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.