Thursday, March 08, 2007

Things I Wish I Knew



We come to day with day with a list of Shoulds we take at face value (--where would you like me to begin? Don't smoke, don't drink excessively, don't be overweight, exercise, take your meds, ingest enough calcium, don't shoot heroin, stay out of jail, don't quit too many jobs, get your screening colonoscopy at 50, yearly mammograms after 40, wear a condom, sunlight is good, sunlight is bad, sunscreen is good, sunscreen is bad, coffee is good, coffee is bad....) only to have them rethought time and again. Roy is now finally off his HRT or so I'm told, he still doesn't look post-menopausal to me.

A few things I find myself wishing I knew the answers to:

Will my children be damaged by all the video-game playing I allow?
Will my relationship with my children be damaged if I don't allow them to play video games and survive the inevitable fights it will cause.


If they go out to ride their bikes instead-- nice healthy exercise--will I wish they'd stayed safely home playing video games if they get hit by a truck?


Why didn't my children come with instruction manuals?
--Inspired by yesterday's snow day and my patient today who is consumed with guilt and a sense of perfectionism with regard to her parenting. Something it's easy to distance myself from during a psychotherapy session, but sometimes strikes a bit close to home.


Will some awful consequence of Gardasil (the new HPV vaccine) be discovered 20 years down the line?

If obesity is so fatal, why, since the 1950's are there so many more obese people and why is the average lifespan 10 years longer?

Why do some people seemed to be unscathed by decades of smoking marijuana?

When my patients chronically misbehave and are completely uninterested in changing (for example, young people who enjoy spending their time drinking to excess in bars, others who repeatedly and without regret sleep with strangers, those who consume large doses of prescription narcotics prescribed by someone else, or people who just won't entertain the idea of abstaining from marijuana)-- am I wrong to continue to treat them on their terms?

If I simply refused to treat them unless they get treatment for their addictions, would they a) stop coming, b) stop telling me about their bad behavior, or c) get treatment and clean up their acts?


When a patient complains of intolerable feelings of agitation or other vaguely defined distress, and gives me the "walk a mile in my shoes" talk, is it wrong that I sometimes offer a prn very low dose of an second generation anti-psychotic, along with the warnings about possible induction of diabetes and dyslipidemia, and let them make the decision about whether to take it? Is it funny that I never ask myself if I should offer that script for very low dose prn Xanax which is what they really want?


And what about the patient whose last depressive episode (of many) lasted nearly a year and who has never been able to tolerate lowering her zyprexa, should I stop it given that her risk factors for diabetes and heart disease are screaming in my face (they preceded the zyprexa, but it can't be helping)? How do we know the worst of two evils?


Were those 250 extra children who died of suicide in 2003 compared to 2004 (see Pediatrics, annual vital statistics, death figures on page 13), children who were not taken for mental health care, or not offered anti-depressants because of the Black Box Warning added to anti-depressants by the FDA?


Sometimes I wish I had a crystal ball that worked, one where I could fine tune it to ask the subtle what-ifs. When it comes to the long-term prognosis for diet Coke and hair chemical abusers, well, there are some things I just don't want to know.

19 comments:

parked said...

Will my children be damaged by all the video-game playing I allow?
(Yes)
Will my relationship with my children be damaged if I don't allow them to play video games and survive the inevitable fights it will cause.
(Yes)



If they go out to ride their bikes instead-- nice healthy exercise--will I wish they'd stayed safely home playing video games if they get hit by a truck?
(Yes)



Why didn't my children come with instruction manuals?
--Inspired by yesterday's snow day and my patient today who is consumed with guilt and a sense of perfectionism with regard to her parenting. Something it's easy to distance myself from during a psychotherapy session, but sometimes strikes a bit close to home.
(no one would read the manual anyway.)



Will some awful consequence of Gardasil (the new HPV vaccine) be discovered 20 years down the line?
(Most likely)

If obesity is so fatal, why, since the 1950's are there so many more obese people and why is the average lifespan 10 years longer?
(The Pickling factor, they eat preservatives and don't move much.)

Why do some people seemed to be unscathed by decades of smoking marijuana?
(I know the answer but can't remember)

When my patients chronically misbehave and are completely uninterested in changing (for example, young people who enjoy spending their time drinking to excess in bars, others who repeatedly and without regret sleep with strangers, those who consume large doses of prescription narcotics prescribed by someone else, or people who just won't entertain the idea of abstaining from marijuana)-- am I wrong to continue to treat them on their terms?
(Doesn't sound like your treatment is working--so stop.)

If I simply refused to treat them unless they get treatment for their addictions, would they a) stop coming, b) stop telling me about their bad behavior, or c) get treatment and clean up their acts?
(I can guarantee it would be A or B. You can't clean up their act--they have to do it)



When a patient complains of intolerable feelings of agitation or other vaguely defined distress, and gives me the "walk a mile in my shoes" talk, is it wrong that I sometimes offer a prn very low dose of an second generation anti-psychotic, along with the warnings about possible induction of diabetes and dyslipidemia, and let them make the decision about whether to take it? Is it funny that I never ask myself if I should offer that script for very low dose prn Xanax which is what they really want?
(Why are you worried about low dose Xanax, when anti psychotics have their own side effects. Give the the Xanax.)

You can probably tell that I have 2 sons. This is an area where you just can't win---I thought I reared my son's the exact same way. Video games, paint balling, sports, etc. One is in law school and the other 2 years sober after rehab for heroin. Hmmmmmm...where' that manual?

Midwife with a Knife said...

If someone would take away my blog access at work, would I get something done?

Uncertainty is the hardest thing for me. If I had delivered that diabetic at 35 weeks, would her baby still have died at 36 weeks? If I had checked my outpatient labs on Saturday morning instead of Friday afternoon, would patient x still have come in with a term fetal death on Sunday night? If I hadn't discharged that preterm labor patient home at 29 weeks, would she have still delivered at 30 weeks?

Each one of the above is a (confabulated beyond recognition) actual case that happened when I was in charge.

I don't have any great thoughts on uncertainty. I try not to think about it as much as possible. It is too easy for me to get paralyzed by the fear of maybes and the could haves or the should haves. So I try to learn lessons as they come up (as painful as that can be), and then I put my blinders on and try to move forward and I try to not think about the "If only I had"s.

So.. yeah. I have no advice. I've been there (although not with parenting), and I have all the sympathy in the world. Uncertainty sucks.

Oh, and if Roy's still having hot flashes, he can continue the HRT. He just shouldn't take it specifically to decrease his risk of heart disease or osteoporosis after menopause. He's going to have to weigh the risks of HRT vs the discomfort he has from hot flashes.

ClinkShrink said...

I'm not sure why all the 'is it good or bad' stuff doesn't bother me. Maybe because most things just can't be dropped into one or the other category. Is coffee good or bad? It wakes me up in the morning so I'm more alert and that's good. It might make me cranky and that's bad. I guess like everything ya gotta weigh out the risks and benefits and do things in moderation.

Running good. Worn out knees bad. Either way, I'm not giving up that or chocolate.

Dinah said...

Parked: I wasn't really looking for answers, as MWWAK points out, it's the discomfort with uncertainty. I'm not the doc for Xanax (why not: it's really addictive), but thank you for the empathy on the video-kid issue.

Oh, and a final thought to Parked re people with driven self-destructive behaviors: Some do give them up with concrete evidence of how they hurt them (or at least cut down or put some protections in place), others seem to get better in other areas of their lives (maybe less anxiety or better mood) even if they continue these maladaptive things they enjoy. The patient often refuses to see these things as part of the problem, they define the problem they want help with, unless I simply can't work with it or around it, I generally choose to do by best with anyone who is invested in coming and trying. Many people feel very much helped by treatment even if they insist on continuing to do things that are harmful. Really, if you think about it, docs don't generally tell people: Stop smoking or I won't treat you, even if the patient has emphysema. (though they may say Don't light up next to the oxygen tanks in my office).
This is a complicated issue, maybe it's own post.

Clink: it's not really the good vs bad that bothers me; I'm fine to say Maybe they'll find out that Diet Coke is toxic, but I know that's a possibility and I like it in the moment and so I'm making that choice: today's pleasure versus tomorrow's uncertainty. Same goes for my morning coffee. It's the combination of Uncertainty and Making Decisions for Other People that's hard--be it my children, Max, or patients. I openly tell people that I don't know the long-term consequences of med (or of No Meds, per the black box influence).

I saw a terrific movie tonight: The Lives of Others.

jw said...

IF, if you are uncertain, you probably know enough and care enough to function well in this society without causing others harm. It is the people who KNOW who cause the harm.

At least that is how I see it.

Linda said...

I'm one of those moms racked by guilt and driven by perfection, with a son in nonvoluntary therapy who doesn't seem to be changing at all but I keep sending him because what else can I do and the therapist is telling me to be patient, but I really don't think he knows how to help him even though he tells me he wouldn't take my money if he didn't think he was really helping. Pass the instruction manual.

Alison Cummins said...

I got most of the post, but two questions have me really confused.

For video games - yes of course lots of screen time is damaging to anyone, kids especially. Of course your relationship with your kids will not be damaged by setting limits: your relationship with your kids is that of parent, not friend. A parent's job is to set limits. Refusing to do your job will damage your relationship. (I thought this was self-evident, hence my confusion and heavy-handed judgementalism. I'm not a parent, hence my utter bewilderment at the question being raised.)

For damaging behaviours: while I share the concern about ingesting large quantities of drugs (alcohol, prescription, street), I have learned to temper my gut reaction. I think there's something about learning to accept oneself as a person who does these kinds of things that is kind of salutary. But whatever, I share the concern. what I don't get is... What does shooting heroin or getting falling-down drunk in a bar three times a week have in common with sex with strangers?

Sex is something most of us need to feel human whether or not we have a spouse-like person in our lives. Many, many people are extremely lonely. Casual encounters allow us, as imperfect (perhaps to the point of being utterly undatable) people, to connect sexually with another imperfect (perhaps similarly undatable) child of the universe.

Yes, the casual encounter is a difficult thing to master. But you can practice it over and over again. Marriage is also difficult, besides being completely unrealistic for very many people.

I just don't see the parallel between damaging your judgement - and ultimately your brain - with drugs and making an appointment with a stranger.

Disclosure: I have, at various times in my life, considered my options and selected sex with strangers as being the best choice available to me at the time. This is not my situation today. I do not think I was mistaken in the past, just as I do not feel mistaken now.

jcat said...

I don't know the answers to anything.

Only bit I am sure about is that while I could handle my general practitioner telling me he won't see me unless (....insert reasons here...), if my p-doc told me that, it would be just about the end of things.

I trust him enough to tell him of the self-destructive things I do, or the excercise I don't do. I know that it would be better for me to change my habits. He knows that I know. We both know that in the current two-year-long depression, there's not much chance of doing self-improving things, even if they might end up helping me get out of this downer.

If breathing wasn't automatic I probably wouldn't bother doing it.

I can't and won't lie to p-doc. If he were to tell me that he would only see me conditionally, it would be option D.

That's the one that says that if even your p-doc rejects you, there really is no point in carrying on.

Dinah said...

Linda-- good luck. I'll send the manual as soon as I locate it.

Alison: you wrote "Yes of course lots of screen time is damaging for anyone, especially kids..." How do you KNOW this??? this is what I mean by "Shoulds" things we take as givens then realize maybe there's a flip side. Do you know studies that prove that video games HARM teenagers? I don't care about violence-- my kid has never been in a fight, has no violent tendencies, and only is interested in Sports games online. He plays two sports, and will run on the treadmill if I complain that he's not getting enough exercise (anything to make me leave him alone to play his games). I'm not arguing that it is GOOD for kids to play video games, I'm arguing that we don't know and this determines the decisions we make for others, the uncertaintly.

If you look at the peds vital statistics link I put up, page 14, it seems that about 8800 kids ages 15-19 died in 2004 of accidents or homocide, there were no reported deaths from video games, and when a kid is sitting in front of a screen, they're not in a car (I assume the biggest source of accidental death) or somewhere they can get murdered.

"Set limits" sounds great, but if you've never tried to dictate then monitor the moment-by-moment activities of a 16 year old, it's not that simple. The arguments are damaging (if not to the kids, then to me) and are worth it when the end result is clear and there is No Negotiation (You will not drink and drive, You will not go to parties where there are no parents, You will not be rude to your mother), but less obviously Worth it at other times, a Pick Your Battles mentality for those who wish to survive parenting with intact relationships. Write back after you've had a few teenagers.

And of course, there's the how do you argue with "Why is better to Blog then to play Video Games?"

Hunger and libido are driven behaviors---some people need more than others, some are more driven then others. I believe (and can't prove) that the same holds for certain addictions such as alcohol, drugs, maybe even gambling-- seems some people have a harder time controlling urges than others.

I wouldn't really ever tell someone "If you don't stop X I won't treat you." I do think there may other docs out there that drive a harder line with "You must go to rehab first in order to continue in treatment with me."

Really, the post is about my discomfort with uncertainy and the decisions I have to make for others.

sophizo said...

Video game deaths actually do happen. Most seem to be related to the stress of playing the game or exhaustion. I remember when this story came out a few years ago about a 28 year old in South Korea who died after playing video games for 50 hours straight.

S Korean dies after games session

As for if video games are good or bad...they're both. There are actually a lot of good things that come out of gaming. With the Wii it is exercise and with other games it is often analytical skills and reflexes (to name only 2). I say it is up to each parent to decide how much or how little gaming they will allow their kids. There is no way to know how it will effect your kid until they are an adult and blame everything on you anyways.

I hate the "what if" game!

Roy said...

==Things I wish I knew==
What's this HRT business? Menopause? Why is Dinah messing with me?

drytears said...

I had a neurologist tell me to stop taking indomethacin (for hemicrania contunia) or he wouldn't treat me. (A neuro at the headache clinic dx me and perscribed the indocin.)

I've had psychiatrists turn me down because I had ODed before and they don't work with people who have ODed. They have also turned me down because I don't want to see a therapist in their same practice (which is a requirement in order to see them) That one I can see why they might require that though.

I guess it all just depends on the person and how they were brought up and their beliefs.

Alison Cummins said...

Dinah,

The harm of video games is similar to the harm of sugar: it's about displacement. Every calorie you get from sugar is a calorie you don't get from eating real food. You miss out on protein, vitamins, fibre, minerals, all those lovely nutraceuticals, and the experience of a recognisable fruit of the earth in your mouth.

Certainly there are people who must get most of their calories from sugar: people with PKU or kidney disease, for instance. Their special circumstances are such that the other things in food could harm them. The sugar doesn't kill them, and it's a good thing they have it. But these people are both exceptional and ill.

Every hour spent in front of a video screen is an hour not spent engaging directly with the world. Not developing a physical skill, not learning how to make clothes or climb cliffs, not sitting in the sun, not cooking supper, not keeping an old person company, not babysitting for the neighbours, not throwing snowballs at the dog.

Yes, for some people this kind of interaction with the outside world is unattainable or undesirable. Some kids are handicapped, or sick, or live in horrible families that need to be escaped from. In this case, watching the Brady Bunch and developing video game skills are the preferable alternatives.

It's not about video games causing cancer. But why would you prefer them for your child over direct engagement with the rich and varied world? Yes, the rich and varied world carries dangers. That's exactly why it's so important for young people to engage with it, to develop skills and confidence, an appreciation for real danger and the ability to evaluate and balance risk and make decisions to protect themselves.

Broken legs and twisted ankles are not necessarily worse than never having had the opportunity to risk one's body.

Sitting in the other chair said...

Yes, stop the Zyprexa, and explain why you are not comfortable using a dangerous drug. Why are you okay with Zyprexa if Xanax disturbs you so much?. Now that its been shown that these "novel" APs are no better than the old ones why risk DEATH. I hate that shrinks are happy to prescribe antipsychotics(and low doses kill too) to get the quick syptom relief. It is convenient for shrinks that they will likely not be there in several years for their patient when they are on insulin or dialysis. The old drugs caused
TD, true. Other side effects as well. There are trade offs. Would you put something into your mouth for long term use that had been approved based on an 8 or 12 week study? Would you give it to your kid? It is so easy for shrinks to distance themselves. Patients are a bunch of odd drug seeking body parts to them.Boundaries are important. The grand canyon or great divide between shrinks and their patients leaves me cold. So, yes, your patients will say, go walk in my shoes.Perhaps its not such a bad idea.

Roy said...

Allison,
What a great explanation. Thank you.

Anonymous said...

I've had pdocs refuse to see me when I used to drink. The reason given was that the depression wouldn't improve unless I stopped drinking. Maybe so but it's chicken and egg. Finally I did find reasonable help, and quit (my depression didn't amazingly go away as a result), and am glad to see that these days dual diagnosis treatment is more in vogue.

Given my past alcoholism, and later Ativan addiction, I am glad now to be given Zyprexa PRN instead of a benzo (no matter how I first whined about it).

I don't take Zyprexa regularly anymore, but I was on 10 mg/day for a couple of years and didn't die or develop diabetes. Instead I got anorexic...but that's still WAY better than TD and I recovered from that while TD can be irreversible. No contest. I think you're making a good choice with Seroquel over Xanax.

Midwife with a Knife said...

I've been thinking about the video game issue. I think video games help develop reasonable skills, too. A lot of the video games that I play (Civilization, SimCity, etc.) are planning/problem solving games. The more arcadey games have been great for my surgical and laparoscopy skills (I think there are even studies that support this, I'll have to try to find them).

Video games aren't necesarily bad, and they help to develop skills that may be helpful in the real world.

Gianna said...

"Were those 250 extra children who died of suicide in 2003 compared to 2004 (see Pediatrics, annual vital statistics, death figures on page 13), children who were not taken for mental health care, or not offered anti-depressants because of the Black Box Warning added to anti-depressants by the FDA?"

Check out the this link to CL Psych's blog pertaining to this issue. I'm sorry you'll have to cut and paste because I don't know how to put html in a comment.

It's a really great analysis.

http://clinpsyc.blogspot.com/2007/02/ssris-and-suicide-update.html

Gianna said...

the last part of the link is missing...I think it was too long...tack on this:

-update.html