Success, but at What Cost?

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

The patient, who was in his late 20's, was clearly very driven. He was a straight-A student from K-12, graduated from an Ivy League school with a 3.9 GPA, and proudly tells me that he works at a startup. He wakes up early every morning for his hour-long commute and works 12-hour days. Admirably, he makes sure to exercise for an hour each night after he gets home. Then, after he eats dinner, he even tries to spend a couple of hours with his girlfriend. When he finally gets to bed, he sleeps from about midnight to 5:30am. Ever since starting college, he has not gotten more than 6 hours of sleep a night.

He tells me he's been feeling more tired and less focused over the past year, a period coinciding with him gaining greater responsibilities at work. This lack of focus is not constant, and he tends to have the hardest time concentrating around 2-3pm, when he would often feel tired and sleepy. Not surprisingly, he wonders if he has ADHD and if a stimulant medication can help.

I tell him: "I can't really diagnose you with ADHD because there is no evidence of impairment when you were younger. Plus, most people really do need close to 8 hours of sleep, and almost everyone who gets less than 6 will eventually have trouble staying alert and focused during the day. I recommend that you try to sleep between 7 and 8 hours a night for a few months and see if things improve." He was both dismayed and somewhat defiant: "Look, I'm really busy, and I'm not about to compromise any aspects of my life. There's no way I'm going to work less or give up my workouts or not spend time with my girlfriend."

This was the patient that came to my mind when I was reading the New York Times article over the weekend about adult prescription stimulant abuse:

Elizabeth, a Long Island native in her late 20s, said that to not take Adderall while competitors did would be like playing tennis with a wood racket.

"It is necessary — necessary for survival of the best and the smartest and highest-achieving people," Elizabeth said. She spoke on the condition that she be identified only by her middle name. […]

Elizabeth’s sleep tracker was confused. Her nightly rests were so brief, the iPhone software thought they were just naps. It recorded her average sleep over nine months: from 4:17 a.m. until 7:42.

After founding her own health technology company, Elizabeth soon decided that working hard was not enough; she had to work harder, longer. Sleep went from an indulgence to an obstacle.

So she went to a psychiatrist and complained that she could not concentrate on work. She received a diagnosis of A.D.H.D. and a prescription for Adderall in about 10 minutes, she said.

"Friends of mine in finance, on Wall Street, were traders and had to start at 5 in the morning on top of their games — most of them were taking Adderall," Elizabeth said. "You can’t be the one who is the sluggish one."

I'm saddened that we live in a world where the founder of a health technology company doesn't seem to care about how sleeping 3.5 hours a night affects her own health. It seems very Kafkaesque and short-sighted to me. How did things get this way, to the point where "success" is defined by individual achievement and productivity above all else?

I found David Brooks's column from last week to be quite pertinent. He traced the changes in American society stemming from the late 1940s, when the generation who had suffered through the Great Depression and World War II let loose and embraced consumerism, transforming the culture from one of self-effacement and sacrifice to one of self-expression and indulgence:

But I would say that we have overshot the mark. We now live in a world in which commencement speakers tell students to trust themselves, listen to themselves, follow their passions, to glorify the Golden Figure inside. We now live in a culture of the Big Me, a culture of meritocracy where we promote ourselves and a social media culture where we broadcast highlight reels of our lives. What’s lost is the more balanced view, that we are splendidly endowed but also broken. And without that view, the whole logic of character-building falls apart. You build your career by building on your strengths, but you improve your character by trying to address your weaknesses.

Instead of "broken," I would've chosen "incomplete," but otherwise I agree with Brooks's main points. And speaking of a glorified Golden Figure, I thought I was reading a late April's Fool joke when CNN/Money ran an article last week titled: "Mark Zuckerberg only works 50 to 60 hours a week." Unfortunately, it was not a joke, and of course the author qualified Zuck's work hours with: "But he conceded that if the definition of 'work' were expanded, he'd be working his 'whole life.'" Is this the sort of role model that we want for our kids? Do we want a society where people are admired for driving themselves to extremes, and a lucky few will become fabulously wealthy, while many more get stressed out and sleep-deprived, and a certain regrettable percentage end up with depression, anxiety, or suicide?

Disruptive Mood Dysregulation Disorder Revisited

In the brief history of this blog, the post where I shared my thoughts on DSM-5's disruptive mood dysregulation disorder (DMDD) has gotten by far the most pageviews. It's been almost two years since I wrote that post, and I would like to revisit DMDD with some updated thoughts on this diagnosis.

As you may recall, DMDD sprang out of a desire to have a diagnosis other than "bipolar disorder" to describe children who are chronically irritable and have explosive tantrums. Almost all of the children with DMDD also meet the criteria for oppositional defiant disorder (ODD) and are at higher risk of developing depression but not mania. The NIMH researcher Ellen Leibenluft, whose work on severe mood dysregulation (SMD) strongly influenced DMDD's creation, had commented in the past that she was not 100% sure that DMDD was a good idea.

In the last few years, I have only seen a handful of children who met the criteria for DMDD. Here is what I noticed in my own practice:

• One boy was being raised by a single mother who worked full time, so his grandparents were very involved in childrearing. The mother tried to set rules, but the grandparents were much more permissive, and whenever the mother tired to enforce her rules, explosive tantrums resulted.
• Another boy was very violent toward his mother on an almost daily basis. His father was home but did not intervene, while the mother had anxiety and literally appeared fearful of her son during their visits with me. When he hit her, she would tell him verbally that it was wrong, but did not do anything else (like using a time-out) to try to change his behaviors.
• There was a girl (who I'd written about previously) whose mother was very emotionally distant and pulled away further every time the girl acted out because the mother was reminded of her own emotionally intense mother. This distancing seemed to lead to the daughter becoming even more irritable.
• And then there was a boy who was extremely aggressive at home, constantly fighting with his 3 siblings. The household was very chaotic, with parents still married but frequently arguing with each other. Both parents often resorted to spankings, which did not seem to decrease the boy's aggression or irritability.

Certainly, correlation between the parental characteristics and the children's behaviors does not tell us about causation. It is very stressful raising irritable, explosive children, and the children described above definitely had intense, strong-willed temperaments. My intuition is that it's an interactive process where both parental and child characteristics trigger maladaptive behaviors in each other that escalate over time. But are these families typical of cases of DMDD? I searched Pubmed for "disruptive mood dysregulation disorder" and found 20 papers published in the last 2 years (out of 29 total).

Of the 20, most were reviews/commentary, and only 6 papers were original research. One was a brain imaging study looking at "neural mechanisms of frustration in chronically irritable children." Another examined the prevalence of SMD 2 and 4 years out from initial diagnosis, and found that 40% still met full criteria at 4 years, but a significant number not meeting the criteria were still moderately impaired. Another study from Duke's developmental epidemiology program used a large database to examine the adult outcomes of those who would have met DMDD criteria as children and found higher adult rates of depression, anxiety, adverse health outcomes, impoverishment, police contact, and lower educational attainment.

To my pleasant surprise, there were actually several papers that included data on family characteristics of children with DMDD. The first was a cross-sectional study of a community sample of 6 year-old children, which found that 8.2% of them met DMDD criteria based on a structured interview of parents. Impressively, the study examined 6 domains ("demographics; child psychopathology, functioning, and temperament; parental psychopathology; and the psychosocial environment") for correlates of DMDD. The parents were also interviewed about what things had been like when their children were 3 years old, and here's what the researchers found:

The age 3 years predictors of DMDD at age 6 years included child attention deficit hyperactivity disorder, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, poorer peer functioning, child temperament (higher child surgency and negative emotional intensity and lower effortful control), parental lifetime substance use disorder and higher parental hostility.

The second study was a prospective one that "followed 317 high-risk children with early externalizing problems from school entry (ages 5-7) to late adolescence (ages 17-19)." The children sorted into 3 groups by the time they were adolescents: one group with conduct/criminal problems and anger, one group with mood dysregulation, and one group with a low level of symptoms. The authors found that generally, those who were more overtly aggressive as children tended to have conduct problems as adolescents, while more emotionally dysregulated children had more mood dysregulation in adolescence. The key finding:

For children with early emotion dysregulation, however, increased risk for mood dysregulation characterized by anger, dysphoric mood, and suicidality - possibly indicative of disruptive mood dysregulation disorder - emerges only in the presence of low parental warmth and/or peer rejection during middle childhood.

Another study (with 13! authors) was published in a much more prestigious journal than the previous 2 papers, and to me it was the least enlightening. The study examined the risk of DMDD in offspring of parents with bipolar disorder and found a much higher risk of DMDD (odds ratio = 5.4 "when controlling for demographic variables and comorbid parental diagnoses") compared to offspring of control parents. Given what those two other studies found, I'm not surprised that parents with bipolar disorder, one of the most severe psychiatric illnesses, would have children at risk of DMDD.

One last noteworthy paper that turned up in my Pubmed search is a recent article on whether DMDD should be included in ICD-11. The International Classification of Diseases is the World Health Organization's standard system for classifying every health problem imaginable, and the 11th revision is due in 2017. Even in the U.S., the ICD diagnostic codes are the standard for coding and billing purposes, and each DSM diagnosis is mapped to a corresponding ICD code. In this paper, the authors, who were members of a task group convened by the WHO to provide recommendations on the classification of disruptive behavior disorders, wrote:

The task group has recommended that WHO not accept DMDD as a diagnostic category in ICD-11, but rather approach the issue in an alternative, more conservative and more scientifically justifiable way. Specifically, the group has proposed that ICD-11 include a specifier to indicate whether or not the presentation of ODD includes chronic irritability and anger. We believe this option provides the most parsimonious basis for identifying and appropriately treating children with this maladaptive form of emotional dysregulation.

In my previous post on DMDD, I thought that it was overall a positive step away from the rampant over-diagnosis of pediatric bipolar disorder. But I did not end up using it; I was not about to diagnose those children with bipolar disorder in the first place. Thus, I find myself agreeing with the WHO task group. With ODD, the standard first line treatments are interventions that help parents better manage their children's behaviors and/or improve the parent-child relationship. I still worry about drug companies trying to market a medication for DMDD that supposedly targets a problem in the brain of the child. Thankfully, at least Abilify hasn't been approved yet for treating DMDD and hopefully never will, having gone off-patent this year.

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.

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.

A Chilling Encounter

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

Late one afternoon, I got a page from the emergency room about a 14-year-old male who was in for a suicide attempt, who was medically stable and ready to be interviewed by a psychiatrist. When I arrived at the tiny conference room adjacent to the ER, I was expecting the typical morose teenager, full of emotional turmoil. Instead, this young man looked at me calmly and nonchalantly, smiled, and said hello. He was thin and looked like he could be 12 or 13, dressed in a polo shirt and khaki shorts. He would not have seemed out of place in a Boy Scout uniform.

I started with the obvious. How did you end up in the ER today? He told me that he had tried to end his life earlier in the day by hanging himself, only to be discovered when his father got home early from work. Has there been anything stressful going on in your life? Yes, he said. Several weeks ago, a little boy had reported him for molesting him. When the police investigated, they eventually discovered several other young boys in the neighborhood with similar stories. Somehow, a judge had allowed the teen to remain in the custody of his parents while he awaited his sex offender psychological evaluation.

He seemed at peace, and neither the crowded space nor the noisy environment fazed him in the least. I tried my best to keep a poker face as I continued asking the standard questions. Have you been sad or depressed? No, he said. He'd been in a good mood all summer, even after the accusations surfaced. He has not lost any interest in enjoyable activities. How's your sleep? He slept very well, at least 8 hours a night. Appetite? Good. Any guilty feelings or negative thoughts? Nope. So how did you decide that today was the day to die? He had just finished the last book of a popular young adult series. "I finally got to see how that story ended, and it was very satisfying. Then I decided, I might as well kill myself so I don't have to go to jail."

I kept searching his face for any sign of tension, doubt, or guilt. There was none; he might as well have been chatting with a friend about his favorite video game. In the back of my mind, I wondered if he could detect that I was more uncomfortable than he was.

He told me that he had a normal childhood, that he got along with his parents, and that he was never mistreated or abused in any way. Do you have any friends your age? Instead of answering the question, he mentioned that he was on the golf team for his school and he got along fine with his peers. Are you attracted to males or females your age? "No, I only go for the younger ones." Any reason you targeted those particular children? He looked straight at me and said, "I take whatever I can get," sending shivers down my spine.

Later, I interviewed his mother and father, who seemed like nice, normal suburban parents. They both appeared stunned, uncomprehending. I felt sad for them, yet I was also glad that their son was caught when he was 14, rather than when he was 40 or 75. I could not decide whether it was a good thing or a horrendous thing that he made no effort to deny what he did. Or perhaps he just wanted to appear honest to hide even greater atrocities.

Did I end up admitting this "patient" to the psychiatric unit? I would have preferred to send him straight to juvenile detention, but the hospital had a protocol: A serious suicide attempt like his had to be admitted if there were beds available. As a service to the community, of course. Even better, I had to admit him under a diagnosis of "depression not otherwise specified," since the hospital could not get reimbursement for an admission diagnosis of pedophilia. Walking out of the hospital that evening, I was glad to see the sun still visible low on the horizon, and that the darkness had not quite set in yet.