Wednesday, June 28, 2006

I think it's time say goodbye.

Like Medpundit, I find that I don't have enough time to devote to this blog.

It's been a lot of fun.

Sunday, June 25, 2006

The Forgiveness Project

"Could you forgive the unforgiveable?" Kate Kellaway, in the Observer:
"The Forgiveness Project...has no religious or political agenda. It has no agenda at all apart from the brave, unfashionable wish to turn the blame culture on its head, to share the stories of people who, in extremis, have discovered that 'the only way to move on in life is to lay aside hatred and blame'. It tells of victims and perpetrators from all over the world: South Africa, America, Israel, Northern Ireland.

"...These stories are tremendously moving but they are complicated too. Would it be unfair to suggest that Rice's sentiment sounds precariously close to revenge? Forgiveness can be uncomfortable. It may induce squeamishness, strain, disbelief in the onlooker and, perhaps, in the forgiven. It can seem artificial. It seems to involve an emotional double-jointedness, an ability to bend backwards further than an ordinary person is designed to go. And yet, at other times, something miraculous occurs. People seem to emerge into a new landscape, a clearing where negative feelings no longer consume them. I imagine that it is not an easy place to be. They are exposed, unsupported - for revenge and hatred were, in their ugly way, crutches - but they are free.

"...Adam Phillips, writer and psychoanalyst, suggests: 'Forgiveness is not an act of will, if genuine.' He is quick to see its darker aspect: 'It puts the forgiver in an immensely powerful position. There is word magic here: the belief that if you forgive, people will be absolved of their guilt. At worst, forgiveness is a tyrannical gift: your life in my hands. You'll feel better when I forgive you.'

"Marian Partington, whose sister Lucy was one of the victims of Frederick West, the Gloucester mass murderer, disengages herself from the word: 'I don't like 'forgiveness'. It is completely barnacled with aeons of piety. I prefer compassion: empathy with suffering.' If the word is to be used, she sees it as 'a verb not a noun. I get a bit suspicious of people who say "I have forgiven", as if it is something in the past...'

"After trauma, she believes, people often experience a 'frozen silence with no words. There are no words to describe this place'. Time involves a thaw and 'acceptance' and, in Partington's case, luminous words to describe her feelings, to break the silence."

Wednesday, June 21, 2006


Grief, originally uploaded by creativity+.

...for Pfc. Tucker and Menchaca.

Sunday, June 18, 2006

"Tell me, who is the president?"

"The president?" The patient's eyes grew wide. She was ninety-two years old, and her memory was "not the best, dear."

We had just met. I'd quizzed her gently, and she'd responded with bemused indulgence...until now. She looked directly at me, and scowled. "Here it comes," said her daughter. Here it came, indeed! A stream of bitter disapproval...

It was 1998, and we had all just heard of Monica Lewinsky.

At times, we must try to learn if our patients are aware of a larger world, beyond their own surroundings and circumstances. If a patient is forgetful or disoriented, how severe is the impairment? There is a long tradition of asking, "Who is the president...and the one before him...and the one before him?" Unsurprisingly, the question can bring the larger world thundering into my office. The interview stops, and I learn exactly what the patient thinks of the old so-and-so, even if they can't quite remember his name.

When Clinton was president, people tended to forget the elder Bush. It was "Clinton, Reagan, Carter..." That changed when Bush, Jr. assumed office. It became "Bush, Clinton, Bush's father." Now, people are unsure about Ford and Carter. The younger the patient, the greater the confusion about where to place Nixon and Johnson. But the quality of memory depends on the nature and context of the information. (A man with mild Alzheimer's could not recall Clinton's name, but called him "the sex guy.")

In the last few months, the emotional impact of this question has again intensified. I don't need polls to tell me what our community thinks of its leaders.

I do have to be careful, though. One elderly lady unleashed a torrent of opprobrium about the president. But her son stepped in: "Mom, what president are you talking about?" It was Herbert Hoover. Now, that's an impressive long-term memory...

When pain meds make pain worse

Michele G. Sullivan, in Clinical Psychiatry News:
HENDERSON, NEV. — Treating medication overuse headache involves a three-pronged approach of patient education, teaching pain coping skills, and addressing psychological issues that put patients at risk for relapse, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

Most patients don't understand that excessive use of opioids can actually make them hypersensitive to pain, said Dr. Lake of the Michigan Head Pain and Neurological Institute, Ann Arbor. “They believe the pain is stronger than the medication, not that the medication is actually making them worse.” This thought process can be the root of ever-increasing medication use, as the patient experiences “pain anxiety” and attempts to forestall pain by premedicating.

The first step is to teach patients how medication overuse exacerbates headache pain, he said. Only when they have a clear understanding of this relationship will they be open to adhering to medication limits.

Sustained opioid use downregulates opioid receptors and upregulates excitatory receptors. This results in increased synthesis of excitatory neuropeptides. “Opioid tolerance is a red flag for induced abnormal pain sensitivity,” Dr. Lake said...

Simply taking away the analgesic isn't the answer, he stressed. Patients need to understand that drugs are not the only way to alleviate headaches, and that they will probably have to tolerate some level of pain. “The evidence, clinically and empirically, shows that it's very difficult for these patients to move to pain-free days. They have to find ways of dealing with headache that doesn't involve drugs.”

Biofeedback, stress management, and antidepressants all may be effective tools in relearning responses to headache pain.

Saturday, June 17, 2006

Thanks for the Ethics classes showed us how to cheat.
Last fall, Bentley College management professor Tony Buono taught a class on corporate scandals with colleagues pitching in from finance, accounting and even the philosophy department. The four picked through the cases of Enron, WorldCom, Tyco and Shell.

At the end of the semester, the number of students in a simulated trading room who were caught in misconduct or misusing information for insider trading was significantly higher than at the beginning. The students said, "You taught us how to do it," Buono recalled.

"For those of us who've spent our careers teaching this, it's been a disappointing time," said Buono.
Buono, the Bentley professor, suspects the students in his class who got caught misbehaving in the mock trading room considered it a game.

"We're trying to tell the students there is no reset button in real life," he said.

Tuesday, June 13, 2006

Dinner at the Bipolar Restaurant

Joel imagines a cafe that brings diners into a "bipolar experience."
1. You would be surrounded by frowning people.
2. The food would be hospital food. If you did not eat it, they would not let you go home until you did.
3. The food would make you constipated or dizzy or wanting more and more and more...

5. The waiters would take notes on your behavior.
6. Voices would tell you that the waiters did not like you and that they wanted to poison you. Other voices would just say things like blab blab blab over and over again.
7. Whenever you lifted a fork or knife, the staff would watch you especially closely...

11. You’d leave the restaurant relieved that you were out of it. When you got home, however, you’d discover that the restaurant had moved into your bedroom.


I've made a rule here: "No medical advice is given on this site."

But suppose that a commenter says: "To taper a med, do A, B, and C." Does that violate my rule? Should I delete the comment?

And if another commenter states that such a taper is unwise or even dangerous, what then? Is that medical advice?

Why does it matter? Each day, people ask Google about "stopping meds." Each day, Google leads some of them here. Note the active, growing comment thread. Baldrick says:
"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."
A crucial that I wish I had made, myself! But Baldrick also says: "To taper meds, do a, b, and c." (You see where I'm going here.) Another commenter vehemently disagrees with Baldrick, and says that such a taper should not even be posted.

I'm trying to walk a tightrope. I've tried to say: "Some think A, and I've seen B, but please talk to your doctor." I believe that I'll have to start monitoring things more closely, and delete anything that might be construed as "advice."

Your thoughts are most welcome. (Add: I've republished the original post, with updates.)

Stopping Paxil.

This can be terribly difficult. But it can be done. (Note updates!)

I note Dr. Stephen M. Stahl's "dosing tips":
"For patients with severe problems discontinuing paroxetine, dosing may need to be tapered over many months (i.e., reduce dose by 1% every 3 days by crushing tablet and suspending or dissolving in 100 ml of fruit juice and then disposing of 1 ml while drinking the rest; 3-7 days later, dispose of 2 ml, and so on.) This is both a form of very slow biological tapering and a form of behavioral desensitization."
So if a dose was lowered from 20 mg to 19 mg, that would be a 5% reduction. But he's describing a 1% reduction. (As the dose gets lower, the proportion changes, of course.) He adds:
"For some patients with severe problems discontinuing paroxetine, it may be useful to add an SSRI with a long half-life...prior to taper of paroxetine."
He also notes that paroxetine inhibits its own metabolism, making tapering even more problematic for some (i.e., the effect of a dose reduction can be magnified. The patient is not only taking less, he's also eliminating it faster). -Essential Psychopharmacology: the Prescriber's Guide by Stephen M. Stahl, Meghan M. Grady (Editor), Nancy Muntner (Illustrator)

Note! Dr. Stahl and I can't tell you what to do. We aren't your doctors! (See disclaimer in sidebar.)

Why I'm posting this: I notice that I'm getting lots of hits from this site today. (5/20 update: the link has been changed, and now there's no access to this forum. There was much outrage about some psych-blogging, including mine.) There's horrific pain and anger in this thread. Obviously, for many, there's been a complete breakdown in the relationship between psychiatrist and patient. I hope that no one has to go through the pain that they're describing.

Update: related post here. And note, please: no medical advice is given on this blog! (I've come perilously close to breaking my ironclad rule, here.) Eat a healthy diet, look both ways when you cross the street, and talk to your doctor about any and all med changes! Patients should have a doc in their corner, looking out for them!

Yet another update (6/13): Baldrick has an important comment.
"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."
However, I'm afraid that I'm going to have to delete any comment that gives, or appears to give, medical advice. That includes posts that say, "Do this" (whatever "this" is). The issue of whether, and how, and when to stop meds is controversial. Each patient is different. Please speak to your doctor! No medical advice is given on this blog.

Monday, June 12, 2006

"I'm afraid I have some bad news..."

A clear winner of the Most Regrettable Bedside Manner Award. In the New Yorker:
Your husband was admitted with extreme pain in the abdomen, which is obviously not our fault...We didn’t want to rule anything out, so we opened him up.

There were no multi-hundred-pound tumors; that’s the good news.

However, it’s a real mess in there. There’s a lot of intestinal tubing squishing around—what you call “guts”—as well as an assortment of small, esoteric organs they don’t spend a lot of time on in medical school. And bear in mind that everything’s pretty much the same color, not like in the textbooks...

Falling into the "doughnut hole"

Some patients are discovering that their Medicare Part D drug coverage has a gap, and stops paying when a limit is reached. For some who qualify, coverage resumes later. The gap in coverage is called the "doughnut hole." Timely advice from OnThePharm:
"Yesterday I had my first customer come talk to me about his medicare coverage. He spends quite a bit of money in the pharmacy, but he had opted for a plan which had the “doughnut hole.” Now. the details of each plan’s doughnut hole vary, but basically they all revolve around the magic $2250 number. There are some common misconception about this so-called doughnut hole, and he had fallen victim to both!

"...As always, I recommend checking out the Medicare website, particularly their plan search tool. Be sure to be specific, and enter your medications, and dosages so the plan can really help you choose the plan that’s best for you. At the end, it will present you with a list of plans ordered by yearly cost that cover the medications taken. The yearly cost is what it will cost you or a loved one in terms of premiums, copayments, and lack of coverage if a donut hole is ever reached. While you can’t change which company you go with now, you will be able to after November 15 when open enrollment begins again."

Question 36

From a multiple-choice pathology exam:
36. The poet Yeats wrote:

An aged man is but a paltry thing,
A tattered cloak upon a stick, unless...

A. He finds a younger woman, has a fling,
And then yells out, 'I never will confess!'

B. He takes Viagra pills, to boldly bring
To his beloved his mighty manliness.

C. He uses Rogaine, and by next spring
Has hair regrowth that's certain to impress.

D. Soul clap its hands and sing, and louder sing
For every tatter in its mortal dress.

E. He burns his 'Path' book, and while it's smoldering,
He shouts out loud, 'I'm DONE with that B.S.!'
-Ed's Pathology Notes.

Heckling the student.

Or rather, don't heckle the student. I'm too late:

More Hawaii

DSC_0002, originally uploaded by shrinkette.

Can't let it go. Sorry.

Thursday, June 08, 2006

We're back.

DSC_0059, originally uploaded by shrinkette.

...and the world can't wait to see my vacation photos, right? I thought so! This is the Napali coast of Kauai, where I completely and utterly forgot about the rest of my life...(and my blog!). A little misty, perhaps, but so are the memories.

One more: this is Maui.

Okay, back to work. I have a lot of catching up to do!
Click for Eugene, Oregon Forecast