Tuesday, December 31, 2013

My Favorite Blog Posts From 2013

As we approach the new year, I would like to reflect on some of my favorite posts from 2013. If you're new to this blog, I think these articles should hopefully give you a sense of what I enjoy writing about. Here they are, in chronological order:

A Most Influential Professor (5/19/13)
I probably would not have become a psychiatrist if not for how my undergrad Abnormal Psychology professor made the class so fascinating. And yet, the more I learn, the more I feel he had a very limited perspective.

Psychiatry Leadership: Uneasy Lies the Head that Wears a Crown (6/7/13)
I was disappointed — but not all that surprised — by how much more cogent psychologist Gary Greenberg was compared to APA president Jeffrey Lieberman and NIHM director Thomas Insel during an NPR Science Friday debate about the DSM-5.

A Chilling Encounter (6/11/13)
A story about interviewing a teenage psychopath in the psych ER. I hope I was able to convey why I felt chills down my spine during the encounter.

Movie Review: The Bling Ring (7/12/13)
I really enjoyed this movie and found it to be a funny satire of adolescent vanity and vapidity. I was surprised that some reviewers thought Sofia Coppola took a neutral stance toward her subject matter. I thought she was anything but neutral, and I even found some YouTube evidence supporting my view.

Hmm…looking at this list, perhaps I should stick to blogging during the spring and summer months…

Thanks to everyone for visiting this blog, and I wish you all a Happy New Year!

Sunday, December 15, 2013

In Whom Does Mental Illness Reside?

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

Dara was a teenage girl prone to outbursts, mainly at home. Her parents have been divorced for many years, and she mostly lived with her mother, a well-heeled professional. Every single week presented another crisis. Dara would refuse to go to school if she did not get up on time. She would push or hit her younger sister Lisa for no apparent reason. She would get so mad at her mother that she would write "I hate you" on the side of their house in permanent marker. Her mother made an appointment for her after discovering that she had written in her diary that she wished she were dead.

When I met individually with Dara and asked her about these outbursts, she was always quick to blame Lisa for provoking her or her mother for being mean to her. She told me about how she feels her mother always favored her sister over her. She could not tell me one thing that she enjoyed doing with her mother, and she felt that her mother has never liked her. With her mother and sister, she was irritable, easily upset. However, when she was with her father or her friends, she was usually cheerful, and that was how she appeared to me during most of our visits. She has never been depressed most of the time for more than a day, and she explained that she wrote that she wished she were dead after an argument with her mother, but she has never thought about killing herself. She has never had any grandiosity, elevated mood lasting more than a few hours, or decreased need for sleep, although she stayed up late reading Harry Potter.

Dara's mother always showed up to our appointments with a stoic, unchanging expression. Over the course of several visits, I tried to find out more about her relationship with her daughter. I eventually learned that she had grown up with a mother who had an explosive temper and was verbally and physically abusive. She has not visited her mother in years, and it appears that she learned to control (or suppress?) her feelings without ever letting them out like her mother did. Dara's mother readily admitted that her daughter reminded her a lot of her own mother; she has felt this way ever since Dara was a colicky infant whose cries kept her awake most of the night for months.

When I asked Dara's mother what she thought was going on with Dara, she told me matter-of-factly: "I believe that my daughter has a mental illness, and that she needs help. I think she might have bipolar disorder, and she should be on a medication for her mood swings."

I did not end up prescribing Dara any medication besides recommending melatonin to help her sleep earlier. I tried to work with Dara and her mother on understanding each other better and de-escalating their conflict. Dara's outbursts gradually decreased in frequency, though I got the sense that both mother and daughter were still walking on eggshells. I began talking with them about seeing a family systems therapist, and neither one warmed up to the idea. After a few months, they stopped following up with me, and I do not know if Dara eventually ended up being put on medications.

So is Dara really mentally ill? Or do both mother and daughter have a mental illness? Would the issue best be characterized as a behavioral problem instead? Or a parent-child relational problem?

I had been thinking about this patient story for months now, but what finally motivated me to write about it was Dinah's recent post over at Shrink Rap in which she shared:
I'm a psychiatrist, and I confess, I have no idea who these "mentally ill" are.  I think if you asked many people in treatment about being mentally ill, they might think you are talking about someone else.  People may not think the term applies to them because they don't have the insight to realize they are sick.  Or, they may not think of themselves as mentally ill because with treatment, they've gotten better. […] It might not occur to a patient to identify themselves as "the mentally ill" even if they take medicine and go to therapy.
When I tried to take her poll on "Who are the Mentally Ill," I realized that I wanted to say "False" to most of the questions (e.g. "Anyone who takes a psychiatric drug prescribed a by primary care doctor is mentally ill"), but I could not fully explain to myself why or how I reached that conclusion. However, I gained some much-needed clarity from reading Dr. Steven Reidbord's very thoughtful post, which concluded:
Since "mentally ill" obscures as much as it clarifies, perhaps no one should be labeled this way.  Indeed, only in psychiatry can a person be declared ill by someone else.  In the rest of medicine, it’s self-descriptive.   In my view, "the mentally ill" harbors too many unstated implications and vaguely shared assumptions regarding whom we are talking about.  Legal restrictions and entitlements should be based on more concrete standards — and actually, they are.  "Mental illness" is more of a rhetorical flourish, a bit of hand-waving when it’s difficult or inconvenient to pin down specifics.
Dr. Reidbord articulated what I long felt, which is a discomfort with the term "mental illness." Thinking back on my own interactions with my patients, I cannot recall ever telling a patient that she has a mental illness. It's just not useful from a clinical perspective.

Sunday, December 8, 2013

Brooklyn Castle Movie Review

I recently had the pleasure of watching Brooklyn Castle, one of the most delightful and moving documentaries that I have ever seen. It follows a group of students on the chess team of Intermediate School (I.S.) 318 in Brooklyn, which is perennially one of the best in the country, even though I.S. 318 is a public school where over 60% of families in the district are living below the poverty line. The New York Times review introduces us to the documentary's young subjects:
Rochelle Ballantyne dreams of being the first female African-American chess master; Alexis Paredes hopes to be a lawyer or doctor so he can ease the burdens of his immigrant parents. The dreadlocked newcomer, Justus Williams, might be a chess genius; Patrick Johnston, who has attention issues, just wants to raise his ranking. Pobo Efekoro helps his mother with her day care business.
Dovetailing with my last post, this film illustrates the importance of having caring adults involved in the lives of children and adolescents. Other reviews have highlighted the important roles that chess teacher Elizabeth Vicary and assistant principle John Galvin play in their students' lives, as well as how budget cuts threaten important programs like I.S. 318's chess team. Here, I would like to highlight another aspect of Brooklyn Castle that was striking to me, and that is the interaction between these students and their parents.

As a child psychiatry trainee, I attended multiple lectures on the importance of authoritative parenting, which refers to parents who have a warm relationship with their children but also set reasonable limits; who have high expectations and try to provide their children with the tools to succeed. The parts of this film that show the students interacting with their parents, while brief, are wonderful illustrations of the authoritative approach.

On more than one occasion, the film shows families sitting at a meal together having a conversation, which by itself is an important protective factor. Rochelle's mother repeatedly emphasizes the importance of her having an education. Alexis's mother reassures him that he does not have to find a job after high school, that he can go to college because that is why she and his father work so hard. She cries tears of joy when she finds out that Alexis had been accepted to a good high school. Pobo, who lost his father at a young age, shoulders his responsibilities at home without complaint. Patrick's mother acknowledges how hard things must be for him and participates in a fund drive to raise money for the chess team.

My favorite moment came when Justus lost a match and called his mother on the phone. He says hesitantly, "I lost a pawn, and then I just…fell apart after." She clearly hears how upset he is, and she validates what he is feeling, saying, "You're upset, right?" When he answers in the affirmative, she reassures him and encourages him to persevere: "Yeah, I can tell. That's ok. Just pick yourself up, it happened." She then says, "Boy, I feel down too I'm not gonna lie." She says this in such a way that is not blaming him for making her feel bad, but to share with him that she understands what he is feeling. This conversation, which lasts less than 30 seconds, can be used in a instructional video to show parents how they should approach their children who are upset.

As a whole, Brooklyn Castle is uplifting and joyous, but also a reminder of the dedication and effort that it takes to help children succeed. Just one last random nugget that I loved: where else are you going to see a kid rap about conquering his opponents in a chess match?

Sunday, November 24, 2013

Putting a Dent in the Universe, One Way or Another

The two men's personalities were more similar than different: both were temperamental, easily slighted. They had similar views of themselves, believing that they had a special purpose in life. Both clearly burned with a desire to shape history.

As young men, both embraced alternatives to mainstream culture: one became a hippie, the other a Marxist. One travelled to India looking for enlightenment, while the other went to the U.S.S.R. in search of a communal utopia. They both returned to the U.S. somewhat disillusioned. 

They could both be quite cruel and controlling: one was known for tearing down subordinates and once implied that the mother of his child was a slut, saying "28 per cent of the male population in the United States could be the father." The other one beat his Russian wife and refused to allow her to learn English.

They both ignored reality, but whereas one was famous for his "reality distortion field" in which he would convince not only himself but also everyone around him that the impossible could be achieved, the other only distorted reality for himself: upon returning from Russia, he was surprised that the press was not waiting for him at the airport to hear his story. His wife later told investigators about "his imagination, his fantasy, which was quite unfounded, as to the fact that he was an outstanding man."

One of these men founded a company by the time he was 21 and became a multi-millionaire at the age of 25. He then went on to reshape the personal computer, animated film, music, and telephone industries. The other also made his mark, on a tragic day in November, and would be dead at the age of 24 fifty years ago today.

So what made their life stories so different? Was it because one of them was more intelligent than the other? Was born with more innate charisma, a better aesthetic sense? Or was it parenting and the environment where each grew up? One was adopted shortly after birth and raised by middle-class parents in a stable home, while the other's father passed away 2 months before he was born. His overwhelmed mother put him and his siblings in an orphanage, then later moved with him across the country, worked long shifts, and left him to fend for himself. He went to juvenile hall for truancy, and his social worker there thought he conveyed "the feeling of a kid nobody gave a darn about."

Looking back on history, one can never be sure of causation. But I can tell you with certainty that childhood matters. Growing up in a safe environment with loving family matters. Having nurturing adults who support a child's interests matters. I wish that all of the attention given to Lee Harvey Oswald and the Kennedy assassination in recent weeks had focused less on the final act of the shooter and more on the formative years that shaped him. As Steve Jobs once said:
I'm 100% sure that if it hadn't been for Mrs. Hill in fourth grade and a few others, I would have absolutely have ended up in jail. I could see those tendencies in myself to have a certain energy to do something. It could have been directed at doing something interesting that other people thought was a good idea or doing something interesting that maybe other people didn't like so much. When you're young, a little bit of course correction goes a long way.

Sunday, November 17, 2013

The Wizard: Psychopharmacology Magic?

One of the most memorable psychiatrists that I worked with as a trainee is someone I think of as The Wizard. He specialized in treating some the most difficult behavioral manifestations of autism and other genetic conditions like Fragile X syndrome. He had a magical ability to calm even the most agitated children and adolescents and seemed to inspire reverence and awe in their parents, who kept voting him to the top of various "Best Doctor" lists.

What most amazed me about The Wizard was his Zen-like serenity. Regardless of how much noise the patient was making or how many toys went flying around the room, he would be like the calm eye of the storm, holding still while everything else moved around him. His gaze was remarkable, intense yet warm and soft, like a bright candle. He would focus intently on whoever he was talking to, making that person feel important and special. His voice was smooth and soothing, almost soporific; perfect for those in emotional distress.

He took no notes during the appointments. His dictated progress notes were usually just a couple of paragraphs long, without pesky details like what medications the patient was taking and what medication changes were made during the visit. However, he did not have to remember those things. During the visit, he would shine his bright gaze upon the parents and say, "So tell me, what did we decide to do with the medications last time?" And the parents always provided the details. Maybe they knew that they would be quizzed this way, so they prepared so as to not be embarrassed. More likely, I think the parents were pleased that this eminent psychiatrist trusted them enough to empower them in this way.

The Wizard was an expert psychopharmacologist, often prescribing medications that I've seen no other psychiatrist prescribe. Things that may have had success in case studies, but no positive clinical trials (and maybe even some negative ones). Yet for him, he was able to get results using those medications. Perhaps he was lucky, or with his experience he was able to intuit the right medication for a certain patient. However, I firmly believe that just being in his presence was one of the major therapeutic interventions that he provided for his patients and their parents.

I attempt to channel him during every patient encounter. But try as I may, I can't help but continue taking notes while talking to patients and then writing overly detailed progress notes.

Sunday, November 10, 2013

On Bullying and NFL Culture

I have always been enthralled by NFL football. Growing up, I was amazed by the super-human strength, speed, and dexterity exhibited by its players, and how they seemed to (almost) always get up from bone-crunching hits and keep playing. Over the past decade though, it has become increasingly clear just what a physical and mental toll the game takes on its players, with the NFL's earlier attempts to deny links between concussions and lasting brain damage in the form of chronic traumatic encephalopathy at the forefront of recent reports.

For some observers, the NFL has definitely lost some of its luster. However, the league's popularity does not seem to be waning. The week-to-week dramas on and off the field have me convinced that the NFL is America's #1 reality show. What I wonder is whether this scrutiny can result in anything positive? Or will the NFL just take advantage of the increased attention, whether good or bad, for gain and profit? I think how the league handles the latest scandal will be instructive.

For the past week, there have been numerous news stories about Jonathan Martin of the Miami Dolphins, who left the team and checked into a hospital for emotional distress following alleged bullying by teammates. Martin, who graduated from Stanford, has made public some disturbing voicemails and text messages from Richie Incognito, a player who was kicked off two different college football teams.

What I haven't heard discussed much on sports shows is what exactly is bullying? The officially accepted definition is that bullying is unwanted, aggressive behavior that involves a real or perceived power imbalance, which is repeated over time. From this definition, it's quite clear that bullying was in fact what was going on. Incognito, an NFL veteran and a member of the team's player leadership council, is clearly in a position of power over the much younger Martin, and the abuse certainly was not a one-time incident, starting with Martin's rookie year and continuing into this season.

Watching the Fox NFL pregame show this morning, I was dismayed but not surprised by some of what I heard. Jimmy Johnson talked about how Martin was not drafted until the second round, meaning some teams must have thought there were some issues with him. Michael Strahan said that people only do to you what you allow them to, implying that Martin is somehow weak for not standing up for himself. Terry Bradshaw talked about how our culture has become too quick to judge. And then there was Jay Glazer's exclusive interview of Incognito, who admitted to sending insensitive messages, but denied being a bully or racist (link to ESPN's summary of the interview):
"When words are put in a context, I understand why a lot of eyebrows get raised," Incognito told Fox Sports during the interview, which aired Sunday. "But people don't know how Jon and I communicate to one another. For instance, a week before this went down, Jonathan Martin texted me on my phone, 'I will murder your whole F'ing family.'

"Now, do I think Jonathan Martin was going to murder my family? Not one bit. He texted me that. I didn't think he was going to kill my family. I knew that was coming from a brother. I knew it was coming from a friend. I knew it was coming from a teammate."
"You can ask anybody in the Miami Dolphins' locker room who had Jon Martin's back the absolute most, and they will undoubtedly tell you [it was me]," Incognito said. "Jon never showed signs that football was getting to him [or] the locker room was getting to him."
"All this stuff coming out, it speaks to the culture of our locker room, our closeness, our brotherhood," Incognito said. "And the racism, the bad words, that's what I regret most. But that's a product of the environment."
Now imagine a high school girl accused of bullying saying the same thing: "But I was her best friend! She said mean things to me, too! In the high school environment, that's just how we talk!" Not much of a defense, is it? Incognito is certainly right that the culture of the team played a role; he just clearly does not think that there's anything wrong with the culture. What the ESPN story does not include though, is the most important fact to come out of that interview: The one question that Incognito would not answer is whether his coaches had directed him to toughen Martin up.

The wisest thing any player has said about the situation has come from Brandon Marshall, a wide receiver who has experienced plenty of his own troubles, but who seems to have turned his life around after being treated for borderline personality disorder and courageously discussing his diagnosis in public.
"Look at it from this standpoint," Marshall said. "Take a little boy and a little girl. A little boy falls down and the first thing we say as parents is 'Get up, shake it off. You’ll be OK. Don't cry.' A little girl falls down, what do we say? 'It’s going to be OK.' We validate their feelings. So right there from that moment, we're teaching our men to mask their feelings, to not show their emotions. And it’s that times 100 with football players. You can't show that you're hurt, can't show any pain. So for a guy to come into the locker room and he shows a little vulnerability, that's a problem.

"That’s what I mean by the culture of the NFL. And that's what we have to change. So what's going on in Miami goes on in every locker room. But it’s time for us to start talking. Maybe have some group sessions where guys sit down and maybe talk about what's going on off the field or what's going on in the building and not mask everything. Because the (longer) it goes untreated, the worse it gets."
A T-group for NFL players, what an inspired idea! Marshall also addresses the role the head coach plays in shaping a team's culture:
“We [the Chicago Bears] look at rookies different,” he said. “You have to earn your stripes, earn your place on the team, earn your place in the NFL. But as far as crossing that line? Disrespecting guys? Demeaning guys? That just doesn’t happen here. Actually, Coach (Marc) Trestman did a great job of really going out of his way to make everyone feel comfortable from Day One.”
Will the NFL take advantage of this opportunity to change how coaches manage locker room behavior? Or will there be another flimsy attempt at a cover-up?

Sunday, November 3, 2013

How to Combat Stigma, Part 2

This is part of of a series of posts on how to reduce stigma around mental health. Part 1 is here.

I'm working my way through Anthony Beevor's The Second World War, a one-volume history covering the major military events of World War II. To me, one of the most interesting aspects of the book is how much the author repeatedly describes the psychological effects of stress from war, which affected everyone involved from civilians to front-line soldiers to generals. One particularly striking passage described an infamous incident that occurred in Sicily in August 1943 when General George Patton was visiting hospitalized soldiers [page 498]:
Patton asked a soldier from the 1st Division, a young carpet-layer from Indiana suffering from battle-shock, what his problem was. 'I guess I can't take it,' the soldier replied helplessly. Patton flew into a blind rage, slapped him with his gloves and dragged him out of the tent. He booted him in the rear, shouting: 'You hear me, you gutless bastard. You're going back to the front!' A week later, Patton had another explosion when visiting the 93rd Evacuation Hospital. He even drew his pistol on the victim, threatening to shoot him for cowardice. A British reporter, who happened to be present, heard him say immediately afterwards: 'There's no such thing as shellshock. It's an invention of the Jews!'
I thought about this passage a lot as I was writing this post. In many ways, it does seem that the stigma of having a condition like post-traumatic stress disorder has greatly decreased. No general today would claim that PTSD does not exist or publicly berate a soldier suffering from it. However, the silence and shame surrounding mental conditions continues to be pervasive. There have been numerous articles and reports about the difficulties returning soldiers have in readjusting to civilian life or having access to appropriate treatment. Suicide rates, which used to be lower in the military than in civilian life, are now higher among members of the military.

I have not come across any good studies about evidence-based ways of decreasing stigma related to mental health, so what follows is my own intuition and opinion. I personally do not believe that talking about how common mental illnesses are would do anything to decrease stigma. Just look at the example of obesity, which despite skyrocketing rates, is still something that leads to kids being teased and bullied at school. Likewise, emphasizing that mental illnesses are biologically-based is unlikely to help. Everyone knows that those with intellectual disability have a brain-based condition. However, that did nothing to stop previous terms like "mentally retarded" and "idiot" from becoming pejorative. Below I'll discuss two broad areas that I think can help decrease stigma.

Normalizing the Expression of Emotion

In the U.S., when someone asks "How are you?", the answer is almost always some variation of "I'm okay," no matter what the truth may be. I believe that this cultural taboo against honestly discussing one's emotional states is one of the root causes of stigma. I have had countless patients apologize to me for crying as they describe the stress or trauma in their lives. The perception that it is somehow a weakness to be emotional or to talk about such difficulties leads to shame, which perpetuates stigma. When I ask about a family history of mental illness, one of the most common things I hear is: "I think my ___________ may have _____________, but my family never talked about it." Needless to say, those family members probably never got any sort of treatment for their suffering.

However, in some cultures, the more open expression of emotion seems to help people be more willing to seek treatment, as this CNN report on psychotherapy in Argentina shows. Even in the U.S., there are starting to be efforts to teach children emotional skills, which are increasingly recognized to be as important as intellectual or social skills. I believe that if children (and adults, but it's certainly easier with children) learn that it's acceptable to acknowledge and discuss their own feelings of sadness, anger, frustration, anxiety, etc., then they will have more compassion for others who are in emotional distress.

Of course, this does not address the stigma surrounding serious and chronic mental illnesses. Tellingly, the CNN article linked above contains the following:
One of the soon-to-be psychology graduates is Agustina, 31, who did not want her last name used because her future patients may Google her name.

Every member of Agustina's family goes to some kind of therapy, but, she's quick to add, "It's not that we are completely crazy or something. Nobody has big issues."
So what can be done for those with "big issues"?

Access to Care/Quality Treatments

I believe that as with other conditions like HIV/AIDS or Hansen's disease (a.k.a. leprosy), nothing stigmatizes more than having a group of suffers treated as outcasts and isolated from the rest of society. Having hundreds of thousands of chronically mentally ill people living homeless in the streets and millions more locked up in jails and prisons is terribly stigmatizing. Similarly, having managed care erect roadblocks to patients getting quality psychiatric care is stigmatizing, as it reinforces the idea that mental conditions are second-class citizens compared to purely physical ones. Despite passage of the Mental Health Parity and Addiction Equity Act in 2008, insurers are still unwilling to pay for many treatments.

Unfortunately, this is not going to get better until we as a society come to our senses and implement a better model for mental health treatment. As fellow blogger Dr. George Dawson has pointed out many times on his blog, managed care's focus on cost containment over quality has had a horrendous effect on the ability of clinicians to provide adequate care. Likewise, taxpayers are paying billions to keep mentally ill people locked up, when the same money could be used to much better effect to provide interventions such as stable housing, assertive community treatment, and vocational training.

It does not help that the NIMH continues to emphasize basic biological research above all else, or that the APA does little to challenge the managed care system, accepting it as fait accompli. But hopefully, with enough awareness and activism around these issues, meaningful change will eventually take place, and we as a society will make a bigger dent in the stigma related to mental health.

Friday, October 18, 2013

How to Combat Stigma, Part 1

The stigma associated with mental illness is something that leaders of the profession such as Dr. Jeffrey Lieberman, the current American Psychiatric Association president, often point to when fighting back against critics of psychiatry. Dr. Lieberman seems to believe that by moving psychiatry away from Freud's "brilliant fiction" and "into the mainstream of medicine," stigma will decrease and people will be more likely to seek treatment.

I think the truth is much more complicated. I believe that well-intentioned interventions can potentially have the opposite effect and increase stigma. I went to medical school in a city where HIV/AIDS was epidemic, and I was part of a medical student-run group that went to local middle schools to teach about HIV and AIDS. Our goal was not only to increase knowledge about the disease and how to prevent it, but also to decrease the stigma associated with HIV by having HIV-positive speakers meet with the students to share their stories. We also administered a quiz before the teaching and again a few months later, to assess for changes in the students' knowledge and their attitudes toward people with HIV/AIDs. Sadly, while their knowledge increased, their negative perceptions of people with HIV also seemed to increase.

An analogous situation is described by writer Ethan Watters in his 2010 book Crazy Like Us, which he excerpted in a NYTimes Magazine article:
In 1997, Prof. Sheila Mehta from Auburn University - Montgomery in Alabama decided to find out if the “brain disease” narrative had the intended effect. She suspected that the biomedical explanation for mental illness might be influencing our attitudes toward the mentally ill in ways we weren’t conscious of, so she thought up a clever experiment.

In her study, test subjects were led to believe that they were participating in a simple learning task with a partner who was, unbeknownst to them, a confederate in the study. Before the experiment started, the partners exchanged some biographical data, and the confederate informed the test subject that he suffered from a mental illness.

The confederate then stated either that the illness occurred because of “the kind of things that happened to me when I was a kid” or that he had “a disease just like any other, which affected my biochemistry.” (These were termed the “psychosocial” explanation and the “disease” explanation respectively.) The experiment then called for the test subject to teach the confederate a pattern of button presses. When the confederate pushed the wrong button, the only feedback the test subject could give was a “barely discernible” to “somewhat painful” electrical shock.

Analyzing the data, Mehta found a difference between the group of subjects given the psychosocial explanation for their partner’s mental-illness history and those given the brain-disease explanation. Those who believed that their partner suffered a biochemical “disease like any other” increased the severity of the shocks at a faster rate than those who believed they were paired with someone who had a mental disorder caused by an event in the past.
Of course, one study in college students is hardly conclusive, but I have had very many similar experiences with my own patients. Those who were told by previous doctors that they had biochemical issues going on in their brains often lost hope when the biological treatments did not help them feel better. I have had patients tell me that they felt like they were damaged or broken after they were told during psychiatric hospitalizations that they had "bipolar disorder" or "treatment-resistant depression."

I feel that many practicing psychiatrists are starting to come around, and I found hope in an unlikely place: the American Psychiatric Association's YouTube page. In particular, the following clip from this year's APA conference:

Below, I've summarized the responses of those interviewed:
  1. Chester Swett, MD: As public becomes better educated, emotional issues are more accepted as a part of going through life; a certain percentage of people may have more trouble than the average person, and that is when we diagnose anxiety, depression.
  2. Ravi Hariprasad, MD, MPH: Role model treating patients and families without stigma. Set a good example. Stigma is fought on individual one-to-one basis; best help is to help patients break their own stigma against themselves.
  3. Darshan Singh, MD: Help patients learn they are not to be blamed, it is a health issue. There is not one cause, mental illnesses are not like diabetes. People should be encouraged to talk to social workers, nurses, mental health agencies, pastors, etc. to learn that they are not alone in their struggles.
  4. Kerin Orbe, DO: Talk about psychiatry and psychological problems more naturally. Educate community about what mental illness means.
  5. Marcos Liboni: Share advances in psychiatry. Show psychiatry nowadays is very different from the past. Historically, psychiatry was linked to prisoners and torture. Now brain diseases can be treated; psychiatry is a medical specialty not far from medicine. 
  6. Laurie Wells, MD: Mental illness is universal, affects everyone. Treatment is whole treatment of mind and body, not just medication. Serving people we treat with respect and respecting autonomy de-stigmatizes them.
There is certainly a diversity of opinion, and I may not have captured the nuances of what each person was trying to convey. But what stands out to me is that only one of the respondents talked about biological advances in psychiatry, while several emphasized the importance of treating patients with respect and compassion. I think that's a good place to start.

Monday, October 14, 2013

Losing the White Coat Part 1: Medical School

This is part 1 of a series on the evolution of my approach to psychiatry. For background, I recommend reading A Most Influential Professor, which is essentially part 0 of this series.

Just about every medical school has a traditional white coat ceremony, during which the incoming class of medical students get their shiny new white coats that they will then wear throughout the rest of medical school during clinical experiences. At my school, the ceremony came with a recitation of a modified Hippocratic oath, adding to the gravitas of the day and helping us reflect on our future roles as healers and doctors.

The psychiatry faculty and residents at my school made it a point to insist that they were “doctors first." As medical students, we were repeatedly told about the contributions our institution made to modern biological psychiatry, and how it was a bastion of biologically-minded psychiatrists even during the era when psychoanalysts dominated psychiatry.

It was not surprising, then, to see psychiatry attendings walking around the hospital and lecture halls wearing their long white coats. Even the lone psychologist that taught some medical student lectures wore a white coat when he was in the hospital.

However, something always felt amiss with this biomedical aura. The psychiatry attendings were very quick – too quick – to defend the medical-ness of their specialty. I was told on multiple occasions that the arbitrary diagnostic criteria used in the DSM-IV are no different than the cutoffs used to define blood pressure in hypertension or glucose levels in diabetes. However, despite the prominent role the school's psychiatry department made in establishing biological psychiatry, physicians in other specialties there did not seem to respect the psychiatrists very much. The psychiatry interns took care of fewer patients on their Internal Medicine rotations than the medical interns, yet the psychiatry program director always insisted that the psychiatry interns performed just as well as the medicine ones.

As a third year medical student, I did my psychiatry rotation in a publicly-funded mental hospital, wearing my white coat just like the residents and attendings. There certainly were cases in which something clearly biochemical was going on in the brain of my patients, such as when a young man came into the ER hearing voices and feeling very paranoid after using a large amount of cocaine. I got to see antipsychotic medications help some patients with schizophrenia, but only so much, and with obvious side effects. There was clearly a vast gulf in understanding between the psychiatrists and patients, with the psychiatric residents spending minimal amounts of time with their patients and going home by 3pm each day. I was not sure how much wearing a white coat contributed to this distance or if it was mostly due to the culture of the place, but it certainly did not help foster empathy.

There were many other cases that left me feeling uneasy. As a fourth year medical student on the consult service, I accompanied a psychiatry resident when he evaluated a patient for suicidal thoughts. Afterwards, he told the primary team, "Don't worry, he's just a boy borderline." The attitude seemed to be that this patient would not actually harm himself because he was just "being manipulative," or that personality disorders somehow were not real, perhaps because there was nothing "biological" that could be done.

I did have a great experience working with the child psychiatrists at my medical school, who because of their specialty necessarily had to take a more holistic view of things. But even so, they tended to focus on the children as individual entities, without deep thought given to how interactions with parents influenced the children's behaviors.

When I asked the program director about learning psychotherapy as a resident there, I was told by that they don't really teach psychotherapy, because that is not going to be part of the job of a psychiatrist going forward. I would learn enough to know what kind of psychotherapy to refer a patient for, if it were necessary. Talking to the psychiatry residents though, some of them clearly wished that they had more psychotherapy training, so they could be more complete and competent clinicians.

I knew as a medical student that this approach to psychiatry was not for me. I would go elsewhere to continue my training.

Sunday, October 6, 2013

A Psychiatrist's Favorite Breaking Bad Moments

I came upon Breaking Bad very late in the game. I have only been watching for the past few weeks, and I still have 8 episodes left. But since watching Season 2, I have decided it's my favorite show since The Wire. While I'm obviously not unique in feeling that way, I wanted to share some of the things I've enjoyed most about the show, from my perspective as a psychiatrist and doctor.

What impresses me most about Breaking Bad is how it portrayed the interactions of its characters with the healthcare system. Just as The Wire showed how individuals were entangled with dysfunctional inner-city institutions, Breaking Bad showed the absurd hoops people have to jump through for good health care in America. This has been written about extensively elsewhere, but what I found most fascinating and revealing was how the characters – like most people in real life – had no recourse but to work with the system as is, since the system is too colossal for any individual to fight.

Breaking Bad, Anywhere but America Edition

Moreover, every single "medical drama" I have ever seen has made me cringe because they just felt off. The doctors and patients were overly dramatic, acting too angry, or too serious, or too witty. They always brought out the paddles when they were trying to revive someone, even if the patient was in asystole. There were too many aha moments, too many exciting procedures, too little quiet suffering. I could go on forever. Breaking Bad made few of those mistakes and got lots of little details right. In particular, I think that the way the characters reacted to being poked and prodded, the look in their eyes as they had to accept the indignity of using a bedpan or stripping down for a PET/CT, and how the doctors and patients talked to each other, all seemed true to life. After seeing the episode in which Walt and Skyler met his new oncologist Dr. Delcavoli for the first time, I had the unprecedented urge to google the name of the actor who played Dr. Delcavoli to see if he was a doctor in real life.

Other details that I loved about the show:

Walt's Family Dynamics

It was clear to me early on that Walt's father was not around when he was growing up, though the show did not reveal why until late in Season 4. I have witnessed numerous patients who grew up in abusive or neglectful homes, who vow to be better parents to their own children, but then inadvertently create a dysfunctional situation of their own. In Walt's case, his justification for starting a meth lab was so he could provide for his family after his death. He likely grew up poor, so his ideal image of a father was someone who could make sure his family did not have to scrape by. However, in embarking on his quest for money, he deprived Skyler and his son Walter Jr. of his presence, driving him apart from the rest of this family. Thinking that he only had months to live, he never seemed to consider whether his family would prefer to have $700,000 or some meaningful time with him. He tries to make it up to his son later by buying Junior a muscle car, but that's no substitute for being a good parent.

My favorite moment of the entire series came in Season 4, Episode 10, when Walt, after the stress of a huge fight with his partner Jesse, broke down crying in front of Junior, who comforted him and helped him to bed. The next morning, Walt talked about how when he was a child, he saw his own father die from Hungtingon's disease, growing weaker physically and mentally, and how he did not want his son remembering him that way. Junior forcefully told Walt that he had no need to feel ashamed, and that unlike how he had behaved for the past year, at least last night "you were real!"

Hank's Post-Traumatic Stress

After Hank's shootout with Tuco Salamaca and then nearly being killed by a Mexican cartel's IED-planted-in-a-decapitated-head-on-a-tortoise in Season 2, he was clearly suffering from post-traumatic stress. The show did not try to get fancy by showing what was going on inside his head from his point of view, but the viewer can clearly see all the external signs of fear and hyperarousal, whether triggered by intrusive recollections/flashbacks or misinterpreting popping noises at night for gunfire. Then, Hank suffered even more trauma when he survived an attempt by the Salamaca brothers to kill him in Season 3. He grew angry and terse with his wife and nearly withdrew completely from life. Even though his emotional recovery from those traumatic events seemed to happen a bit too smoothly and quickly, it felt true to me that what helped him most was having a purpose in life again when he put his energy into going after Gustavo Fring's meth operation.

Jesse's Misinterpretation of Acceptance

While Jesse was in rehab at the start of Season 3, the show did a good job of illustrating the concept of acceptance when the therapy group leader talked about accidentally killing his own daughter, and how beating himself up for it only led to more drug use. Acceptance, as I understand it, does not mean thinking that something is ok. It's an acknowledgement of fact, that something unpleasant or terrible has happened and that one is imperfect, but also acknowledging that one cannot change the past, but can only control how one acts in the present moment. However, Jesse seemed to interpret acceptance somewhat differently, because after he left rehab, he told Walt that he had learned to accept the fact that "I'm the bad guy." Later in Season 4, after killing a man, Jesse berated the same group leader at a 12-step meeting, asking if he is supposed to accept himself no matter what he does. Given Jesse's emotional turmoil and the extent of his grief and guilt, it is not surprising that this was a difficult concept for him to, well, accept.

Walt's "Fugue State"

In Season 2, Walt went missing from his family because he was stuck in his mobile meth lab out in the desert. Upon hitchhiking back to civilization, he stripped naked in a convenience store and made up a story about being in a fugue state. What I love about this scenario is that it fits my experience (admittedly based on a very small n) that most of the time, when someone is found far from home claiming to have forgotten everything, it's B.S. made up by a somewhat sociopathic person to get out of trouble of some sort. And just like in real life, first Walt was seen by his medical providers, who ordered various tests and called a neurology consult. Then, when no answers were forthcoming, they brought in the shrink. I got a good laugh when Walt told the consulting psychiatrist the truth about how he made up the fugue state after the psychiatrist explained the rules of confidentiality. This, unfortunately, is not something I've had the fortune of seeing yet in real life.

I'm impressed if you've never seen Breaking Bad but managed to read this far. What are you waiting for? In addition to being thrilling entertainment, Breaking Bad is an incisive examination of the follies of our society, with some of the finest acting and thorniest moral questions that I have seen.

Sunday, September 29, 2013

A Simple Case of Depression

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

It started off as a seemingly straight-forward case, as it often does. The patient ("Kevin") was a shy, quiet 13 year-old young man, one who had "never caused any trouble," according to his parents. Until earlier this year, he had gotten straight A's, enjoyed reading, and regularly hung out with several friends. Then, during the second semester of the previous school year, he just stopped doing his homework. He also started spending more time on the computer and less time with friends. His grades dropped to C's and D's, and two weeks into this school year, he was still not doing his homework, which is what prompted the evaluation.

Talking with Kevin, his face was a blank mask. He did not feel sad or depressed, but he no longer enjoyed reading or felt motivated to do homework like he used to. He spent all his time on Facebook or playing computer games. He stayed up late and woke up early, felt tired all the time and had trouble concentrating at school. He occasionally had thoughts of not wanting to live, though he has never seriously contemplated suicide or harmed himself. He was also eating less than usual, and often had negative thoughts about himself, that he was a failure.

He clearly met the criteria for a major depressive episode, and if I were using a purely biomedical approach to psychiatry, I might have been satisfied with starting him on a serotonin reuptake inhibitor and hoping that he will be feeling better in about a month. However, his seemingly out-of-the-blue changes in mood and behavior struck me as odd. I was also struck by the fact that he was only now being evaluated, even though his grades started dropping over 6 months ago.

During the initial visits, Kevin's parents had insisted that there was no family history of any mental illness or substance abuse. They had a close relationship with their son, and they frequently went to the movies or baseball games as a family. However, the more I talked to Kevin, the more I learned about the nuances of his family. His parents were widely inconsistent in how they approached his struggles. His mother yelled at him when he got bad grades and told him he could not use the computer, while his father was more lenient, did not set limits, and even bought him an iPad after his grades started slipping. When one parent's approach did not seem to work, the other parent took over for a while, until that approach failed as well.

I spent a good deal of time talking with Kevin's parents about the importance of them both agreeing on their parenting approach, so they can set reasonable limits around electronics use and enforce bedtimes that allow Kevin to get adequate sleep. After a couple of weeks, Kevin's sleep improved, and he felt less tired during the day, but he still was not doing his homework. I continued to talk with Kevin about his family life, having him walk me through what happened in the evenings. The picture that emerged was not that of a close-knit family. Over the last few years, the family had stopped eating together at the dinner table since Kevin's father had been getting home later from work. After work, both parents tended to unwind by drinking. Their jobs have gotten more stressful in the past year, and Kevin told me that they have been drinking more as a result, at least 3 to 4 drinks per parent per night. He was essentially left to his own devices while his parents enjoyed their beverages.

I have no way of proving this, but I thought it was a strong possibility that Kevin's refusal to do homework was an attempt to get his parents to notice him and reengage with him. When I brought up the issue of alcohol with Kevin's parents, they both seemed surprised that he was aware of their drinking habits. They told me that they were doing most of their drinking when Kevin was already asleep, which really made me wonder just how much they were drinking. I did not tell them outright to stop drinking, but I asked them to think about if and how their drinking may be impacting Kevin.

After that, I never heard from them again. Perhaps I came across as judgmental, or perhaps I tried to push for too much change before I had established enough rapport with the family. But it was clear to me that Kevin's "depression" could not really improve without some serious behavior change from his parents. Sometimes I think about the appeal of simply focusing on the identified patient and what brain chemicals may be awry. But then I remind myself that complexity is what drew me to psychiatry in the first place. With a more comprehensive approach, at least I sometimes feel that I get a peek behind the curtain at what's really happening, even if I am often unable to do more to influence the outcome.

Sunday, September 22, 2013

Louis C.K., Mindfulness Guru?

Note: The last couple of months have been very busy for me, so I apologize for the infrequency of posts. Now that things have gotten back to normal, I hope to resume posting weekly.

Louis C.K.'s recent appearance on Conan has already been linked to on multiple sites, with most of the headlines reading something like "Louis C.K. on why kids shouldn't have smartphones." Check out the video below if you haven't yet see it:

C.K. is one of my favorite comedians, and this clip shows why. Like many comedians, he often says things that people are thinking but are too afraid to say themselves. Here, he puts a voice to many things that I as a child psychiatrist would love to say to parents, but have a hard time finding a diplomatic way to do so.

To me, what he said is not about "hating cellphones" or "kids shouldn't have cell phones." His riff is much broader than that. He starts out talking about parenting, and how parents give in to their kids and get them phones because "all the other kids have the terrible things." Of course, this happened long before cell phones became common, and gets to the heart of how much trouble parents have in setting appropriate limits because they are afraid of momentarily making their child sad or mad. However, if a parent doesn't teach his or her child how to handle being being disappointed or told "no," then who is? Why not "let your kid go and be a better example to the other [bleeping] kids," as Louis C.K. says?

He then talks about how face-to-face interactions can help build empathy, but when a child engages in cyber-bullying, he or she does not get the feedback of seeing the other child's expression turn to sadness, and instead "when they write 'you're fat', then they just go mmm..that was fun, I like that."

Next, C.K. gets to the heart of what mindfulness is about to me. "You need to build an ability to just be yourself and not be doing something. That’s what the phones are taking away. The ability to just sit there, like this. That’s being a person." I would add that of course, the ability to just sit and tolerate being yourself was already difficult before smartphones became ubiquitous, with a 2006 Kaiser Family Foundation report showing that American youth spent almost 4 hours a day watching TV/videos, over 1.5 hours listening to music, about 1 hour on a computer, and almost another hour playing video games, with many of these activities happening simultaneously. Let's not forget all the other mindless ways of distraction other than smartphones.

C.K. even ventured into existentialism, how "underneath everything in your life, there's that thing, that forever empty…that knowledge that it's all for nothing, and that you're alone." He dares to utter the truth, long known to Buddhists, that "life is tremendously sad, just by being in it." He adds, "That's why we text and drive, pretty much 100% of people who are driving are texting…people are willing to risk taking a life and ruining their own cause they don't want to be alone for a second."

Lastly, Louis shared a story about how he was driving one day, and a Bruce Springsteen song came on that made him feel really sad. Instead of avoiding his sad feelings by texting people, "I pulled over, and I just cried…so much, and it was beautiful…sadness is poetic, you're lucky to live sad moments…I was grateful to feel sad, and then I met it with true, profound happiness." His overall message is one that I try to tell patients all the time. They often tell me that they don't let themselves feel sadness or grief, because they're afraid of feeling overwhelmed. However, attempts to suppress those sad feelings just get in the way of a person truly being content with life. As C.K. said, "Because we don't want the first bit of sad, we push it away...and you never feel completely sad or completely happy, you just feel kinda satisfied with your products, and then you die."

Despite the jokiness of the delivery, Louis C.K.'s message is quite serious and well thought-out. I hope everyone listens.

Wednesday, August 7, 2013

What Jean Twenge Gets Wrong About Narcissism

Earlier this week, a New York Times article, Seeing Narcissists Everywhere, featured psychologist Jean Twenge, who has documented the rise of narcissism in Millenials in academic papers and two books. She has also made numerous appearances on TV programs such as Good Morning America and Today touting her view that the promotion of self-esteem over the past few decades has led to the current generation's sense of entitlement. She bases much of her views on standardized questionnaires given to college students, especially the Narcissistic Personality Inventory (NPI).

Unfortunately, the article featured only the most superficial criticism of Dr. Twenge's work, including other researchers who "calculated self-esteem scores" over time and did not find a change, or who disagree that the NPI actually measures narcissism, or who analyzed other sets of NPI data and did not see a significant change over time. I would like to offer some more in-depth critiques. To be clear, I absolutely agree that narcissism is prevalent in our society and that it leads to a host of ills.

Endemic, not epidemic

First, I find the title of one of Twenge's books, The Narcissism Epidemic, to be deeply misleading and alarmist. According to the MedlinePlus Medical Dictionary, "epidemic" is defined:
affecting or tending to affect an atypically large number of individuals within a population, community, or region at the same time
What's "atypically large" about the prevalence of narcissism, given our status and wealth-obsessed culture? I think it would be more accurate to call narcissism "endemic" rather than "epidemic." We all have narcissistic tendencies, and to characterize it as an epidemic externalizes and puts the focus on others. It's as misguided as those "how to spot a narcissist" articles. The title also implies that Twenge has somehow discovered something new, which is certainly not the case. In 1979, Christopher Lasch published The Culture of Narcissism: American Life in an Age of Diminishing Expectations, a deeper critique of our culture that obviously predates the "self-esteem movement" of the 1980's.

More than meets the eye

Narcissism presents in more than just one way. There is the stereotypical view of a self-absorbed, overconfident, extroverted, somewhat callous individual, and this is likely the construct that the NPI measures. However, there's also covert narcissism, which is well-recognized in the literature, but which Twenge does not seem to appreciate. For example, suppose there are people who think I'm more altruistic than anyone else or no one else can appreciate the uniqueness of my suffering, or who base their sense of self-worth entirely on what other people think while outwardly appearing anxious or depressed. I would argue that these people also have narcissistic issues, even though their form of narcissism is not well-measured by the NPI or formally a part of the DSM definition of narcissistic personality disorder (NPD). Originally, the DSM-5 draft had proposed changes to NPD that encompassed the covert form as well, but ultimately (and unfortunately) those changes did not make the cut.

Beyond the explicit message

Twenge seems to think that there's a direct path from parents telling their children how special they are to the children becoming narcissistic and entitled adults. That may be true, but people are a bit more complicated than that. I won't talk about any particular person, since it's unethical for me to diagnose someone I'm not treating. But let's say there's a politician who has done little over his career other than appearing on TV and provoking the opposition. And suppose this politician admits in a major interview that when growing up, his parents were distant and far from the self-esteem boosting types. And then suppose that this man's sexually-charged text messages are released to the public and reveal a deep fount of insecurity rather than confidence.

Thus, the implicit message that children and adolescents receive from parents and from society is just as influential or more so than the explicit message. Take for example this passage from the NYT article:
 "I got a onesie as a gift that I gave away on principle," said Dr. Twenge, 41, a professor of psychology at San Diego State University and a mother of three girls under 7, in an interview at a diner on the West Side of Manhattan.

"It said, 'One of a Kind,' " she said, poking at a fruit salad. "That actually isn’t so bad, because it’s true of any baby. But it’s just not something I want to emphasize."
So she's not telling her children they are "unique" or "special." That's all well and good, but what if she's reinforcing society's message that to be successful, one has to publish best-selling books or appear on the Today show? How she handles these issues with her children is far more important than what's on the onesies that they wear. If she truly is not aware of this, then perhaps the article would be better titled: "Seeing Narcissists Everywhere, Except the One in the Mirror."

Tuesday, July 30, 2013

Is Psychiatry Residency Training Backwards?

For decades, the process of turning a medical school graduate into a psychiatrist has remained essentially the same: A post-graduate year 1 (PGY 1) internship that includes rotations in medicine and neurology in addition to psychiatry, followed by 3 additional years of residency training focused on psychiatry. Even though psychiatry residency programs are famously diverse, they almost always follow the pattern of mostly inpatient psychiatry for PGY 1-2 and mostly outpatient psychiatry for PGY 3-4. Child psychiatry exposure typically occurs for only a few months during PGY 2 or 3.

Earlier this year, 1Boring Old Man had an excellent series of posts that included a look back at his experience as a residency training program director in the 1970's, when he pulled his residents from a large state hospital because the experience was no longer educational. Yet most psychiatry programs across the country still have their psychiatry residents staffing inpatient units during their first two years of training, even as the length of stay at acute inpatient psychiatry units continues to decline. What does this do? I think it puts an emphasis on "medication-first" thinking, because changing some meds around (usually by adding more rather than taking any away) is really all one can do for a patient who is just going to be in the hospital for a few days.

Additionally, I believe that being exposed to the most severe mental illnesses during PGY 1-2 primes young clinicians to over-pathologize when they end up interacting with less ill patient interactions later on. Ordinary sadness or grieving may be called depression. "Hearing voices" (which is how many people describe their intrusive thoughts or internal monologues) starts to sound like schizophrenia. Mood swings or anger outbursts often get diagnosed as bipolar disorder. Of course, there are certainly other forces driving the pathologizing of normal behavior, but I do think the way training is structured facilitates this type of thinking.

Lastly, the focus on treating adult individual psychopathology deprives trainees of developing a crucial developmental and social perspective. Family therapy is something that is usually taught briefly, if at all, during the PGY 3 or 4 years. During my years of general psychiatry residency, I had the vague sense that a patient's interactions with family or her experiences growing up may have influenced her symptoms over the course of her life, but the attitude of my attendings seemed to be: since those things can't really be changed, why focus on them? It wasn't until my two years of child psychiatry training that I finally started to understand the roles that early childhood adversity and interactions amongst family members play in an individual's patterns of behavior.

I think that psychiatry residency programs would be improved immensely by earlier clinical exposure to assessing children (both "normally-developing" and ones with behavioral problems) and their families, as a counterpoint to the biomedical neurotransmitter-based framework that residents are most familiar with. This not an original idea. Other psychiatrists have suggested the same thing, including Dr. Carl Feinstein, head of child and adolescent psychiatry at Stanford (which is somewhat ironic given Stanford psychiatry's overall biological orientation). Daniel Carlat's book Unhinged proposes some more fundamental changes in the process of training psychiatrists.

Sadly, as psychiatry becomes increasingly driven by managed care, it looks like residency training will continue to languish as psychiatry departments come under pressure to increase patient volumes so they can operate in the black.

Friday, July 12, 2013

Movie Review: The Bling Ring

Sofia Coppola's The Bling Ring is one of my favorite movies of the year. Set in 2009 and "based on actual events," it tells the tale of a group of SoCal teens obsessed with celebrities and their bling, who end up stealing millions from the homes of Paris Hilton, Lindsay Lohan, Audrina Patridge, Orlando Bloom, etc. The ringleader Rebecca (played by Katie Chang) is fearless and quite possibly a psychopath. The closest thing to a protagonist in movie is Marc (Israel Broussard), a social outcast whose fortunes rise after he meets Rebecca at his new school. Also part of the group are best friends Nicki (Emma Watson) and Sam (Taissa Farmiga), and Rebecca's friend Chloe (Claire Julien).

Although the acting is fantastic, many professional film critics were lukewarm about the movie as a whole, as exemplified by the concluding paragraph of A. O. Scott's New York Times review:
“The Bling Ring” occupies a vertiginous middle ground between banality and transcendence, and its refusal to commit to one or the other is both a mark of integrity and a source of frustration. The audience is neither inside the experience of the characters nor at a safe distance from them. We don’t know how (or if) they think, and we don’t know quite what to think of them. Are they empty, depraved or opaque? Which would be worse?
Ignatiy Vishnevetsky has a similar conclusion in his review at rogerebert.com:
[...] Coppola neither makes a case for her characters nor places them inside of some kind of moral or critical framework; they simply pass through the frame, listing off name brands and staring at their phones. About an hour into the film, one starts to get the nagging feeling that Coppola's "neutrality" is a dodge; she avoids moral commitment, thereby creating a movie ambiguous enough to be interpreted in several ways, but too vague to have much meaning in any interpretation.
I disagree completely. I don't believe the movie is neutral or uncomitted at all; it is a satire aimed at not just the adolescents who browse TMZ, but also at their parents and society as well. Certainly, how I interpret the movie is a reflection of my own experiences working with families in which parents are at a loss as to how to rein in their teen's behavior. When I suggest setting some sensible limits, like no electronics after 10pm, I sometimes hear parents say things like: "That wouldn't work. He's like water, he always finds a way around things." Well, that's completely normal! The job of a teenager is to test the limits, to see what they can get away with. What's not normal is parents who cannot set limits or teach the teenager about acceptable behavior. The more the teen is like water, the more the parent needs to be like a vessel that can provide structure for the water.

In The Bling Ring, we see what happens when there is no such water container. For most of the main characters, we only get brief glimpses of their interactions with their parents, which I think was intentional, to reflect the fact that their parents are just not very involved. Katie's parents are divorced and her father lives in another state. Marc's father is often away on business. Chloe's parents are around but barely involved: there is a great shot of Chloe and her parents at breakfast, each separated from the others by the maximal distance that would allow them to still be in the same room. Sam was abandoned by her parents and adopted by Laurie, Nicki's mother. Laurie is the parent who gets the most screen time. Though she means well, she is portrayed as clueless and ineffective, a dispenser of Adderall who tries to teach her children lessons about character using a collage of Angelina Jolie photos. Instead of chastising her daughter after the teens are arrested, she tries to steal the limelight when a reporter interviews Nicki at their home.

In his review, Vishnevetsky's found the movie's use of celebrity cameos problematic:
[...] Paris Hilton and Kirsten Dunst have non-speaking cameos as themselves; more importantly, Hilton's real house is used throughout the film. The characters gawk at Hilton's real possessions and rifle through her real closets.

This points to the movie's most serious problem: the "impartial" viewpoint. Is "The Bling Ring" a movie about characters ogling at celebrities, or is it an excuse for the audience to ogle along with them? [...]
I really believe that Coppola was being subversive in her use of Paris Hilton's mansion. Sure, filming in Paris Hilton's home causes the audience to ogle, but my impression is that Coppola's goal was to show how ridiculous the place was, with its overstuffed glitz and wall-to-wall monuments to Paris herself. She returned to that location repeatedly, I believe, as a way of evoking disgust in the audience. After forming this opinion, I came across an interview that Coppola gave in which she was asked about the experience of filming at Paris Hilton's house (starting at 3:25). Here's what she had to say: "When we first got to see Paris Hilton's real house, it was like nothing I've ever seen before, and I had heard that she had a nightclub room, but then to really see it, and just all her pictures, and the pillows, with her pictures and stuff, it was very, um...exotic [shrugs]. I really appreciate how she let us into her, you know, real private world [smiles]." All that was missing was a wink.

The Bling Ring may not be a Great Movie, but it is certainly an important and alarming one. It's unfortunate that so many missed its subtly, and only 47% of film-goers on Rotten Tomatoes liked it. However, I do wonder about the reasons for audience members not liking the movie. Did it make them feel uncomfortable with themselves? If so, then perhaps Sofia Coppola has achieved her desired effect.

Thursday, July 4, 2013

ADHD, Laziness, or Neither?

Child and adolescent psychiatry, like much of life in general, has its seasonal variations. Around September, I tend to get a cluster of new patients (usually kindergartners and first graders) whose parents or teachers are concerned that they cannot seem to sit still or keep on task during school. The winter months bring in more people with depression and anxiety as the stress of work/school, decreased hours of sunlight, and more time spent indoors take their toll.

In the past month, as the school year ended, I've seen multiple new patient evaluations for another reason: high schoolers or college students who have made it through the academic year, but just barely. Most of them have gotten good grades in the past, but have had gradually declining academic performance over the past few years. Now their parents—and it's almost always the parents who make them come in—want to know if they have ADHD, or if it's "just laziness."

I'm fairly confident whether I can diagnose ADHD, but I'm not even sure how to answer the second part of that question. How does one determine whether someone is lazy? Is being lazy equivalent to "procrastinating" or "avoiding hard work?" It definitely feels more pejorative, like a character flaw that will never go away. Fortunately, I've been able to avoid the issue somewhat, since it seems there is always something else going on besides laziness.

In general, I do not readily diagnose older adolescents with ADHD if they had been able to focus on schoolwork previously. ADHD generally manifests long before high school, though it's still possible that an older teen may have previously undiagnosed ADHD. Often, these teens have a fairly high IQ and never had to study much prior to high school, but they eventually get overwhelmed by academic demands. However, multiple other causes of poor school performance are much more likely. Below are some of the ones that I've come across lately.

Depression: An obvious contributor to lower grades, but it surprises me how often parents (and even the patients themselves) miss this. Perhaps it's because they have difficulty telling depression apart from the normal moodiness of adolescence, or perhaps depression often manifests in adolescence as anger, irritability, and mood swings. However, a teen doesn't have to be clinically depressed to be unhappy, and I believe that unhappiness can also lead to academic decline. One example I saw recently is a patient who moved across the country right before 11th grade, and her grades went from A's to C's. Not having any friends at her new school and being somewhat shy, she spent most of her evening time trying to stay connected with old friends via texts and social media. Studying made her feel less happy, so she did much less of it.

Anxiety: I often see teens who are perfectionists, afraid of making a mistake, and stay up late at night unable to sleep because they can't stop worrying about an upcoming test or assignment. The anxiety can also contribute to procrastination, because thinking about the work brings up unpleasant feelings that dissipate when the teen does something else, like checking Facebook. Of course, actually starting the assignment can decrease the anxiety as focus shifts and a sense of self-efficacy builds, but Facebook is often easier and more fun.

Sleep: Teens often go to bed late and have to wake up early. However, in recent years this has been greatly exacerbated with the proliferation of bright back-lit devices that teens have access to their bedrooms, combined with a dearth of parental monitoring/control. It's amazing to me how much coffee or energy drinks teens are consuming these days to avoid falling asleep at school.

Substance use: Yes, drinking and smoking weed (and/or hanging out with those who often do) can make it harder to focus on doing schoolwork.

Family conflict: Family dynamics are complex, but needless to say, many different types of stress within the family can contribute to a teen not doing well in school. For example, I saw one teenager whose drop in grades seemed to have no rational explanation, until I found out that his parents were alcoholics who had recently both taken up drinking again, leading to a big decrease in the time the family spent together doing other things. Even though this patient insisted that his parents' drinking did not bother him, it seems that when he started to fail in school, his parents ended up engaging with him more, even though they continued to drink. In another case, I had a patient whose parents divorced and her mother almost immediately found a boyfriend, who moved in a few months later. The patient denied feeling upset by this, but her grades tanked when she "just couldn't motivate myself to do homework" after school. This caused considerable distress for her mother, who valued academic success.

Habitual avoidance: This is certainly not a DSM diagnosis, but I do believe avoiding work in favor of fun can become a habit that is difficult to change. I'm not calling it laziness, which implies a flawed character. Rather, I think this has a lot to do with the interaction of culture, parenting style, and a child's temperament. Most of us would rather not do hard or tedious work if we didn't have to. Society tells adolescents that they should have fun and enjoy themselves while they're still young, while parents often tell their children to work hard for some benefit that will accrue years down the road. Unfortunately, some parents want to avoid conflict themselves, so they may not impose the necessary consequences or structure to back their words. Furthermore, adolescents can avoid the tedium of work by multitasking like mad: simultaneously listening to music, texting friends, checking social media, all while trying to study with the TV on in the background. Thus, many teens never develop good study skills (to say nothing of the capacity for deep, focused thought); it's amazing to me that more aren't failing school.

More often than not, the reason for an adolescent's falling grades is a combination of the above factors. I used to be a big believer in laziness, in the sense that I was quite sure it existed as a trait. However, after being asked to evaluate for laziness many times and finding more plausible explanations, now I'm not so sure.

Monday, June 24, 2013

What to Do if Your Kids Are Obsessed with Technology

I clicked on author Steve Almond's piece in yesterday's New York Times Magazine fully expecting to roll my eyes at yet another alarmist screed about how electronic devices are destroying childhood. However, after reading (and re-reading) it, I came away mostly impressed. I think he made many salient points about the challenges of parenting in the touch-screen era, which I would like to explore some more.

Look in the Mirror

One of the most important influences on how children interact with technology is the example set by their parents. Many parents take the approach of "do as I say, not as I do," which almost never works. Here, Almond does a good job of self-examination:
[...] But even without a TV or smartphones, our household can feel dominated by computers, especially because I and my wife (also a writer) work at home. We stare into our screens for hours at a stretch, working and just as often distracting ourselves from work.

Our children not only pick up on this fraught dynamic; they re-enact it.
He also recognizes when he is using technology as an easy pacifier:
After all, we park the kiddos in front of SpongeBob because it’s convenient for us, not good for them. (“Quiet time,” we call it. Let’s please not dwell on how sad and perverse this phrase is.) We make this bargain every day, even though our kids are often restless and irritable afterward.
That he views this strategy as one of his "failings as a parent" is a bit harsh. Almost all parents do this at least some of the time. Unfortunately, what he does not discuss in detail is just what his relationship is like with his children. That is the critical piece. If he is having meaningful conversations or one-on-one play time with his children, or if he is helping to get them involved in a variety of activities, then he is probably not failing as a parent.

Set Limits, Maintain Balance

The American Academy of Pediatrics recommends the following: "Children and teens should engage with entertainment media for no more than one or two hours per day, and that should be high-quality content. It is important for kids to spend time on outdoor play, reading, hobbies, and using their imaginations in free play." The AAP also recommends that children under age 2 not be exposed at all to television and other entertainment media. It's best to start implementing rules around technology use early on; waiting until a child becomes a teenager is way too late. Almond tries to set some appropriate limits for his children:
[...] We ostensibly limit Josie (age 6) and Judah (age 4) to 45 minutes of screen time per day. But they find ways to get more: hunkering down with the videos Josie takes on her camera, sweet-talking the grandparents and so on. The temptations have only multiplied as they move out into a world saturated by technology.

Consider an incident that has come to be known in my household as the Leapster Imbroglio. For those unfamiliar with the Leapster, it is a “learning game system” aimed at 4-to-9-year-olds. Josie has wanted one for more than a year. “My two best friends have a Leapster and I don’t,” she sobbed to her mother recently. “I feel like a loser!”
He is certainly right about just how much various devices have become a seemingly vital part of children's lives; it is unrealistic to think that any child can be immune from their allure. In my mind, an important task for parents is to help their children learn how to use technology without being consumed by it. Setting appropriate limits and having a plethora of other activities for the child to engage in helps this learning process. It sounds from this anecdote that despite his daughter's heart-wrenching words, she did not end up getting a Leapster. Perhaps she was able to learn a small lesson here, that her life will go on even if she does not have the same shiny thing as everyone else.

Be Aware of Family-of-Origin Issues

When it comes to parents' attitudes about raising their children, it's always interesting to see how some parents recreate a similar dynamic with their children as the one they had with their own parents. Others go to the opposite extreme: if their own parents were too harsh, then they might be too permissive with their own children. Thus, one of the most interesting paragraphs hints at the author's own relationship with his parents:
My brothers and I were so devoted to television as kids that we created an entire lexicon around it. The brother who turned on the TV, and thus controlled the channel being watched, was said to “emanate.” I didn’t even know what “emanate” meant. It just sounded like the right verb.

This was back in the ’70s. We were latchkey kids living on the brink of a brave new world. In a few short years, we’d hurtled from the miraculous calculator (turn it over to spell out “boobs”!) to arcades filled with strobing amusements. I was one of those guys who spent every spare quarter mastering Asteroids and Defender, who found in video games a reliable short-term cure for the loneliness and competitive anxiety that plagued me. [...]
Later, when Almond talks about seeing his children drawn to electronic games and cartoons, he wrote: "I’m really seeing myself as a kid — anxious, needy for love but willing to settle for electronic distraction to soothe my nerves or hold tedium at bay." I can't help but wonder how the approach his parents took to child-rearing might have influenced his anxiety and loneliness. I did find it curious that he wrote his daughter's "job is to make the same sometimes-impulsive decisions I made as a kid (and teenager and young adult). And my job is to let her learn her own lessons rather than imposing mine on her." However, his actions seem to indicate otherwise: he is much more active than his own parents were in setting appropriate limits around his children's technology use. There is nothing wrong with parents imparting lessons learned in their 20's to their own children, if those lessons are about not letting technology rule one's life.

Understanding the Purpose of Technology

Of course, not all uses of technology are equal. A child could be using an iPad to learn how to read, draw, or even program. Alternatively, a child could be playing mindless games nonstop. The distinction is crucial, so parents need to know how their children are spending their time on these devices. While Almond acknowledges that iPads may be good educational tools when used effectively by good educators, he raises the following concerns:
The reason people turn to screens hasn’t changed much over the years. They remain mirrors that reflect a species in retreat from the burdens of modern consciousness, from boredom and isolation and helplessness.

It’s natural for children to seek out a powerful tool to banish these feelings. But the only reliable antidote to such burdens, based on my own experience, is not immersion in brighter and mightier screens but the capacity to slow our minds and pay sustained attention to the world around us. This is how all of us — whether artists or scientists or kindergartners — find beauty and meaning in the unceasing rush of experience.
If a person mainly uses a screen device to banish unpleasant feelings, then that is indeed very unfortunate. I do agree with Almond's emphasis on the importance of children learning about the real physical world that surrounds them. I would add that it's important that they learn about their own inner world of thoughts and feelings as well, so that when they inevitably experience anxiety or sadness or boredom, they do not automatically seek to banish it with a screen of some sort.

I once tweeted:

If I could have a do-over, instead of "do nothing" I would say: "I wonder if all these children raised on touch-screens can keep themselves occupied without one?" Almond ends the essay by writing about how his daughter is able to sit for five minutes while waiting for a cardinal to visit their family's compost bin and his hope that she does not forget the wonders of the real world. I think there's reason to be optimistic, despite the very pessimistic title of the article: "My Kids Are Obsessed With Technology, and It’s All My Fault." I'd like to say to Mr. Almond, it's not your fault. Most kids are obsessed with technology. If they were obsessed and you allowed them to spend all their time in front of a screen, then it's your fault.

Tuesday, June 18, 2013

The Treatment of Early Age Mania Study Revisited

The Treatment of Early Age Mania (TEAM) study is not news, and more diligent and timely bloggers have already written about it. However, it is one of the more infuriating outcomes of the whole pediatric bipolar disorder phenomenon; in the last few years, few publications have irked me as much as the ones from this study. Thus, I'd like to chime in as well. 1 Boring Old Man had a lengthy blog post (the sound and the fury...) summarizing the main findings [I added the links]:
The first report shows that these children respond better to Risperdal® than either Lithium or Depakote®. That’s no surprise. They don’t respond to the traditional anti-manic treatments [that suggests to me that they don't have mania]. They do respond to Risperdal®. That’s something we knew before we ever heard of Risperdal® – you can control disruptive behavior with antipsychotic medications. It also showed that the metabolic side effects of Risperdal® were already apparent at only 8 weeks. Notice that there’s no placebo group in this study so we can’t really say that the Lithium or Depakote® responses were clinically significant.

The second report set out to define moderators of response. What it ended up showing was the extremely high overlap between ADHD and the presumed Bipolar Mania and the more ADHD, the greater the likelihood of a response. But there was another moderator of response – site. What in the hell does that mean? To me it suggests that there is bias in making this diagnosis or in measuring the response. I think that says something about the study and the diagnosis, not the afflicted. So in my reading, one thing it doesn’t mean is that Bipolar Disorder has some intrinsic regional difference.
1BOM used the study to illustrate how a fad diagnosis could become mainstream, to the detriment of children and their families, while benefitting pharmaceutical companies and the researchers (such as MGH's Joseph Biederman) they support. It's worth noting, though, that the TEAM study did not include the MGH group and was funded by the NIMH, not by pharma. The first author of the initial publication is Dr. Barbara Geller, and I've written about how her conception of childhood bipolar is different from Wozniak/Biederman's chronically irritable patients, with Dr. Geller trying taking into account more classical manic symptoms such as grandiosity. Thus, I've often wondered "what the hell happened?" when pondering this study.

Fortunately, Dr. Stuart Kaplan, child psychiatrist and author of Your Child Does Not Have Bipolar Disorder, has an excellent series of posts on his Psychology Today blog with additional insights into the TEAM study. In Dr. Kaplan's first post (The World Series of Child Bipolar Disorder), he describes a session from the 2011 AACAP meeting in which TEAM researchers talked about their study:
During the discussion, another nationally known presenter gave a wildly incorrect interpretation of defiance. The presenter claimed that defiant children are psychotic because they have a delusional belief that they can take on the far stronger adult world. Defiant children are not psychotic based on their defiance alone. They are mistaken in their belief that they can overpower the adult world, but this is a mistaken belief not a delusion. If the investigators believe that defiant children are delusional, this may explain how they found the high rates of psychosis in the children they studied (77%).
If defiance in children counts as psychosis, then my partner and I are both psychotic every time we argue, because we each have a false belief that we can convince the other with our arguments. Maybe some of the TEAM investigators would consider this folie à deux?

Dr. Kaplan's second post (Credulity Stretched) highlights the reasons why the children included in the study probably did not have bipolar 1 disorder, given the >90% comorbidity with ADHD, the 99.3% of patients with "daily rapid cycling" moods, and the fact that the average "manic" episode in the study lasted 4.9 years, which is about half the life of the average study participant (mean age 10.1 years). His third post in the series (Location, Location, Location) replicates the table from the second publication showing just how wildly variable the treatment response was at the various sites: "This was not a minor statistical artifact, but was the central finding of the study."

Besides highlighting the incredible (as in, not credible) aspects of the study that Dr. Kaplan already wrote about, I wanted to provide one additional anecdote: Several years ago, one of the renowned lead investigators of the TEAM study gave a talk at another institution. This mood disorder expert claimed that a 3-year-old who masturbates may be exhibiting the hyper-sexuality seen in mania. When audience members pointed out that a 3-year-old masturbating is actually normal behavior, the investigator appeared flabbergasted. Which makes me wonder if they thought 6-year-olds who were repeatedly touching themselves in defiance of parents telling them to stop were having manic episodes with psychosis.

One of the biggest problems in the field today is how biologically-oriented psychiatrists look at behavior in a vacuum without considering developmental, social, or familial factors. This study is one of the most egregious examples, not just of that problem, but also of how researchers at prestigious institutions, backed by NIMH funding, can get even the most ridiculous studies published. If I see a 16-year-old who is truly manic, I'm still going to seriously consider lithium over risperidone, "evidence-base" be damned.