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?