Tuesday, March 31, 2009
Monday, March 30, 2009
Sunday, March 29, 2009
This a blog post about vulture poop. It's a long story, but let me just say that when you're a rock climber there are certain hazzards of the sport that you just have to accept: bats sleeping in crevices, nasty long spinning falls, copperhead snakes and, yes, vulture poop.
Vulture poop is probably the most vile smell I have ever come across, and that includes a four month stint crouched over a formaldehyde-soaked corpse in anatomy lab. It's bad.
The trick with writing a blog post about this is that you have to tie it in somehow with psychiatry. This is problematic since I haven't had any patients with delusions about vultures, vulture obsessions or vulture phobias (does anybody know the word for vulture phobia? Ornithophobia is for birds as a whole). I'm left grasping at nasal straws, so to speak.
I have had patients who smelled bad and patients who suffered from bad smells. If the smell doesn't actually exist, it's an olfactory hallucination. Olfactory hallucinations are rare, much less common than visual or auditory hallucinations. Typical olfactory hallucinations are very unpleasant experiences and are often described as resembling rotting meat, burning rubber or excrement (although not necessarily vulture poop). I've seen olfactory hallucinations in a patient with major depression and in one or two psychotic patients. Another "bad smell" illness is a rare but interesting delusional disorder known as olfactory reference syndrome. In this disorder the patient is convinced that he or she smells bad and that others around them can also smell them. Olfactory reference patients may shower multiple times a day to get rid of the "smell", or may seek repeated medical consultations to find the source of the problem. Like most delusional disorders, olfactory reference syndrome tends to be resistant to medication. I've seen two cases of this disorder and they both improved (but didn't get completely well) on neuroleptics.
Olfactory hallucinations can be seen in other medical conditions, specifically in migraine sufferers and in people with seizure disorders. In this case the smell generally precedes the onset of the headache or seizure and is sometimes described as a 'burning rubber' smell. Treatment of the odor depends upon control of the underlying condition.
So there's my vulture poop post. I even made it relevant to psychiatry. Climb on!
And for those without cathartophobia (my proposed name for vulture fear, after the genus cathartidae):
The Turkey Vulture Society
Thursday, March 26, 2009
I've never treated either of these guys before, have no old records of my own and have no way of knowing if they're actually one and the same person who just lies about different things at different times. Someone just shoot me now.
So is John Doe someone with no previous psychiatric history who is malingering now because he's facing a serious felony charge? Or is he a chronically mentally ill person who is going to relapse if I don't put him on meds? (And relapse in a big way if it required a six month hospitalization.)
Oh yeah, one more thing---he won't answer any questions other than to confirm his middle name and birthdate (which may be a lie). When I try to do a mental status examination he sits there and stares at me.
Gawd, ya gotta love this work.
Wednesday, March 25, 2009
Roy wrote about the NAMI mental health report card by states, Maryland got a "B." The post got a heartfelt comment by Retriever, and I'm borrowing (with permission, and some minor typo editing) that comment to use as a guest post. Retriever writes:
Stigma limits advocacy. The main one is that patients who are trying to pass as normal-- to hold onto jobs or not embarrass their children-- can't lobby politicians, educate peers at work or at church, because, if they have a family to support, they can't risk outing themselves.
We have a kid who is autistic and bipolar. High functioning, but spent nearly a year when 8 psychotic, manic, a danger to himself and others, with no meds working at all for him. My husband was laid off from a job because his company would have had their insurance rates doubled if they continued to keep him on the payroll and insured, because of our kid's diagnoses. Mental health care is expensive.
People still judge mental illness, especially in kids. Social workers at least initially assume that the parents are abusing the kid. Neighbors and coworkers assume that the child is ill because of bad parenting. Parents would actually like to blame their own bad parenting because that is actually under one's control as, say, mania is not. They'd be happy if they could just go to a course to improve and Junior would stop seeing snakes and hearing voices.
People like cute, grateful pitiful victims to help. The reality is that people pass the hat to collect money for a piteously bald kid with leukemia and his family, but nobody ever passes the hat for a psychotic eight year old whom the hospital will not admit because (I quote) "your insurance will only pay us 60 per cent as their reasonable and customary charge, but DCF pays 100 percent. " Hence the kiddie psych unit having 95 per cent DCF kids.
Increasingly the move is towards care "in the community" and to closing public facilities like the state hospital that saved my kid's life (when manic and psychotic) because it would actually admit him and keep him there long enough until he was no longer a menace to himself. Where I live (one of the richest communities in the country) none of the private clinicians are willing to treat severely mentally ill children, so one is sent to a child guidance clinic which limits the care and usually provides it with cheap, relatively new social workers who can barely spell the name of the diagnosed condition let alone have any expertise in it.
And my state got a B.
I do what I can in our church, to educate the SS teachers about how to work with our many kids with various mental health issues (we are the most hospitable in the area to them, and bend over backwards to include them, provide one-on-one shadows, and make equal demands of them so that they are not marginalized--this approach was what most helped my kid). And I talk with parents of the newly diagnosed kids, and badger them to take the various special ed courses on how to do battle with the school system.
But it's a drop in the bucket. You can't talk openly about the truly appalling behaviors of your beloved kid, or people would never feel comfortable around them. You can't tell people why it makes you yourself hideously depressed. You dread any phone call from the school lest it be the dear sweet Buddhist teacher telling you that Junior (hypomanic despite meds tweaking) just told him to STFU.
Most of all you can't testify publicly, or write except anonymously or lobby or preach (I am a former minister) for real parity, and greater compassion for these reasons (to recap):
- The ill child (and their siblings) are entitled to anonymity. I am uncomfortable with all the mommies writing first person accounts with their real names. I wonder how their kids feel? It may be therapeutic to the mom, but could mortify and increase prejudice against the kids.
- Employers lay off people with high insurance costs, although they do not admit it. Sometimes, if one is a valued worker (as I have been), the employer will look the other way. But in cost cutting times, if one advocates publicly, the bean-counters at HR will find a way to get one axed.
- At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home. They don't care that spouses lose their jobs because of having to keep picking up an agitated kid from school, or stay up all night with one and getting too many phone calls at work from MDs.
Community care is like all the " I want a pony" stuff back when people abolished the snake pits in the fond hope of lovey dovey community group homes, etc for the mentally ill. In reality people said NMBY, there weren't the funds, and it is actually harder to prevent abuse and bad care in group homes than in large institutions.
Monday, March 23, 2009
The Chicago Sun-Times has an article today by Carla K. Johnson about a tragedy occurring in a nursing home where an older man is beaten by a younger resident who has a mental illness. She refers to how "nursing homes across the nation have become dumping grounds for young and middle-age people with mental illness."
Thursday, March 19, 2009
In our prison system we get blast emails. Dinah recently has listened to me rant about how much I hate random blast emails from the many organizations I belong to. I get blast email from my professional organizations (two of them), the local symphony, my car dealership, two academic institutions and any company I've ever done business with. I spend more time deleting email than I do reading and responding to email I really want.
But anyway, I get blast email from prison. The majority of it are press releases about various and sundry governer or secretary initiatives, but for some reason they also send out emails about deaths in the system. Not prisoner deaths, not anything work related, but the deaths of anybody who works in the system or is related to a DOC employee. These are called "family passing" notices, after the subject heading of the email.
Today I got three "family passing" blast emails. I don't know any of the people who died and all of them were relatives of DOC employees, and I didn't know the employees. They work in institutions on the opposite end of the state from where I am and it's unlikely I'll ever meet them.
I'm not sure why DOC officials decided I needed to know about these deaths. I'm not sure what I'm supposed to do with this information. I don't understand how they think it will help morale to know that people are dropping like flies right and left. I wonder if they realize that for most people this just reinforces the idea that when you die the majority of people will have no clue that you ever even existed.
I have my email rules set up now to automatically delete any message with "Family Passing" in the subject heading. I suppose I could send in a request to be taken off the notification list but in the bureaucratic world I live in, I know that would only last until the next employee comes in and takes over the death notification job. I'm sure I'll get a blast email to let me know when that happens.
Wednesday, March 18, 2009
A reader wrote in the following:
At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home.
Actually, when I initially read the comment, I thought it said the kiddy shrinks don't really "care how bad it is".... as I've re-read it, I realize it's a more accurate portrayal: "the Shrinks don't know how bad it is..." Oh, if it's okay, I'm going to springboard off the "don't care how bad it is"...it's likely quite true that the docs don't know how bad it is.
It is a regular sentiment, however, that people feel their docs "don't care." I'm always perplexed by that because caring is an internal emotion, how do you know if someone cares? You could ask-- hey do you care that I'm miserable? Oh, of course, the answer will be yes. Maybe a doc cares but doesn't quite know what to do, and feels internally squirmy at the inability to fix a patient's suffering. Maybe the patient has a low-key personality style and doesn't adequately convey that they are suffering. One can say they are tormented, but if they say it wedged in between a discussion of NCAA pics while they are knitting, sometimes the tenor of the suffering is attenuated. And one can scream and rant and rave about their suffering, but if they've screamed and ranted and raved about the poor service in a restaurant, well, there's that whole crying sheep issue that makes it hard to filter.
It's not that docs don't care, it's that there is some professional distance. And if the kiddy shrink has lived through the same exact nightmare, he may or may not state this out load. There's an unpredictable element of trade-off in the perception the patient's family might have: 1) I'm so glad you know exactly what I've been through and it's comforting to have this kind of empathy 2) Your experiences color your ability to see clearly all the possible options and you're too caught up in your own kid's issues to fully appreciate my kid's issues, or 3) You've screwed up your kid, why do I want you near my kid? I've used the kid example because our reader provided it, but it could just as easily be a case of pneumonia-- yours got better in 3 days so you can't appreciate that I'm still sick 2 months later.
Some of what comes off as "caring" isn't really about caring at all, it's about the doctor's external display of concern. Some peeps are pretty reserved--they can be distraught, eaten up inside, thinking about a patient's problem, going home and reading about, calling friends for ideas, and still not convey this to the patient-- they can look uncaring and cavalier. Another doc can jump up and down and seem very concerned, but not actually change anything or do anything.
In medical school, I had a brief period where I got eaten up by other people's problems. The summer after my first year, I did a rotation in a psychiatric unit with some more advanced medical students-- it was a very psychoanalytically-oriented staff and we constantly being asked to process what had happened on the units, how we felt about things, and for weeks it seemed we were being asked how we felt about leaving. There was a suicide in the hospital, there was a long-term (meaning years) patient there who was being treated for borderline personality disorder, and she kept lighting fires. The drama was non-stop, the emotions were intense. By the end of the summer, I wasn't sure I should be a psychiatrist, not because I didn't like it, but because I was emotionally over-involved. It got better.
Medicine as a whole, requires some distance. You want your doctor to care enough to hear your pain, to address it, to explore a variety of treatment options, but you don't really need, or perhaps even want, your doctor to feel your pain. And my guess is that our reader is correct that the doctors don't really know how bad it can be.
Note to Retriever: May I use your entire comment as a free-standing Guest Post?? It was a good synopsis of some of the policy problems behind the mental health system.
Tuesday, March 17, 2009
In medicine we're generally careful not to judge our colleagues harshly on paper. We may report what the patient or another doctor tells us, but we usually hold off on condemning people in a chart-- it makes for messy liability issues, and it's really just poor form to write "Can you believe that idiot prescribed this combo of meds" or "the last doctor never even listened to the patient's complaints."
In real life, I don't believe we're quite so generous. It's not at all unusual for docs to condemn-- in an off-the-cuff manner in casual conversation with friends-- their disdain for the practices of others. Can you believe his former doc prescribed 10 mg/hour of Xanax? Or what about the doc who demands every patient come for weekly therapy sessions even if they don't think they need therapy? Or the doc who only sees patients for 10 minute med checks and never really listens to the patients? How 'bout that doc who gave his suicidal patient a 90 supply of Hemlock? Or how could he start a patient with bipolar disorder on an antidepressant-- of course it de-stabilized him!
I think we're quick with our Can You Believe stories. More in psychiatry than in other branches of medicine? Maybe. Why? Perhaps because less of what we do is clearly defined and even amongst ourselves, we have no full consensus on exactly what it is we do, and in what units. We're certainly getting closer with our use of medications, but still, the guidelines don't take into account what to do if a patient fails many trials of many medications and still has a myriad of symptoms. Sometimes our patients are very sick and we get very desperate. And then too, our label says little about what exactly we do-- one shrink only does med checks, another only does therapy, and we amongst ourselves have not come to a consensus about what is the absolute 'right' thing to do, for whom, in what settings, with what staffing and reimbursement issues, how frequently, and when.
What do you think: are we gentle with each other or not?
This week's Medical Grand Rounds has some great links, including:
Sunday, March 15, 2009
The National Alliance on
Saturday, March 14, 2009
He used to write blog posts. Now he Twitters. Same stuff, but Roy likes new toys. His Twitter feed runs along our sidebar, so go for it.
I thought I'd point out that Roy twitted (is that the word? It's soooo unmasculine) about a post on PsychCentral that was later picked up by the NYTimes Well blog:
The Twelve Most Annoying Habits of Psychiatrists
I have to say, I don't agree with number #10, simply because dress and jewelry are such subjective issues and one person's view of gaudy is another expression of individuality and I don't believe that on most things there would consensus among all the patients in a given therapist's practice as to whether their dress was appropriate or not. Therapists should be dressed professionally and comfortably (they should be concentrating on their patients, not their wedgy underwear) but the issue of 'inappropriate displays of wealth' is not a clear barrier. One could say, "I don't like that my shrink's diamond engagement ring is bigger than mine, so they shouldn't wear it." The shrink below wears so much jewelry as to clank? Most shrinks sit quietly during therapy, so clanking shouldn't be a big issue. I would probably agree if the issue were something like "My psychiatrist comes to treatment in just his Speedo." Here's #10 in the original.
10. Inappropriate displays of wealth or dress.
Psychotherapists are first and foremost professionals, and any displays of wealth and style should be discarded in exchange for dressing in an appropriate and modest style. A therapist slathered in expensive jewelry is a put-off to most clients, as are blouses or dresses that show too much skin or cleavage. Too casual of dress can also be a problem. Jeans may suggest too casual an approach to a professional service that the client is paying for.And it seems I forgot PsychCentral from list of Shrinky Links. Please forgive me.
Friday, March 13, 2009
Here and there, now and again, people have come on to the blog or written in to our temporarily dormant My Three Shrinks podcast and asked for our opinion on clinical matters. Scenarios are described and questions are asked about the specifics of treatment or side effects. Our unified response as blogger-psychiatrists has been to not respond.
It's not that we're ignoring anyone and it's not that we don't have thoughts or opinions, but there's a lot going on here, and it's really not possible to say much with only part or one side of a story. More cogently, it's not that we don't care about anyone's concerns, questions, or distress. It's simply very clear: We can't respond. It is unethical for us to express medical opinions, tantamount to medical advice, on a patient we have never examined and to render those opinions in a public place.
There's a rule in psychiatry known as the Goldwater Rule-- this could be a ClinkShrink post, she knows all this stuff. The Goldwater Rule is based on a section of the The Principals of Medical Ethics of the American Medical Association that reads:
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.
And why is it called The Goldwater Rule? From a 2007 article in Psychiatric News,
This passage is referred to as the "Goldwater Rule." How did this eponym come about? A presidential column by APA's 126th president, Herbert Sacks (1997–1998), explains its origin:
"We are reminded of the 1964 Goldwater-Johnson election, when 1,189 American psychiatrists responded to an inquiry for their opinions of the candidates by a now defunct magazine [Fact magazine]. The bulk of the political responses, couched in psychiatric terminology, were so unfair and so outrageous to Goldwater that he sued and won a substantial settlement. APA issued public statements decrying such analyses and in 1973, when The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry were drafted, Section 7.3 stated [see above]."
Dr. Sacks also noted in his column, "Psychobabble reported by the media undermines psychiatry as science." His words remain true today.When commenting on individuals in the public eye, psychiatrists should be governed by concerns for the potentially inflammatory and harmful consequences of their statements. The reputation of the public figures involved, their own credibility, and the dignity of our profession are at stake. Only after performing an examination and receiving an appropriate waiver of confidentiality should psychiatrists comment on persons in the light of public attention.
But it's just a question and you're not a celebrity and you're not the subject of media attention! Oh, but our blog is public and it seems prudent to observe the standards of our profession that dictate what it is or is not appropriate for us to comment on.
Thursday, March 12, 2009
Is there life after homicide? No, I obviously don't mean for the victims---I mean for the killers.
This is a question that struck me after one of my patients, a convicted murderer who violated his parole, said to me: "I don't feel good about the fact that I'm a killer."
For some reason that statement just struck me and I'm not sure why. Of course someone would feel bad about killing. Sociopaths don't, but most normal non-sociopathic killers do. I think it hit me because my patient's offense had happened over a decade before and he had done well on parole since his release. He was really sad about what he had done and was trying to make things better.
The fact of the matter is that all killers aren't the same. You have the barfight killers, the enraged jealous lover killers, the cold and calculating hit man killers, the child abuse killers, the sadistic serial killers, the drunk driver killers, the school shooting killers, the newborn infant hidden pregnancy killers, the "teenager who kills his entire family" killers and so on and so on. Everybody's different. Ever since the middle ages and the old English common law, killings have been broken down into different categories of murder and manslaughter so that killers would be punished in accordance with the type of killing they're guilty of.
But back to my patient. The question that came to me was, "How do you handle the guilt of being a killer?"
Is it like dealing with grief in the bereaved, where you never really expect someone to just 'get over' something? Is it something you just have to learn to live with? Do you tell the patient that they're now obligated to live the rest of their lives paying their debt to society? Is there a point where the guilt should end? Or is the person really obligated to spend the rest of their life beating himself with a knotted cord? What good does that do?
It's a matter of public record that the Emmy Award-winning actor Charles Dutton was an inmate in our correctional system back in the 1970's for killing someone. To my knowledge he's never been in trouble since then, he's turned his life around, and he's contributed a lot to society since he's gotten out. Most killers don't put their pasts behind them quite so successfully. In my experience a killer who successfully has turned his life around is someone who gets out, has a job, has a place to live, has people who love him and who doesn't commit too many more crimes. It's a bit much to expect someone to never get in trouble again---life is weird, circumstances happen beyond your control and bad reputations throw a long shadow---but at least it shouldn't be another violent offense.
As all of my patients know, it's better to make a life than take a life. It's just a lot tougher to make a life.
Monday, March 09, 2009
So when I give a medication recommendation I talk about why I think the medication would help, I talk about what it treats, what the side effects are and what the risks of taking the medication are. That's a lot of information to absorb all at once so I ask my patients if they have any questions about what I've said. Most of the time they decide to take medication, sometimes they don't. When they decide not to take it they've got good reasons, most of the time.
The only bad reason I've heard is: "I talked to my mother and she heard bad things about it, so I'm not going to take it."
Every inmate has a sister, a girlfriend, an aunt or a mother somewhere with some health care training. All of these family medical advisors know more about psychotropics and are more reliable sources of information than I am, apparently.
I try to be generous and remember that maybe there are idiosyncratic issues here, like maybe the patient did have a weird reaction to some medication that he doesn't remember but his mother does, or maybe there are multiple family members who all had the same problem with a certain medication so he might too.
But usually it's just a matter of trust. The inmate's LPN sister has taken care of him all of his life, has rescued him and given him shelter and sent him money when he needed it, so what she says about medication goes.
It reminds me of a story I heard when I was an intern. My attending went to visit his mother, who was in the hospital for elective surgery. He offered her some advice about her anesthesia, and she responded: "I'll talk to my doctor about that." Her doctor was an intern. My attending was the chairman of the anesthesia department at a major academic institution.
So I guess it goes both ways when it comes to being the family medical advisor. Are you the family medical advisor? Do you want to be? And if so, do they listen?
I heard a talk today on CBT4CBT: Computer Based Training for Cognitive Behavior Therapy where substance abuse treatment is supplemented with On-line real-time psychotherapy groups. I hope I'm saying this right.
The patients go to regular appointments, but in addition, there is an on-line group. The patients and a therapist all 'meet' at a pre-arranged time. There is a camera on the therapist, so his image pops up in the corner of the screen. He can write on the main part of the screen. The participants call in over their computers (each is given a microphone). They're aren't seen, but they have screen names, and they talk one at a time: they press a button to speak and release it when they are done, assuring that people don't talk over one another (I could use one of these buttons in real life). All the patients liked it and they did as well as the controls who had real-life treatment without the supplemental on-line group.
Here's a link if you want to read about this stuff.
And the talk I heard used a platform designed by eGetgoing, an online substance abuse treatment service. I learned something new today.
Sunday, March 08, 2009
When we started blogging, we looked for the blogs of other psychiatrists, and even other non-shrink docs, and linked to them. It's been a while (oh, nearly 3 years) and mental health blogs have come and gone. I thought I'd survey the scene again. So just a list:
Dr. X's Free Associations : psychology with a conservative (?) bent.
May Shrink or Fade: a young(?) inpatient psychiatrist in New England ponders the world.
Turn Your Head and Scoff: by our correctional friend in San Diego, FooFoo5
The Last Psychiatrist: Assorted psychiatric and other rantings
Garth Kroeker is a blogging psychiatrist
The Psychiatrist Blog is written by Dr. Michelle Tempest.
Mind Hacks: Neuroscience and Psychology
Psyched Out: Musings of a psychiatric social worker
In Practice: Peter Kramer's psychiatry blog in Psychology Today.
Oh, Psychology Today actually has a whole list of mental health blogs: try here.
PsychCentral is ...oh, psych central.
Carlat's Psychiatry Blog: focuses on medications and medical research
Clinical Psychology and Psychiatry: A Closer Look
CorePsychBlog: psychiatry with a radio show.
Psychiatric Drug Facts with Dr. Peter Breggin features a psychiatrist who doesn't like meds
The Treatment Advocacy Center -- kind of describes itself.
Mental Nurse: a multi-author mental health blog in the UK
Intueri: to contemplate -- by a psychiatrist.
Ars Psychiatrica: by another psychiatrist! mixes with art and literature Couch Trip: by a psychologist (or soon-to-be?)
Everyone Needs Therapy by a PhD in social work (--Really?)
Jung at Heart by a Jungian psychotherapist
Somatosphere: a multi-author, multi-specialty blog, includes psychiatry
And from Irving, Texas: A psychiatrist who learned from veterans.
I've somehow lost Shiny Happy Person and her Trick Cycling for beginners blog.
The Snarky Gerbil is a psychotherapist-in-training.
Our blog friend psychiatrist TigerMom writes with two other docs on Two Women Blogging (these people can't count).
Juliaink is a psychiatrist who posts on Mothers In Medicine.
Modern Psychoanalysis is a blog by Jim about....psychoanalysis.
Shrinkwrapped (!!!) is a psychiatrist/psychoanalyst in New Jersey. Ah, he needs a better blog name. Might I suggest....
Dr. Deb talks about her work as a psychologist.
Katie Malinski is a social worker who is a parenting coach.
CoffeeYogurt is a blog by a psychologist who visits us.
Dr. Doug Bremmer writes: Before You Take That Pill.
Dr. Shock, M.D., PhD, has a 'neurostimulating blog' with a chocolate post!
Oh, there are more. I tried to confine it to blogs by mental health professionals...but there are so many great medical blogs, and blogs by patients, and many of our readers have neat things going on. More another day. If I missed a psychiatry blog, then by all means....
Friday, March 06, 2009
So I was bitching to Roy (What, me bitch?) and he responded with "What doesn't kill us makes us stronger." Or some version thereof. Roy, Nietzsche, one of those smart guys said something like that. They actually even kind of look alike.
One thing about being a psychiatrist is that most of us believe that what we do, or hope to do, relieves suffering. We believe that the treatments psychiatry has to offer make people better and relieve their psychic torment. Sometimes they work, sometimes they don't, and sometimes "the remedy is worse than the disease" (--Francis Bacon).
In medicine, the patient's history begins with the "chief complaint." As doctors, we often view our job as being to address that complaint: hopefully to make it go away. Often it is an ache or a pain, physical or mental. And yet, our society clearly values Growth through suffering. What doesn't kill us makes us stronger. When we take away the torment, do we stifle the soul?
Thursday, March 05, 2009
Working with violent patients has its challenges. The main one is when they actually do become violent. When they act up, smash things or assault someone there is a quick need to coordinate interventions between security and mental health staff. Of course, safety is the primary goal. Nothing therapeutic can happen until the patient regains control of himself, or someone else gets him under control.
After that, we get him. Violence is actually pretty rare in my facility---a credit to the quality of the correctional staff---but occasionally it does happen.
The only reason I'm writing a blog post about it is because the management of violent patients gets tricky when you're the one they're violent toward. It can be a challenge to continue working with a patient who has threatened you or, god forbid, actually committed violence against you. I've never been decked by a prisoner but I know colleagues who have been. Bless them, they came back to work the next day too.
The question is, what happens next? I don't have the option of firing a patient from my practice and the patient doesn't have the option of switching physicians. For better or worse, we're stuck with each other.
I've put together some general principles about how to manage this situation. Here they are:
1. Safety first
This is obvious, but I'll say it and get it out of the way. Make sure he's cuffed, in leg irons and a waist chain. Custody may forget this in between appointments, so remind them to cuff him the next time he comes down. Have an officer standing outside the office door. If for some wierd reason you don't want him cuffed, have someone sitting in the room with you during the appointment. Bodies count, and it can't hurt to have someone to call for backup if you don't have a security alarm in your office. Confidentiality? Doesn't count here. In cases of imminent dangerousness, there is no confidentiality.
2. Be upfront
Don't pretend that there is a therapeutic rapport when there isn't one. Bring the issue out into the open by saying out loud what the patient is thinking: "You're probably not too happy about seeing me again but we both know you need treatment." It's also OK for you to acknowledge, out loud, that you're going to have a hard time treating someone who threatens you or hurts you.
3. Use timeouts
You and the patient both may need to take timeouts. If the patient starts to get angry, call attention to it and give him a chance to pull himself together. He may not realize how he's coming across. If he continues to escalate, terminate the appointment. In the parlance of the medical progress note, the phrase "appointment terminated for safety reasons" is another way of saying "I let the guy go back to his cell because he was about to swing on me". If you do this, make sure the patient knows you will continue trying to see him and treat him. He may want to run from you, but you can't abandon him. Sometimes that is enough to impress the patient that you're committed to helping and may engage him in treatment.
You need to take a break too if you find yourself getting angry in return. You need to be impartial and calm in order to give the inmate a fair and thorough clinical evaluation.
4. Remember noise is just noise
An angry prisoner will be loud. He might swear. He will complain (a lot). That's all OK. Let it happen, knowing that eventually he will run out of energy. As long as he's not moving toward you or throwing things or physically out of control, it's OK. Don't be intimidated by noise. When he does calm down, quietly ask permission to make a treatment recommendation. There's a chance he might listen once he's had a chance to vent and be listened to.
5. Work on awareness
Like I said before, in all likelihood the inmate is not going to have any awareness of how he's coming across either in volume or in the intimidation factor. When custody starts peeking in the office to make sure everything is alright, you can carefully point this out to the patient and explain that people are concerned because of how he's behaving. That might be enough to trigger insight.
So that's what I do, for what it's worth. Sometimes it helps, sometimes it doesn't. But at least it's worth a try.
Wednesday, March 04, 2009
Interesting topics include PTSD of being ill, Twitter discussion about remembering doc's instructions, and EMTALA and ER visits.
Scicurious writes in the Neurotopia blog everything you wanted to know about serotonin (*but were too anxious to ask).
This is a very well-done post on this topic. Go there. Read it. Tattoo optional.
"Serotonin is a pretty wild molecule for many reasons. First of all, it is formed form the amino acid L-tryptophan, which is one of the 20 standard amino acids required for life as we know it. Interestingly, tryptophan is also one of the few "essential" amino acids for humans, meaning that we don't make it ourselves, and have to get it from the diet. But don't worry, you've usually got plenty. The only way anyone could really suffer "tryptophan depletion" is if you're in a lab and they give you tons of other amino acids, or if you're starving. And if you're starving, you've obviously got bigger problems.
To make serotonin, start out with some L-tryptophan. This gets broken down in cells by an enzyme known as tryptophan hydroxylase to 5-hydroxytryptophan, this then gets broken down using the enzyme amino acid decarboxylase to 5-hydroxytryptamine, or 5-HT. Then the 5-HT is ready to be stored in vesicles in preparation for..."
Go to Neurotopia for more.
Tuesday, March 03, 2009
Okay, I'm going to ramble (I know it, even before I've started) and I don't quite know where I'm going with this. Please notify me if I get there.
There's an assumption in medicine that the responsibility for pulling out the truth rests with the doctor. Really? I don't know, and I've never seen it stated as such. It feels like it's there, though, in insidious ways that leave us with the sense that if we don't ask the right questions, don't elicit the right information, that the fault (and, yes, I think I mean fault), and the liability, is with the physician.
Let me explain a little better: a patient commits/attempts suicide...people (which people? I don't know: People! Perhaps everyone. Lawyers, supervisors, family members, other physicians) will ask: Did the psychiatrist ask if he was having suicidal thoughts? A plan or intent? In the two clinics where I work, there is a check-off box on the doctor's progress notes regarding Suicidal Ideation. It's a good jog to the memory to remind us always to ask, but it's also intrusive. It must be checked off and the doctor doesn't have the space to decide it's inappropriate to ask that particular question on that particular day. Some might say it's always appropriate to ask about suicidal ideation, but when I'm seeing a patient whom I've known for years, who has never been suicidal, who tells me they are doing well, feeling fine, well, it sometimes feels a little weird for me to ask, "Are you having any thoughts about hurting yourself?" Them's the regs.
But it's not just suicide, or homicide, or any form of violence. It's other things as well. Roy mentions in his Xanax post that the doctor needs to ASK the patient about a history of substance abuse to find out. Oh, but patients can lie, or forget, and doesn't everyone know Xanax is addictive? Shouldn't a patient with a history of addiction volunteer this information to any doctor who may prescribe an addictive drug that will re-activate a past problem?
It's not mental health issues, it's all of medicine, though certainly, each specialist feels an obligation to attend to his organ system. Do internists second-guess themselves if someone walks out and has a heart attack: "Oops, I forgot to ask if he was having chest pain." Do they check their notes and hope they've documented an appropriate assessment for cardiovascular disease?
So what's my point? It's certainly not that we shouldn't ask questions. We should. And there are issues that might not be obvious to the patient, things they might have forgotten or may not know are relevant-- like asking about a past history of mania/hypomania before prescribing an anti-depressant. But, I think, at some level, we've taken on the burden of blaming ourselves (or our colleagues) if something goes wrong and the doc didn't ask. Maybe it's a fallout from the malpractice era: in terms of a lawsuit, it's probably not good form to have a bad outcome about something one didn't ask about. There is also that sense that if you asked, and the patient said No, then how could we know otherwise? It's not that we don't feel sad about a bad outcome, but if there's the sense that all that could have been done was done, at least there's not that feeling of responsibility.
Sometimes, though, it doesn't just feel like a moment of omission, it feels (to me, at least) as though we blame ourselves and each other for a bad outcome if we didn't ask the right question, as though it's our fault, like we've caused something bad to happen, or at the very least, failed to prevent it. We blame ourselves, we finger-point at our colleagues.
I told you I was going to ramble. Well, what do you think?
Sunday, March 01, 2009
This is another one of my hypothetical questions.
So you're a health care professional (if you're not, pretend) and you're on vacation far, far away. But before you left, you arranged for someone to cover your practice and you gave the covering doc an emergency number. Why? Why not.
You're getting some much needed rest and relaxation-- you've left work behind and it feels so good not to worry about other people. But back home, something bad has happened to one of your patients-- if you're a primary care doc, perhaps someone had an unexpected and fatal heart attack. If you're a shrink, may be a patient committed suicide. Whatever it is, it's awful, and it's done: there's nothing you can do now that would change the outcome.
Do you want to know before you return home? And if you're the covering doc, Do you call? After all, you were given that Emergency Number.
I've never fully come to peace with this one: many years ago, I got a call on vacation that one of my patients had died in a car accident. It haunted me and there was nothing I could do-- I called the mom from my trip, but I had no relationship with the parent, my call seemed to offer no comfort. After that, I went for a time leaving my cell phone home and being inaccessible while away; this is what coverage is for. At some point, I started to realize that I'd return and get anxious as I turned the phone back on: what bad news would I hear? Might it be better to have the phone with me, to keep it mostly off, but to know that no news is good news?