evaluation.  I had my doubts about this enterprise.  At my most anxious, my therapist reminded me I would get air miles.  That would be something, at least.  To my surprise, I also received some surprises.  And the experience was worth a couple of blogposts.  This one will be about PTSD, or make reference to it.  Next week we will play with the DSM.

I start at the Hilton.  Well, before that, my pension plan, which is how I ended up at the Hilton, not to mention how I ended up getting a three day psychiatric evaluation at the Gabbard Center, which does not usually happen for loonies in my tax bracket. 

Decent Benefits For People With Mental Illness? 

The Episcopal Church Pension Fund was established by one of the biggest robber barons of the 19th century, J.P. Morgan, doing penance for his sins.  Like how Charles and David Koch aren't.  Since then, clergy have put the equivalent of a whopping 15% of our salaries into the fund.

Unlike United Airlines or General Motors, this retirement fund is not run by people who have the option of stealing it by threatening to close up shop unless the pensioners just hand over their hard-earned savings to increase the compensation of the CEOs.  The shop being the Episcopal Church.  Plus for some reason, in defiance of the way managed mutual funds work in the real world, the Pension Fund beats its performance indexes year after year after decade after decade.  Maybe this has something to do with karma.  Maybe the angels.  Choose your metaphysical system.  Whichever, for me, this is good.

As a consequence, my disability pension comes from one of the last defined benefit plans in America.  And it regularly has to come up with ways to spend its excess revenues, like by providing good benefits for its disabled beneficiaries, even those whose disability is of the loony variety.

And since the people who manage that much money are used to staying in places like the Houston Hilton, then that is where they put up their loony beneficiaries when we are getting our heads examined.

Which is how I came to spend four days there, two blocks north of the Galleria. 

Galleria As A Tourist Attraction 

Malls called Galleria don't have stores with names like Old Navy.  They have stores with names like Giorgio Armani, Christian Dior, Chanel, Louis Vuitton, Saks, Baccarat, Tiffany's, Cartier, De Beers.  A whole store called De Beers, for God's sake.

Galleria is where the restaurants are, where we went when we were tired of sitting next to tables at the Hilton where we had to overhear earnest mentors training earnest mentees for their presentations to their big clients.  The oil companies were meeting at the Hilton.  Down the street, Bechtel was meeting at the Westin.  Bechtel is the construction company to the Saudi monarchy.  So it may be the timing was not a coincidence.

We walked to the Galleria.  The neighborhood isn't really designed for walking.  Houston is more of an internal combustion engine kind of place.  So as we picked our way through parking lots, we overheard a father and young son comparing their Beemer to the Beemer they parked next to.  We dodged  Maseratis and Mercedes while crossing streets.  Well, you get the idea.  There was a closer restaurant.  But the doorman appeared to be wearing Kevlar under his vest.  Well, you get the idea.

One of my docs, making small talk as we entered her office, asked if I was getting to look around Houston in the off hours when I wasn't getting my head examined.  I said, No I am too tired.  Except, we went to the Galleria.  She responded, Well, THAT's something! 

It was something alright. 

Galleria As A Mental Health Hazard 

One evening on our way toward sushi, a young man held out soap samples.  I said, No thanks, I don't do scents.  Then he grabbed my hand.  Okay, he asked permission.  I see your nails are clean.  You don't paint your nails?  No I don't.  Let me show you something.  So he explained about ridges and natural oils while he did his flirty little small talk and buffed one of my nails.  Now don't scream when you see the results.  Indeed, the nail was beautifully shined, and made the notion of painting nails seem cheap.  I agreed it was beautiful and said I was not going to buy the buffer anyway.  Why not?

Because I don't buy things. 

That took some explaining, both to him and to myself, since I had never said those words before.  He decided I had made a life style choice.  Well, okay.  That would be one way to look at it.

But it was more like a commitment than a choice, made then and there.  I would no longer buy things.

Don't get me wrong.  I am as fem as they come -- short of destroying my feet in those instruments of torture that women willingly put on their feet nowadays.  Evidently, all that work we did in the 1970s to get women to love ourselves was a waste.  In other cultures, women are forced to deform their feet.  Having stopped in the 70s, now we do it again.  In the US, we call that freedom.

Where was I?  Oh yes -- I found those beaded dresses in the Gucci windows quite lovely.  And I have some beaded things in the back of my closet from pre-loony days.  Maybe not pre-loony, maybe just not-yet-identified hypomanic days, who knows.

But tripping past them, dodging the Lexus SUVs, all of that, I felt this growing sense of doom about the American way of life.

What The American Way Of Life Costs 

I couldn't shake the images of three young men.  One is a friend of my son's, who came home from Iraq with a TBI and PTSD.  Another is a relative with a couple tours of duty in Afghanistan and a troubled marriage.  The third is a young man I counseled, who signed up, hoping to come home a hero in a box. 

Support the troops, people say.  Support the ones who are protecting our freedom.  Freedom to shop at Galleria.

There I was, surrounded by the way of life they were protecting at the cost of their brains and their families and their lives.

It is too high a cost.

It is too high a cost.

These thoughts, coming in the midst of getting my head examined, make me think we need to get America's head examined.

Money, Military and Mental Health

This isn't a political blog.  I do advocacy about mental health issues.  I am not here to plug political opinion.

This is not an opinion.  This is a photograph.


This is another photograph.

And here is another.

And now we return to the shoes.

As I look at one picture, then another, as I listen to those young men, and then to the people in that restaurant next to me, I do have an opinion.  Here it is.

These shoes cost too much.

They cost too much.

Actually, I don't think this is about mental health, after all.  It is a sickness of the soul. 

What Is The American Way Of Life? 

I did meet some very nice people at the Houston Hilton.  One man was from Ethiopia.  He drove the shuttle, and we got to know each other in twenty-minute conversations each day on the way to the Gabbard Center.  He came to this country because he wanted opportunity.  And he found it.  He drives a shuttle bus.  His eldest is a policeman.  His daughter is about to graduate from college, and his youngest about to enter.  He doesn't need a Maserati to have the American way of life.

The other shuttle driver came to the US during the war in El Salvador.  We talked about Archbishop Romero, and the strength we still get from his witness.  If I remember right, somebody gave Archbishop Romero a pair of shoes for his consecration.  People gave him lots of things, but his friend asked him what he wanted, and he said shoes.  This former refugee, now shuttle driver, also found the American way of life.  Emphasis on life.  He doesn't need a Lexus. 

Freedom And Addiction 

People say our young men and women are sacrificing their minds and their bodies to protect our freedom.

We need to protect our freedom ourselves.  We are not free.  We are addicted.  Addiction is a disease of the soul.  And it is progressive.  The more you feed it, the worse it gets.

Our freedom begins when we acknowledge our addiction for what it is. 

Step One -- We admitted we were powerless over our addiction - that our lives had become unmanageable.

I don't want those shoes.  But I do want that beaded dress.  And having resisted it, having told that young man I don't buy things, the very next day I still almost bought an Eileen Fisher sweater at Nordstrom's across the street.  Because it was on sale.

Just in time I remembered those three young men.  That sweater cost too much. 

My Bit For The War Effort 

PTSD, Post-Traumatic-Stress-Disorder is bankrupting the defense budget.  Researchers are trying to figure out how to prevent it.  Does it take a neuro-scientist to figure out that you prevent Post Traumatic Stress Disorder by preventing the trauma?

I have decided to support the troops the way the troops do, by caring about what happens to their buddies and acting to prevent harm from coming to them.  I will not wrap a flag around my shoulders nor post one on my facebook page for Veterans' Day.  I will hold before me the faces of those three young men, and wrap myself in my love for them.

I will work the Steps, always remembering that I am just as addicted to things as any of you.

With God as my higher power, the next time I buy something, it will be a bicycle.  So I can leave my Civic in the garage.

photo of J.P. Morgan by Edward N. Jackson and in the public domain
photo of Bacarrat Chrystal Sculpture used under the terms of the GNU Free Documentation License 
photo of Maserati, Gran Turismo by Rudolf Stricker and usedunder the terms of the GNU Free Documentation License
photo of Louis Vuitton shoes used under the Creative Commons Attribution-Share Alike 2.5 Generic license
photos of medical evacuation and coffins in public domain