Wednesday, July 12, 2006

So What's Wrong With Whining??

[posted by dinah, in response to Peter's Guest post: "A Culture of Whiners?"]

So, I liked the article in Harvard Magazine, and I loved Peter's metaphors comparing taking aspirin for headaches and seeing a doc for a sprained ankle to taking psychotropics for human distress, and I love thinking about this stuff which is why we have this blog.

I think, in my personal, non-affiliated opinion, that we've grown into a society that expects people to fit into a very small box: if you don't think and feel and function in a very limited and circumscribed way, then something is wrong with you. Worse than that, people become very distressed that they aren't living up to their expections of themselves (or other's expectations of them) and become demoralized and consumed by their sense of failure; sometimes it's very hard to get people to look at the idea that maybe they weren't meant to live the life that was prescribed or self-imposed, and the fallout becomes it's own problem.

Having said that, let me limit my discussion to two specific disorders: ADHD and Social Anxiety Disorder, and I may throw in a mention of medicating Grief. Let me also say that I don't know a whole lot about ADHD (I don't treat kids) or even Social Anxiety Disorder, but hey, I've read the DSM, I prescribe the meds, and I even watch the Paxil commercials--I just meant that I haven't read the research in depth and while these problems surface in the course of my routine general adult psychiatry practice, I don't label myself as an "expert" and if my sense on the phone is that someone is calling for nothing more than a prescription for an amphetamine, I send them to someone else.

So part of the box we've created: kids are supposed to sit still and concentrate in school. Let me give you a funny example from my personal life. When my son was 10 and entering middle school, he was accepted into a math/science magnet program in the public school system. The program had an excellent reputation and my son spent a day shadowing another child. The school day went from roughly 8 to 3 with 25 minutes for lunch (it took him that long to get through the line, he ate cookies). No recess, no gym, and the kids were assigned 2 to 3 hours of homework a night. Now whose idea was that to come up with this sort of curriculum for sixth graders? The school he ended up at gives middle schoolers a 20 minute break after 2nd period, a 45 minute lunch, gym 3 days a week, and an extensive after-school sports program. An all boys school we looked at included 2 recesses a day in addition to the other stuff.

So, the ADHD diagnosis is a complicated one, because it entails sometimes unreasonable expectations of children (and some restless adults), it often doesn't take into account that people just don't concentrate well on things they aren't interested in, and with the diagnosis comes the expectation of treatment with an addictive, even dangerous medication that has often unpleasant side effects, so it's not a benign designation. The Last Psychiatrist tells us that little research has been done on the carcinogenic effects of Ritalin, and psychiatrists are uneducated about the few studies that are out there. For the psychiatrist, it's a hassle: all this press about physicians being monitored, prosecuted even for over-prescribing controlled substances (ok, pain meds, but just wait...), and amphetamines in particular can't be phoned in or re-filled in Maryland, so getting the hard copy to the patient is always an issue. And the other consideration is that amphetamines help everyone, even folks without ADHD, perform better, faster... so maybe they belong in the water supply? And I suppose there's this funny little question that no one dares ask adults with ADHD: What if it's not that you're not living up to your potential, what if you're just dumb? (and no, I don't ask my patients that!) When does someone fall far enough off the curve that we question if the problem is disorganization such that it's a Disease, versus a varient of the norm, simply a character trait?

But here's the thing: there are children who just can't function, hyperactive kids who prevent other children from learning, who can't hold still long enough to get educated, and there's no issue here: they need medication and it's preferrable to putting them in special environments (--if you choose to homeschool your ADHD kid rather than give them ritalin, more power to you). And there are people who take stimulants and function much better, hold on to jobs they wouldn't otherwise be able to keep, stop having those funny little episodes of disorganization (hmm, locked the keys in the car while it was running again...) and who feel life is much better on medications.

Social Anxiety Disorder I have less to say about. Mostly, I see this in people who are otherwise anxious, and I don't have a hard time giving someone who is suffering a non-addictive medicine. People have been taking a little inderal (an anti-hypertensive) for stagefright for a long time, and this doesn't seem to bother anyone. If someone is my version of Shy and wants a medication so they can function better in crowds, and I can't convince them that it's okay to be shy or cure them with my great psychotherapy skills, then I'm not adverse to giving someone who is suffering an SSRI, or even a little benzodiazepine for specific events (I write lots of people for a few pills of ativan for flying since 9/11-- I don't think I'm altering the makeup of the world, but maybe I should suggest non-addictive Support Ducks instead?) I tell people the risks of Paxil (since the commercials, that's what they want): I tell people the risks: sexual dysfunction, possible weight gain, a possible discontinuation syndrome upon stopping, and the fact that we don't know the long term side effects, and that it may not work (meds often don't for these milder spectrum problems), I'm willing to prescribe it. Sometimes people I don't think need meds feel much better, their lives improve, and they're very grateful. And if they have side effects or don't work, they can always be stopped.

Grief: just briefly. Most people don't go to a psychiatrist for grief, if they're coming to me they are usually quite symptomatic. Meds don't do much for uncomplicated grief anyway. This view that SSRI's just numbs people isn't usually so--though everyone is different.

The diagnoses themselves, without a demand for medication, can be extremely helpful. It often comes as a tremendous relief to people to have a name for their difficulties, to know someone else somewhere has felt this way before. And there are non-pharmacologic ways of dealing with ADD or social anxiety, or whatever problem you have, things one can do to compensate if one is aware, in which case I don't see a downside to the label. Now if only I could have gotten extra time on those SAT's....

And you can take medicines and get talk therapy, too, I'm all for it, see The Psychiatrist as Therapist post. Of course the insurance companies want whatever is cheapest, and of course they are molding how psychiatry is practiced. It sucks. And do I think psychotropic medications are altering the fabric of society? Yup, but maybe in a good way. Artists don't paint, composers don't compose, and writers don't write if they're dead or so depressed they can't crawl out of bed. A little existential angst does fuel creativity (or worse, the need to have a blog) but I haven't seen anyone rush to the psychiatrist because of their creative juices, they come because they are suffering, and until you've walked in their shoes, try not to judge. Of Course, Tom Cruise knows what's best, but as Brooke Shield put it to him in her New York Times Op Ed reply to his criticism of her taking medications, "I'm going to take a wild guess and say that Mr. Cruise has never suffered from post-partum depression.'

On the issue of illness versus character trait, I think Shiny Happy Person said it best with this thought: "Mental illness robs you of your right to be a weirdo." The designation as such robs you of the right to be many other things as well.

And so the giraffe: He was photogaphed by ClinkShrink's sister and he has a number of issues. For one, he is too small, and growth hormone shots will be starting next week with the hope of giving him a few more inches. He's fond of rainbows, cut out of the pack to shine beneath one, and we're wondering if he's schizoid, avoidant, seclusive, or anxious, or if he doesn't play well with others; perhaps he's just thinking his own, possibly brilliant, thoughts.