Category / Psychiatry

by drcpatc

…with both hands and a flashlight.

Dear my friends in the news media, repeat after me:

An infant cannot be born #$%#$% addicted to drugs.

I do not know what’s been going on lately, but I have seldom heard so much flat-out stupid, uninformed, backward reporting on the opioid epidemic as I have been hearing in the last couple of weeks. It’s been so widely distributed among different outlets that I’m not sure it’s even fair to single out any one particular corporation.

The first such noises I heard were about “fetal assault” laws. It boils down to threatening imprisonment for women who are pregnant while using illegal drugs if they don’t get treatment. The getting-into-treatment part I dig; however, interestingly enough, one often finds such States have a lot more room in jails than they do in treatment programs. Funny, that. Wouldn’t it be nice if the States had enough treatment slots to provide treatment on request and massively ramp up the drug court system, instead of all this retroactive stuff? I think so.

The media pointing out the ethical problems of this is fine with me. However, we got into a whole other realm when pregnancy outcomes started getting discussed. One was the neonatal abstinence syndrome – basically, opioid withdrawal in an infant. In some of these reports, reporters were constantly and unself-consciously referring to “infants born addicted to drugs,” including when talking about kids born to mothers who take methadone or buprenorphine.

There are several huge problems with this and I’m only going into a couple because I’ve already had too much coffee and I’m trying to maintain normotension. The first is this: Why are you not talking about cigarettes and alcohol?

To be fair, this is a problem with the media and with the legislatures. Illicit drugs are tremendously stigmatized and they do godawful amounts of damage, but let’s face it – the legal drugs probably cause the most public health harms. If your goal was seriously to impose consequences to prevent pre-natal injury to infants, you would hang a breathalyzer around every pregnant woman’s neck and lock up anyone who tested positive for nicotine while pregnant. In terms of long-term outcomes, “neonatal abstinence syndrome” is probably nothing much compared to fetal alcohol syndrome and all the stuff that smoking can do.

So that’s one. Here’s the second: the constant lumping of therapeutic drugs in with active addiction.

It happens several ways; one of them with the use of the word “clean.” As in:

She couldn’t tolerate the withdrawal, and her doctor told her that quitting cold turkey could be dangerous. So she went to a methadone program, hoping that it could serve as a bridge to getting clean.

Because, you know, nobody on methadone is really “clean.” Even if, for the last 5 years, she happens to be showing up to work at 8:00 every morning, leaving at 6:00, looking after her kids, abiding by the law, paying taxes, and generally being a productive human being. She is still “dirty.” Unlike that guy who just walked out of detox two days ago and refused to get into the treatment that would keep him from relapsing in the next two weeks. He’s “clean.” Right? Right.

I wonder how many reporters writing these stories spent the morning talking about who’s “clean” and who’s “dirty,” and then hoisted a couple at happy hour after work.

I get my knickers particularly twisted about this because this stigma kept coming up for the people in a program I worked in. They had to be careful in the Fellowships because even though some newbie might be nodding out in the back row with pupils the size of the period at the end of this sentence; if they talked about being on methadone, they were instantly “unclean.” It’s even more ridiculous out in the community, where being on either methadone or buprenorphine cuts you off from all kinds of resources. You can have treatment for your cravings and withdrawal, or you can have a roof over your head, but not both. Crazy.

The common thread to this craziness is a fundamental confusion.

Addiction is a behavioral disorder.

You cannot know how people are behaving based on what chemicals are in their blood. Go to a cancer ward and check out how much morphine and fentanyl are floating about. Now ask which of them should be locked up, or which are “dirty.”

This also is why you can’t be born addicted. No three-day-old is going to raid Daddy’s medicine cabinet or slip out to the corner to meet his boy to cop some pills.

It’s about how you act. There are situations in which taking opioid medications, like methadone and buprenorphine, helps people act better. It helps them stop using, stop getting infected with really nasty viruses, helps them turn into functional parents and citizens. As long as there is some implicit assumption that success only counts if you do it without medicines, and the highest goal for addiction treatment is to be medication free; we will be encouraging people to stop doing stuff that works. That is not the way we’re going to dig our way out of this hole.

I don’t know why these various media outlets feel they can file such reports with an obvious lack of expert guidance. Any good they do questioning the ethics and effectiveness of criminal justice based responses gets washed away when their next sentence stigmatizes some of the most effective treatments we’ve got, and further teaches potential patients that such treatments render them “unclean.” They are operating with exactly the same stigmatizing assumptions that lead these legislators to pass these laws.

Dear my friends in the media:

Find some actual addiction docs, talk to them. Take this seriously.

The truth is out there, but on your own, you’re not going to find it …

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by drcpatc

Stick to your knitting, please.

Not too long ago I had a look at this on what I am learning is the outlet of all medical knowledge in the blogosphere, KevinMD. I have another bone to pick with Kevin, M.D. later.

This one, however, is about a post that took as its jumping-off point a book by Allen Frances about the ins and outs of developing DSM-V.

So here’s where things started to go wrong:

It defines mental illness, and in the process also defines what is normal.

Is that what it does? Funny, I have never once consulted a DSM manual (to the extent that I do) to figure out if someone was normal.

Then, we round the bend with this one:

Objectivity is often mistaken for science and truth, but no line cleanly separates disease from normality. Both reside in the Gaussian curve.

No. No, they don’t. Not at all.

The author is a radiologist. I am wondering, when she looks at a chest radiograph, how she decides what percentile of pneumoniation the patient has. Is it 70th percentile, “borderline pneumonia?” 95th percentile, “severe pneumonia?” Where, on the Gaussian pneumonia curve, does one draw the line for “having pneumonia?”

I note the slippery word “disease.” Is what we mean by “disease” being in the 5th or 95th percentile on some Gaussian curve?

It’s not what I mean when I say that. When I have the flu, I’m not saying “I believe that I am currently in the 95th percentile of malaise, fever, rhinorrhea, and myalgias.” What I am thinking is

Well, what I’m thinking when I have the flu is mostly unprintable.

Disease, though, fundamentally, involves a qualitatively abnormal state, rather than a quantitatively abnormal one. Which is why so many of psychiatry’s conditions fit awkwardly there.

I really, really don’t want to get in the business of “What fools these mortals be” with non-psychiatrists. Because, most mortals are not fools and there are plenty of fools in psychiatry.

However, in the words of the not-exactly-immortal-but-with-remarkably-little-body-fat Henry Rollins, “Knowledge without mileage equals bulls–t.” When I hear someone talking about what I do, and I detect a distinct lack of mileage in their conceptualizations, I will listen. But expect a jaundiced eye.

I have a theory, and it is fundamental to the point I’m about to (try to) make. Always good to state your assumptions at the outset, yes?

From talking to lay folk, I think people appreciate that there are various propensities to negative human emotions and behaviors; sadness, anger, anxiety. That is, undoubtedly true. The variation in those emotions or behaviors is fundamental to current theories about personality.

Here’s where I think common assumptions diverge from reality: Psychiatry is about identifying people on the “bad end” of this distribution, and medicating or therapizing them to get them closer to the “good end.”

Mind you, I think in some cases that’s close to true. However, there are plenty of cases where it isn’t; and assuming that’s all there is to it leads to a lot of confusion.

When looking at someone with schizophrenia, I am not trying to assess what percentile on the auditory hallucinations Gaussian curve this patient is. There is no Gaussian curve for hearing the CIA agent who is monitoring your thoughts from across the street talking through your vents.

Then we have mania. Alzheimer’s Disease. Huntington’s Disease. Catatonia. Lead intoxication. Highly recurrent and chronic depression. OCD. Panic disorder.

It seems that every time there is any sort of disturbance in The Force around psychiatry, the media and the public erupt into a roil about how psychiatrists are pathologizing or medicalizing everything. This tends to center on the most ambiguous and fuzzy categories in psychiatry at the time, while ignoring how very little the most severe and clear cut diagnoses have really changed since, well, Hippocrates. Probably earlier.

Here are some things worth knowing:

  1. Nobody who actually uses the thing, including the people who write it, thinks the DSM is anything resembling a “Bible of Psychiatry.” If it were, it wouldn’t get changed around every two decades or so (thus creating the disturbance in the Force previously mentioned).
  2. Psychiatrists do not prowl the streets looking for people to medicalize and medicate. By and large, people come to us; and they typically do it because they are suffering. (Some are forced. They may be suffering too, but sometimes they’re just making other people suffer. That’s a different dynamic, and tricky.)
  3. A whole lot of people who come to see us are really just sick. Really. That’s it. They have major depression, just like their mother and grandfather; or they have manic-depressive illness or schizophrenia.
  4. When you have somebody in front of you who is suffering and asking you for help, you @#$#ing try to help, whether what causes that suffering fits into some neat category or not. In order to do that, you have to write something down for why you’re helping and (sadly, in many cases) the DSM is the lingua franca to do that.

From where I sit, the fundamental problems with the DSM fall into two areas: lump or split, and diseasifying in the name of reliability.

The lump or split problem has to do with the fact that the most disease-like entitities in psychiatry have funny variations. It may be that people with bipolar disorder with really frequent episodes need to be treated in a different way than people who have more intermittent episodes. Some people get psychotic during their episodes, others don’t. Should we have separate categories for these things, or not? Notice it’s not a question of whether such things happen. We know this is real, it’s just how we write it down. One place this has played out recently is in the substance use disorder categories, in which the “abuse” and “dependence” distinction finally has been dumped in favor of a severity specifier. There are those who will look at the fact that the “Substance Use Disorder” prevalence will increase and screech about overdiagnosis; and then there are those who will note that the overall picture really just looks like those who fell in the old “abuse”category now fall into the “mild SUD” category.

The diseasifying problem mainly has to do with things that don’t fit the disease mold so well, but that we can still help out with. Often we can help quite a lot. Things like personality disorders, addictions, and maybe some stuff like generalized anxiety disorder or ADHD. In these things, overlearned behaviors, or being at the wrong end of some Gaussian distribution(s), are what lead to the suffering. Of course, it could be in twenty more years we find some reasonably qualitative-looking pathophysiologic difference in these folks, and it turns out the disease model will work better.

Even so, it would be a lovely, lovely thing if somebody could say “This person is 95th percentile on Neuroticism and 2nd percentile on Agreeableness and the fear, anger, distrust, and hostility with which he approaches the world is limiting his life and causing all kinds of frustration and trouble for him.” However, the medical system (and the medical payment system) is built around the disease model, and for all the furor when something iffy gets talked about in disease terms, heaven help you if you want to help people like that and keep your shingle out, ’cause nobody is gonna pay unless it’s real,  by which I mean (sing along with me) a brain disease.

If people are really so concerned about medicalizing everything, here’s what I would suggest:

  1. Keep your eye on the most disease-like entities in psychiatry. When you get bent out of shape about how the prevalences in some other categories change, notice how little the prevalence of schizophrenia, bipolar disorder, major depression, panic disorder, OCD, etc. change. Then, breathe deeply and calm yourself. They’re not coming to drag all you normal folks in to a psychiatrist’s office and shove pills down your throat.
  2. With respect to the ones where the prevalence does change around, first ask how would I figure out what the right prevalence is if I were trying to do this? If you simply think any increase is a mistake, you have an implicit bias. Figure out what it is, and question it. (Same the other way.)
  3. If you would like to stop pharmaceutical companies from influencing diagnosis, stop the direct advertising and push for limitations on how they influence doctors. The place to start with the latter, by the bye, might well be with primary care physicians (including pediatricians).
  4. If you would like to stop stuff that isn’t particularly disease-like getting diseasified, push for a world where a professional can get paid to help someone who is suffering so long as a clinical entity can be reasonably defined and there is a treatment that can work. Then the everything-is-a-disease crowd don’t have a built-in advantage.
  5. If you really, really, really care about vague diagnostic entities, diseasifying stuff that doesn’t fit disease reasoning very well, and so forth; psychiatry may not be the only place to look. Look up the history of fibromyalgia, or think about obesity, diabetes, cardiovascular disease, smoking, and on and on. That line of reasoning has led me to think that psychiatry is mainly special in that we are earlier in our history and we know we are often missing the boat. Perhaps such humility, applied to the rest of medicine, might yield some interesting results.
by drcpatc

Lyin’ Lies

Carroll’s 5th Law of Psychiatry: Anybody who says “I’ll be honest with you,” isn’t. Anybody who asks, “Why would I do that?” did that.

One thing I found hard to digest when I was starting out is that people lie to you. Well, not just people. Patients. People I’m trying to help.

I suspect I get lied to with the approximate frequency of a judge, but less than a cop. I have statistical evidence to back that up in the form of many anecdotes. I will share one with you now.

(At some point I will write a post about how anecdotes are stories of things that never happen. Ignore that, it only applies to other people’s anecdotes. Mine are entirely true, widely generalizable, and say something very important about the human condition. Promise.)

Once upon a time in Baltimore or its near environs there was a psychiatrist. He (or she – could have been anybody, really) was in a meeting where an absolutely real patient who is not at all abstracted from dozens of identical encounters was talking to him.

ARPWINAAAFDIE (Arpie for short): I am being treated horribly unfairly!

Dr. C. (not his real name, I’m sure): In what way?

Arpie: I keep getting put into all these groups. It’s just too much, I can’t get to all of them.

Dr. C. : Is there some reason for this?

Arpie: I keep coming up positive for weed! (“Coming up positive” means testing positive for a drug. Oddly enough, almost nobody ever says “I used.” One “comes up positive” as though there is a lottery for such things.)

Dr. C. : That can happen sometimes. There are false positives. So you have to go to some extra groups for a week?

Arpie: No!

Dr. C. : No?

Arpie: I’ve been in groups for six weeks!

Dr. C : For a single positive urine test?

Arpie: No. I’ve been positive for six weeks!

Dr. C. : And why do you think that is?

Arpie: I was around some people who were smoking. My cousin does it in the house all the time with his friends.

Dr. C. : I see. You ever have a problem with marijuana?

Arpie: Used to.

Dr. C. : I see. So you previously had a problem with marijuana, and you have been in a house with several people who are smoking constantly, and you have been positive on urine testing for weeks, but you have not been smoking?

Arpie: Right. I mean, I have been doing great in this program. It saved my life. Why would I do anything to jeopardize that?“

And there it was. The “Why would I do that?” Notice she did not say “I did not do that.” In fact she never flat out denied it.

The practiced eye will also note that Dr. C. never said whether or not he believed her.

From this exchange, we can conclude one very, very important thing. Arpie is probably not a raging psychopath. We’ll get back to that.

Most people really, really suck at lying. The main reason people really, really suck at lying (and I have evidence to back this up in the form of expert opinion, because I am an expert) is that we are wired for consistency. Saying one thing and believing another produces an internal tension that psychologists give a catchy name, “cognitive dissonance.” People act to minimize this. One way people minimize this is they re-align their beliefs to fit what they say. As one student of mine once said, “You remember when you were a kid and you were acting sick to get out of school, and after a while, you started kinda feeling sick?” That sort of thing.

When lying, people often minimize dissonance by half-a%%ing it. They try to get away with saying something that is as little untrue as possible. They fudge details but leave the main story intact, they talk around the lie without ever flat-out lying. This, in terms of prevarication, is a terrible mistake. Because this almost always produces an internally inconsistent narrative.

You can get away with that if your listener doesn’t care much about the answer.

Compare and contrast:

Friend: “How are you?”

Depressed person who hasn’t smiled in a month: “Fine.”

Friend: “Did you hear about what happened at that picnic?”

and:

Doctor: “How are you?”

Depressed person: “Fine.”

Doctor: “OK, now that we’ve got that out of the way, how are you?”

Depressed person: Dissolves into tears.

In the first, the question is a social nicety and nobody particularly pays attention to the answer. In the second, when somebody notices the disconnect between what is seen and what is said, and asks for real; the truth comes out.

So, if your listener is paying attention and knows what she’s doing, you’re probably screwed. If she’s good at this, she’ll be calm and nonjudgmental, so you don’t have any excuse to act angry and throw up a smokescreen. She’ll watch how uncomfortable you are. She will never commit to either disbelief or belief. Either way would let you off the hook. She will never accuse you, nor give you an excuse to attack her and discharge all that pent up tension.

She’ll also be watching to see how hard you are working not to say something. That something will be the lie. She could toss out some not-quite-neutral comment about how she’s open to believing you, like how “false positives do happen. ” She might alternate that with pushing you right into a corner repeatedly, giving you a choice between telling the lie and making up some new detail, to increase the dissonance. I was taught by one of the great masters of this, who advocated the Columbo Technique – adopting a non-threatening, bemused manner from which you can endlessly ask about “just one more thing.”

Eventually, dear liar, you’re going to be feeling quite squirmy, and she’s going to be calmly sitting across from you with one more bland, open-ended question ready to ask. A good interviewer on the scent of a lie is a lovely and terrible thing to watch.

Really, the way to lie is to go bawlz-out and tell a whopper. (Apologies for the gendered reference, but the opposite is equally vulgar and a bit too serial killer.) You can make up the details as you go, and there are no conflicts, as long as you don’t go on too long. The Nazis, vile bastards that they were, were right on that one.

Which brings us back to a point above. Arpie is not a psychopath. Psychopathy is, roughly speaking, lack of a conscience – a sort of wired-in incapacity to treat anyone else as more than a means to your own ends. People who are highly psychopathic will look at such an interaction as a game to be played for a win, and the win is getting what they want; or getting away with it once they have it. They will have no qualms about telling great big lies, even to someone who cares about them. That internal dissonance wouldn’t be there, because to such a person, lying is a matter of strategy and tactics, not morality.

So, to sum up, in order to lie effectively:

  1. Lie to someone who isn’t paying attention (Usually easy).
  2. Tell a whopper (Hard if you’re not a psychopath, so . . . ).
  3. Be a psychopath.

Under ordinary circumstances, only number 1 applies, which is the only reason most people get away with the lie.

Now this is short term. This is all about whether the lie is internally consistent – meaning somebody can pick it apart right there. The main reason I’m not nearly so bugged by lies nowadays is that I’ve learned that what works in the short term, is pretty much dead opposite to what works in the long term. 

To give a concrete example, once upon a time there was a patient who had a habit of coming into the ED in distress because various family members died in terrible ways. Everybody took him at face value, until he had gone through more grandmothers than a cat has lives.

Big ol’ whopper? Yup. Inattentive listener? Well, maybe that’s unfair, but the pace of most EDs is not conducive to deep curiosity. Yet, eventually, the big lie gets too big to fit in with the rest of reality.

The psychopath thing? The very thing psychopaths have going for them in the short run fails them in the long run. No matter how superficially disarming they are, they show their colors. Then nobody believes them. Even when they tell the truth.

So to make a lie work in the long run:

  1. Keep it simple, with the deception trivial, so that most details will fit reality and not lead anybody to be too curious.
  2. Don’t be a psychopath.

Lies mostly amuse me, now. This is not to say I haven’t swallowed some in my time, and I will no doubt swallow many more before I’m done. I don’t take it personally. The best goalie on earth is still going to let some through. I do take a certain delight in the game of detecting them. If I don’t catch it at first, though, usually all I have to do is wait and watch. The truth finds a way. 

Back to poor Arpie, squirming internally while trying to hold onto this program that really has made a world of difference in her life, staring right down the barrel of losing it because she’s in too deep. What is her way out, though? To admit she’s doing exactly what may cost her that program? 

And what about this Dr. C. character? There he sits, knowing the truth, but still going through this ritual. Isn’t it a little uncomfortably cat-and-mouse? Wouldn’t it be kinder to just come out and call bull#$@t, or even just drop the hammer and throw her out?

You’re right to wonder about him. He certainly does, from time to time. Maybe we should pick up this story later. Could be, there’s redemption to be had for all. That always makes for a better story. 

by drcpatc

Three cheers, and a minor quibble.

I am here to praise Caesar, not to bury him.

Well, not Caesar, really; the good Dr. Makari is my subject.

I saw this in the NYT a few days ago and found myself singing hosannas. The upshot is that in the relentless push to destigmatize psychiatric illness, our fearless leaders decided that we must stick to the party line that psychiatric conditions are diseases, and diseases are biological, and the organ affected is the brain. Therefore, since diseases are “real,” we could convince everyone that the stigma is irrational. It didn’t work, near as I can tell.

Dr. Makari takes this apart in a thoughtful, cleanly-argued way with the obvious authority of a clinician. Hats off, doc.

Not only do I think this failed, I think it played into the wrong hands as well. One way it’s done that is to reinforce the idea that psychiatrists do the “biological” stuff and other people do the other stuff. Which means psychiatrists are paid to spend 15 minutes with their patients asking strictly about doses and side effects, rather than dealing with the actual complexity of psychiatric cases.

This is another post, but I rather think many of our troubles in health care stem less from not considering the biology of psychiatric illnesses; but rather in not thinking of medical conditions in the way we have considered psychiatry. Do we really think that increased education, social support, and reinforcement of functional behaviors works only for psychotic disorders, but not for diabetes? Don’t you believe it. The best cardiologist I ever saw spent about 1 minute talking about cholesterol meds, and about 10 minutes going through people’s diets and how much time they spent sitting. (The guy could smell an anxiety disorder from five rooms down, too. A true Jedi, that one. Our loss, cardiology’s gain.)

My quibble, though, is with the universally cited, nearly universally misunderstood, and sadly misapplied “biopsychosocial model.” Dr. Makari seems to be telling us our failing is in not adhering to it. I think our failing is that we still try.

My quibbles are both practical and theoretical. The theoretical one is that it’s not a model. It makes no testable predictions at all. If it does much that is useful, it might define different levels of explanation, and encourage us to consider each possible level in dealing with a clinical situation. I’m not sure that’s any better than simply being told, “You should take everything into account.” I call that good advice, not a model.

The practical gripe, which is more a problem with us than the model itself, is that we just renamed dualism so we could feel a little better about it. I take as evidence the constant use of the word “psychosocial” in medical parlance, as in, “We must also consider the psychosocial component to this.” Note:

  1. The psychosocial component, as if there is only one.
  2. Ever hear somebody talk about the bioppsychological aspects? The sociobiological aspects? Me neither.

A teacher of mine, a highly experienced consult-liaison psychiatrist, once facetiously remarked that there was a monosynaptic reflex in internal medicine residents which linked the recognition of a psych thing with a call to the psychiatry consult service. I think “psychosocial” has turned into the psych thing of our medical culture. It means important, but not-disease, not-quite-medical, not us.

So we now have an implicit dualism renamed in “biopsychosocial” terms. This breaks down quickly in real life. In addictions, there’s a pill called disulfiram. If you drink, it makes you sick; and it’s given to people with alcohol addictions to deter them from drinking. It is, basically, a pharmacologic implementation of something like punishment or an avoidance schedule. So it’s a behavioral intervention that is done by altering the person’s alcohol metabolism. In what box do we put that? Biological? Psychological?

We could go through similar thought experiments with stuff like methadone, bariatric surgery, psychotherapies for headache, and on and on.

Dualism by any other name is still dualism. It didn’t work, but renaming it doesn’t mean we dumped it. You replace ignorance with understanding, not reductionism and marketing.

by drcpatc

He makes me wish I was a guy

My resident said that the other day, right after a patient of ours walked out of rounds.

The patient was a man who acted even younger than he was. I had met him before, and like everyone else on my unit he was wrestling with an addiction.

From where I was sitting, he was making progress. The first time I met him he couldn’t keep his mouth in check to save his neck, and he had a critical word for everything from staff’s interpersonal skills to the clinical management on the unit. While thus acting in loco JCAHO, he found himself too busy to make it to many of the therapeutic groups; though he found tremendous therapeutic benefit in the big-screen in the day area.

He did what young people who act that way tend to do – left the unit with a crappy plan and then relapsed post-haste, to return some time later looking even more beaten up. Such is the nature of the beast.

It could have been worse. First off, he was still alive. He didn’t stay out all that long before he came back, and he left with a (slightly) better plan. After some frank discussions with the nurses about the value of keeping one’s mind on business, he seemed to spend a bit less time talking about others’ failings and more about what he should be doing. He even reduced the F-bombs to every fourth sentence, thus perhaps improving on my performance in that area. Still, this was gradual improvement; nobody would mistake this admission for a life-changing epiphany and there were no shafts of light and celestial choirs to be noted.

So, really, this looked like business as usual to me. Then, on the last day as he was walking out the office, my resident said that.

My first reaction was that was a really odd thing to say, and I had no @#$^ing idea what that meant. My second was to notice that every other person in the room obviously did.

A thing you might want to know is that, as usual, everybody on my team is female. That could just be a consequence of demographics. Both nursing and social work are female-predominant professions and doctoring is going that direction too. It’s happened so many times in my life, though, that I suspect there’s something more to it – like how I kept winding up with the really chronic, refractory patients when I was a resident; while one of my crew who ended up treating eating disordered patients had a waiting room full of thin, depressed young women. Your people tend to find you, or vice versa, and there’s some funny juju to that.

As mentioned, it became instantly clear that something was going on that was utterly obvious to other people and lost on me. I employed the combination of odd facial expressions, quizzical noises, and curse words which my team has come to understand as a request for clarity.

My resident splained it for me. (This may be irrelevant to the point at hand, but she is aces. Sharp, thoughtful but quick, with that intuitive diagnostic sense that marks the true Jedi.) This isn’t verbatim, but I will try to get it close:

“I talk to him and he’s so flirtatious and it just never stops. He does it to all the women. Sometimes I just wish I was a guy and I didn’t have to deal with it.”

Again, every other head in the room seemed to be nodding. One looked downright disturbed, now that it was said out loud.

Doing psychiatry changed me in a lot of ways. I look at things with a slightly different set of eyes. It also has knocked a lot of humility into me. It is tremendously easy to make judgments about others until you have heard their story, and wondered, if I started out that way, would I have ended up any differently? Appreciating the complication of human life is hard unless you’ve had an inside view of so many of them. Yet, here I sat, with my much-vaunted perspective and skill in observation, in a room full of people who I work with constantly and who bail my a@@ out of trouble on a very regular basis. Every single one of them was going through something right in front of me that I knew absolutely nothing about. Suddenly I had this feeling that  we were in some Star Trek episode where we were slightly out of phase with each other, in some overlapping not-quite-the-same realities.

I have never once had any patient encounter in which I could walk out and say, I really wish I was a girl so I didn’t have to deal with this crap. Sure, I have dealt with my share of female patients with warped transferences – from the needy and dependent to the psychopathic and manipulative. Usually, though, the tricks are more along the lines of Oh, you’re so very very smart and handsome Dr. C. Thank you for your brilliant advice. Sometimes consciously manipulative, sometimes just an automatic pattern. Yet very seldom dismissive. If anything, the opposite.

I flashed to a time when I called this guy on his language. More than a little hypocritical, I know, but I do try to clean it up in public. He walked out of the room with his eyes down and the last words he said were, “Yes, sir.” I could joke and engage him, but if push came to shove I could also pull out the, “I have the grey hair and the letters after my name so settle down, kid,” routine and it would probably work, at least while he was in front of me.

As it turns out, that probably had less to do with the grey hair and the letters, and instead was about having a Y chromosome.

I started thinking what it would feel like to be capable, experienced, wise, and loaded with general badassery as all these folks on my team are, and yet to be standing in front of an immature misguided young man who nonetheless treated me like somebody he was trying to pick up at a bar.

It felt really, really icky. I-need-a-shower icky. Then the more I thought about it, the more it made me mad.

This would be the place where a large proportion of the population will be slapping their collective foreheads at my naivete, and I certainly have to cop to that.

I am not sure I have a point in this other than being slightly dumbfounded at my own ignorance. I have the strong sense I’ve been doing something wrong. I don’t quite know what, and it’s not coming clear to me yet.

I think this is going to be on my mind a while.

by drcpatc

Another coffee time grump.

I was slurping down my third cuppa while waiting for my resident to finish an evaluation and reading a column by Kristof in the New York Times.  It was a commentary on a book which I should emphasize I haven’t read. It’s a rough story, about a child who had some serious problems. Right up at the top was this:

When he was 5 years old, a psychiatrist prescribed Ritalin. As he grew older, he disrupted classes and was given a growing number of potent antipsychotic and other medications.
These didn’t work, so he was prescribed more. Pushed out of one school after another, Andrew grew frustrated, unhappy and sometimes alarming. His parents hid the kitchen knives. Then his mother died at 54; the family believes that the stress of raising Andrew was a factor.

The book was by the father of this boy, who is a pharmaceutical company insider. As you might expect by now, things went badly. The child had a rare complication of medication treatment and wound up dying.

Kristof took the pharmaceutical industry to task for a number of things for which I think they richly deserve a task-taking-to. Drug companies are now pushing to be able to market off-label indications, which both Kristof and I think is a bad idea.

A drug is used “off label” when you’re treating a disease or symptom that it wasn’t FDA approved to treat. This happens often in clinical practice, which may sound shocking but is really not so sinister. For example, divalproex is a drug used for seizures. Turns out, it works for manic-depressive illness as well.

Divalproex was on the market a long time to treat seizures. It is neither the safest nor most dangerous drug on the planet. It does have my favorite safety feature: A long, long time on the market. That’s how you find out about the rare, weird complications that don’t show up even in large clinical trials.

There are some weird things about FDA indications. For one thing, a drug that works for many aspects of a disease can have an indication for only one. Divalproex has an FDA indication for treatment of acute mania. However, there’s good evidence that it works to prevent future episodes as well. Now, if you treat someone for mania with divalproex you’re treating for the FDA indication; but if you keep her on it after the mania resolves you’re off-label. Which still is, in my estimation, an evidence-supported strategy.

Back to the article. My reactions were, in rough order:

  1. Huh. Ritalin. They must have thought he had ADHD.
  2. Wait a minute, antipsychotics? Multiple antipsychotics? That doesn’t sound like ADHD. This kid sounds like he was pretty sick. Early onset manic-depressive illness? Maybe. Pediatric schizophrenia? Rare as hen’s teeth, but maybe.
  3. Hiding knives? Frustration? You talk about the family of a child having to hide knives from him like frustration is a reasonable explanation for that?! Are you nuts? Are you listening to yourself?

I’ve often said psychiatrists look at things with a different kind of eyes. In this case, mine were looking for the diagnosis. Kristof’s seemed to be looking for the understandable causes and finding them – a hard time in school and weird drugs, apparently. Mine were seeing nothing at all understandable here.

The trouble with looking for understandable things is that we’re really good at finding them even when there is nothing understandable. You can play a recording backward and hear “Satan wants you to eat your babies” in the static. You can turn a puff of ice crystals in the high atmosphere into a sailboat.

You see, if you’re going to imply something improper in how somebody is treated, and that drug companies are producing that impropriety, and you want to maintain any kind of intellectual integrity, you have to talk about whether the treatment makes sense for the condition being treated. That means you have to know what is being treated. That means listing stigmatized medicines as if that is prima facie evidence of bad treatment doesn’t cut it. That just looks like you’re playing to the “psychiatric medicines are scaaaaaarrrrryyyyyy” crap that all our patients have to wade through on the way to getting adequate treatment.

I don’t want the drug companies to be able to advertise off-label because I think it keeps them halfway honest, and letting them advertise to the general public has been a bloody fiasco. I don’t like the way they influence doctors, and Kristof’s point on how they contributed to the opioid epidemic is solid, though I’m not so inclined to let doctors off the hook on that one.

However, I do not want to be making that argument by talking as if a horribly ill kid was just having a rough time at school. I do not want to make that argument by implying that putting horribly sick kids on medicines by itself is evidence that it is a terrible and sinister thing to put horribly sick kids on medicines. Because that is simply playing into the hands of stigma and ignorance.

Here’s what I think we should do:
  1. Stop the drug companies advertising, particularly when they masquerade as “education” about illnesses.
  2. Stop putting the studies for getting FDA indications in the drug companies’ hands, so they’re not about advertising points. For example, can we stop having some company to be able to advertise “The only drug approved for cyanodermia in Malignant Lilluputian Cyanodermia Syndrome” when there are four other drugs that work for the entire syndrome, that don’t have a big manufacturer behind them to do that one targeted study just to be able to make that commercial by getting an FDA indication for that one symptom?
  3. Following 2 above; how about we start using publicly-funded research to speak to what the best thing is for the patient; rather than just that one more medication works for the disease? For example; which medicine do you start with? Which one do you use when that one fails? We have books full of me-too meds with mostly meaningless FDA indications.
  4. When well-meaning crusaders start spitting out arguments that reek of stigma and science denial, even when we agree with their goals; disagree with the means while agreeing with the ends, and offer more realistic arguments. Which I just tried to do.

Moar coffee.

by drcpatc

Just a little rant.

In the last few days I have had several of the following experiences. They are not unusual, just unusually concentrated in time. I have altered things, but this is representative.

I saw a patient some weeks ago with a significant depressive disorder. Not get-thee-to-a-hospital severe, but also not a time to mess around. He also has chronic pain. There are a set of antidepressants that work for chronic pain. There are a subset of those that have fewer side effects. There is one in that subset that can be titrated up to a maximum dose in two steps (rather than the three or four others might take). I run through all this with the patient and the choice of pharmacotherapy is made. Yay team! We’re on the road to wellness.

The next morning, in my box the pharmacy fairy has deposited a request for “prior authorization” for said medication. Which also means my poor patient showed up at the pharmacy and couldn’t pick up his medication.

I get somebody on the phone. She is neither a pharmacist nor a physician. She simply asks the following questions: “What was the medication?” “What was the strength? (i.e. dose),” and “Have you considered anything on the formulary list?”

Noteworthy in this conversation were:

  1. When I said I had decided on the medication because reasons, there was no corresponding, “You know, Smurfatrol XL (little R-in-circle thing) might do about the same thing and it’s more affordable.”
  2. The reasons clearly did not matter either. I could have said, “Smurfatrol causes Malignant Lilliputian Cyanodermia, and that risk is unacceptable in this patient,” and the person on the phone would be none the wiser.
  3. She was utterly stunned when, just to be a good sport, I asked what was on the formulary list. I’m not sure anyone ever even asked before.

In other words, this was entirely form, with zero content. My patient couldn’t pick up the medicine because I had to first call someone in a call center to read off exactly what was on the prescription. 

A week later, the patient came in and told me after all that, he hadn’t been able to pick up the medication from the pharmacy and had not started the treatment. So much for being able to move faster.

Experience 2:

I have a patient who is taking 150mg of ectavan (not a real drug), and I’ve told her to use 1 ½ tabs of 100mg each. I did this because the only other way to get a 150mg dose would be to prescribe 50 & 100mg tablets; which would wind up being more expensive overall and make the patient pay two co-pays. I always write prescriptions as generic.

With me so far?

She’s been taking this medication for months, when again the pharmacy fairy drops a love note in my box in the form of a 1 – page fax form for authorization. Mind you, this medication is exactly the only one in its class. There is absolutely no other medication available on the market that does this. It has also been approved for months on end.

I dutifully fax this waste of my time, only to hear two days later that was disapproved.

I am now, officially, p@#&ed off. There is attempting to control medical care costs, and then there is just straight-up $%#$ing with me and my patient.

I’m back on the phone now.

Again I go through the dance, and at the end of that we have this exchange:

“Did you consider the generic Vantec?”

“I have always written the script as generic. I don’t care what brand it is.”

“OK. We can approve the generic.”

Success! I didn’t even have have to imply an abnormally intimate relationship between the medical director and a close relative! Not out loud, anyway. Problem solved.

Nah.

A day later my patient shows up only to have the pharmacy tell him he can’t pick up the prescription.

Care to know why?

No, you really, really don’t.

My patient finally walked away with two co-pays, having to take 3 capsules per day when previously she had one copay and 1 ½ pills per day. If you look up these meds, this new regimen would cost $500/month. The previous one costs a hair over $300. So maybe the payor figured some kind of sweetheart deal, but I’m guessing they’re not getting the 40% discount it would require them to break even on that. Not to mention the time they have to pay the people to read faxes and listen to physicians implying abnormal family relationship dynamics for their medical directors.

Pervading all this is the sense of absurdity. I am a physician who, by and large, takes care of poor people. I think a lot about what they can take and what they can’t. I spend a lot of time thinking of the cheapest thing I can prescribe. People don’t need one more reason to not take their medicine.

I see insurers creating barriers to health care which then require health care institutions to produce countermeasures which then cost more and get taken out of someone else’s pocket. The costs of all this prior authorization stuff, in terms of payors’ staffing and such; as well as doctors’ time and office staff, is probably in the low tens of billions from what I have read. 

One would really, really hope that all this crap would be worth it. Personally, I can’t tell it is. It seems to me that the system of cutting medical care into little monetizable widgets and then trying to force people to use fewer widgets hasn’t changed much, except to create new jobs defining and pricing the widgets. While all that’s going on, the prices of the widgets keep rising way faster than any efforts to reduce their use. It looks to me like whatever real savings we get out of this may just as well be due to people just not getting treated.

It’s mutually assured destruction, applied to health care. This thing is coming apart at the seams.

by drcpatc

Shower thoughts over coffee.

As I sit through my fourth cup of coffee eating a mooshy veggie burger at the hospital coffee joint, something keeps rattling around in my head.

I have training and experience in both pain and addictions, and I go back before our current prescription opioid epidemic. This really followed a typical pattern of a drug epidemic; the greater availability and high potency of the “new” version of the drug class, the perception of greater safety, the dissocation from the stigmatized population, etc. We’re working our way through it, and right now as everyone’s trying to get their thumbs into the dam controlling prescription opioids, the second wave is starting. Some will enter recovery, some will convert to the endemic heroin and we will see all the ugliness that comes with that; new HIV and hepatitis cases, and all the social disruption.

As that settles out marijuana is now legal in many places, talked about as if it is “medicine” though we’re not really sure how well it works – that partly because doing any real research on it is very, very hard due to government policy. Despite all this talk about it being “medicine” it is remarkably divorced from the medical system. Scheduling, regulation, even the necessity for an actual no-kidding prescription. It’s also funny how quickly after it’s medicalized-but-really-not we find greater acceptance of its use recreationally.

I have all kinds of thoughts on this, but one thing keeps clanging in my head. I gather there is a strong economic argument that legalization (which is a vague term if you think of it, ranging from laissez-faire to repenalization) is a good way to manage the problems of addictive drugs. I rather like some versions of a repenalization system myself. It might take the steam out of the illicit drug trade and reduce some of the crime associated with that underground economy. However, what happens to the prescription regulatory system?

It strikes me as an odd thing to decide that once we understand that a drug is addictive, it should then become less controlled and regulated than, say, an antihypertensive or an NSAID. Do we simultaneously allow people to buy oxycodone in a 7-11 while requiring patients with pain to go to a doctor? Right now, there are places where you can buy cannabis in all its weird chemical complexity but you have to have a prescription for purified, tested, pharmaceutical grade cannabinoids.

I do not pretend to get all the policy implications of this, but I do like people who advocate a position to be able to tell me how it would actually work, and I don’t think I’ve heard that from folk who support decriminalization, including for cannabis. I also wonder a bit about where responsibility lies. If a clinician prescribes a drug there is a clear chain of responsibility, but if someone “recommends” a drug with no clear indications which a patient could buy anywhere for any reason, where does responsibility lie? Do we just live with the “pill mill” down the way?

Moar coffee.

by drcpatc

Dimensions, Diseases, and Bad Medicine.

Imagine you have a child who has a full scale IQ of 70. This means that about 97.5% of the people on earth will have a higher IQ score than she does. She doesn’t have any particular illness or syndrome that accounts for it; she just happens to be on that end of the distribution of human cognitive capacity.

It doesn’t mean much about her worth as a human being, of course. I’ve met people who have IQs around 130 that I would personally feed to Walkers in the event of a zombie apocalypse. Intelligence – if it exists – is a capacity, not a virtue. You can use your brain to cure malaria or you can use it to run a billion dollar Ponzi scheme.

It does mean she’s going to have problems other people don’t have. She won’t get as far in school and she will have more trouble finding work. She’s probably not going to make a whole lot of money and will be more at the mercy of the cold world than most. She’ll need more help from others, and your grandchildren may not start out as well as they would otherwise.

Now imagine there is a medicine that for a solid part of the day let her operate as if she had an IQ of 85, or maybe even better. You will notice a difference. So will she, and her teachers, and her employers. Her paycheck. Your grandchildren’s home life.

Imagine, just for giggles, that medicine might even protect her from addiction and getting into serious accidents.

Would you give it to her?

Whichever answer you pick, does that make you a bad parent?

This article came to my attention through an old family friend. It’s about ADHD, written by a psychologist who asserts that there are a lot of things that are different about ADHD in France.

ADHD is a plenty controversial subject. There is plenty to controverse about. It’s a gender-biased diagnosis, which makes you wonder whether it’s a legitimate gender bias (like breast cancer) or some subtle and harmful stereotype being played out in the medical field. Then there’s the question of whether we are “medicalizing bad behavior” and these kids need behavioral interventions and discipline. The flip side argument is maybe we need to develop more tolerant systems to handle kids with different behavioral and learning styles.

Tricky stuff.

One of her core argument I will dispense. That is the idea that the American lifestyle, loaded as it is with TV and toxic food, is ADHD-o-genic compared to the French. I don’t buy it. The prevalence of ADHD symptoms in kids, and the number of kids who meet criteria for the disorder is pretty similar almost everywhere you look. A big component of risk is genetic. Prenatal alcohol exposure and smoking probably matter; and lead toxicity is a clear cause. There may be some effects of food colorings and such, though it’s less clear if FDA approved stuff is bad, and it also looks like they might have something to do with hyperactivity in general, but perhaps removing them only helps some kids diagnosed with ADHD. If there’s a reason prevalence estimates vary, though, it’s most likely differences in methodology for making the assessments. Studies that are designed so they likely undercall the diagnosis do so, and vice versa.

I also find fault with those who say it has no biological basis and start arguing how it’s caused by “toxicity.”

The author of the article (and book) later said that ADHD is a collection of symptoms with no biological basis, and therefore “socially constructed.” Another tricky word; used as if a synonym for “wrong.” A collection of symptoms (and signs) that go together in time and place in medicine is called a “syndrome.” The author lists out the symptoms of diabetes (mellitus) and says that’s not what diabetes is; i.e. the syndrome is a consequence of diabetes, not the thing itself, which is a problem of glucose metabolism.

Which, following the logic, means that diabetes mellitus did not exist until at least the late 1800s, when removing a dog’s pancreas was shown to cause it, which over quite some time led to the discovery of insulin. Apparently, those descriptions of the syndrome written down 3500 years ago were something different, because then it had no known biological cause.

When I talk to my residents, I call this the “Excessive Eye Blinking Disorder” problem. Let’s do a little thought experiment:

Imagine you found that there is a group of people who blink their eyes 30 times or more per minute (as opposed to 15 times as average). 

Question 1: Is this a disease?

Then let’s say somebody puts these people in some souped-up 600 Tesla neuroscanner and discovered that they have a cluster of neurons in their motor cortex that are overactive relative to people who blink at an average rate.

Question 2: Now is it a disease?

I hear this in the media all the time. “People who act differently have just been found to have slightly different brains. Clearly, what we once thought was ‘psychological’ is truly  ‘biological.'”

In truth, finding a difference between the brains of people who act in two different ways should be viewed as what it is; entirely trivial. Of course their brains are different. Of course the eyelid motor neurons of people who blink twice as often are more active. Duh.

The existence of the difference is no surprise, and as in diabetes, it mostly depends on whether you have the right technology to find it. Stuff doesn’t become real as soon as you have an instrument fine enough to find the biological difference. It’s there, and eventually we get the right microscope.

Sometimes the microscope gets good enough to suprise you. “Diabetes” isn’t one thing. Sometimes it’s due to destruction of insulin-producing cells (Type I), sometimes insulin resistance (Type II).

Last point on this and I’ll stop beating this horse: We seldom find the “real cause,” and when we do there’s often a lot of uncertainty about all the steps in the chain. If we waited to find the “real cause” to call something “real” or a “disease” we would almost never get there. Case in point, Type I diabetes. First you find out it’s caused by lack of insulin. Eureka, we have the cause! Wait, why do you lack insulin? Eureka! They have no islet cells in their pancreas! Wait, why do they have no islet cells in their pancreas? Eureka! It’s due to autoimmune destruction of the cells. Wait, why the ever-loving #%$& does their own immune system destroy those islet cells?

So a set of symptoms and signs doesn’t make a disease (though it’s necessary), demonstrating a difference between two groups of people on some dimension doesn’t make a disease, a biological difference between those two people doesn’t make a disease, and in practice we don’t wait around to find the one twue cause if that’s even possible. We expect diseases to cause dysfunction or suffering, but we don’t define everything that causes suffering as a disease. Some of these things are necessary, none are sufficient. What makes a disease?

Maybe, just maybe, there is absolutely no such thing as a disease out there in the world. Maybe, in fact, “disease”  is…..

wait for it….

Socially constructed.

Maybe it’s a concept with a relatively clear center with archetypes we can all agree on; but very, very fuzzy edges. Pneumonia? Yup. There’s a qualitative difference in where bacteria are growing, it is clearly linked to the symptoms of the disease, and causes dysfunction and even death. Prototypical disease. Still, though; the disease is in the eye of the beholder. No bacterium growing in your lungs thinks, “Huzzah! Back when I was on that piece of bread I was a lowly bacillus, but now I’m a disease!” Nah. It’s just happy in a warm place with nutrients and water.

Another thing that doesn’t make it a disease: Having a pill for it. Caffeine can improve some cognitive tasks (though it’s really complicated). Is everybody who is two cups behind demented?

Not counting me. I heard that, smarta@@es.

I think this is far, far less about what’s “real” than it is what’s “right.” There is a very, very strong moral tone to a lot of these articles and positions. You do need to know what’s real to take an ethical approach to it, though.

I think there’s a fundamental assumption that if it fits neatly into the disease box, disease = biological = biological treatment. Also, in some cases, maybe it doesn’t have to be a disease, but it does have to be “biological.” If we were to think it through, hypertension and obesity both might fit these bills. We are quite happy to look for medicines for these. In the case of severe obesity, we even re-arrange people’s insides surgically, and it works. Maybe they are not diseases, but at least they’re not “psychological,” and doing something about it improves people’s lives. In some cases, a whole lot. This is not helped by the fact that people who want to treat something have to dress it up in syndromic, disease words to get paid to treat it. That’s another post.

If it doesn’t fit the disease box, and particulary if it’s “psychological,” treating with medication is “medicalizing.” It’s reductionistic, manipulative, and dangerous. There is something to be careful about here, though. Higher brain functions seem to be where we put the self. Moral worries about altering the self of someone else sure are worth a thought or two.

The evidence so far as I read it is that ADHD is a dimensional, not qualitative, difference. It may fit awkwardly into the disease box, but there are objective measures of its severity and plausible biological correlates.

Interestingly, I seldom hear the argument that people who meet criteria for ADHD don’t need some treatment. Usually it’s about medication versus other things. That’s a legitimate question, so long as we agree that better is better. That sounds easy, but implicit is the question of how much better counts as better. You can’t have better is better unless it’s from medicines in which case it isn’t really better.

You can decide that there is some threshold of problems that deserves clinical attention. You can decide what counts as a meaningful level of improvement. You can figure out which treatments have a decent chance of achieving that level of improvement. You can quantify the risks of those treatments so people can make an informed decision. You can even compare treatments to see which ones do better.

We’ve really done most of that, or at least we’ve got a solid start.

I suspect our problem is this: As a culture, we have not answered the question: When is it right to alter the mental function of someone who is on the far end of a brain-based capacity with medication, when being on that end clearly causes bad things, but that does not easily fit into the category of a disease?

What would happen if people spent their time figuring that out, instead of talking about all these different versions of “real/legitimate vs. imaginary/contrived?” What would happen to all the victim-blaming, parent-shaming, and conspiracy theorizing about doctors? Could we be more compassionate, and maybe even less likely to do all those things people say they’re concerned about; like stigmatizing unjustly, mistreating, and overtreating?

I tend to think so.

Here’s my answer to the question I just posed, because I think you always have to take your own dares. I think it’s ethically correct to do so when the intent is to remediate an impairment rather than to enhance normality, when there is minimal threat that the person’s self will be fundamentally or permanently altered, and when the person involved understands what is being undertaken and consents to it.

If I were to think about it more, I might come up with other ideas. The floor is open, if anybody wants to set me straight.