Wednesday, January 14, 2009

Clinical Notes



It's become just like a chemical stress
Traces the lines in my face for
Something more beautiful than is there

Rilo Kiley

1. Speaking of ambiguity in psychiatry, benzodiazepines are a great example. A certain and significant subset of patients crave them, and sometimes they seem to be more trouble--and harm--than they are worth. It might be such a relief to be a fundamentalist and determine never, ever to prescribe them; but there is a moral microcosm here about personal purity and meeting the world as it is. Not only do lots of patients come to a new psychiatrist already on benzodiazepines, but for every person who may abuse them there seems to be at least one who is an ideal candidate, and for whom no other treatment will do. So the peculiar dance, part waltz, part tug of war, goes on. Xanax is where I draw the line though; and yet...never say never.

2. While I don't know of a good colloquial or clinical term for it, I am convinced that there is a kind of psychological hypochondriasis, that is, overconcern for psychological rather than physical conditions, that is far harder to treat than either pure anxiety or classic hypochondriasis relating to physical symptoms. You can't really give yourself cancer by worrying yourself about the possibility, but can you worry yourself into having a riproaring depression or anxiety disorder by brooding on the potential of such maladies? Unfortunately, yes.

3. There was moral panic in the 1990's about Prozac and other newer antidepressants making people "happier than happy." The theoretical concerns persist, but by now I think most people realize that antidepressants aren't strong enough to afford much euphoria to the normal (they're only moderately good at treating the unambiguously depressed). However, the situation appears to be different with so-called "stimulants" like Ritalin and Adderall, classically used for ADHD.

As William Saletan at Slate notes, stimulants may be the new enhancement drug in baseball. Compared to a 3-4% prevalence in the general population, apparently upwards of 8% of pro baseball players are submitting medical justification (in the form of a diagnosis of adult ADHD) for taking stimulants. The problem is, unlike antidepressants, stimulants may well enhance useful qualities like energy and attention in normals, and as with depression, the boundaries of ADHD are quite fuzzy and subjective, vulnerable to being stretched all sorts of ways. However, one might object that ADHD folks might be expected to be overrepresented in sports settings, because the syndrome often inclines those who have it to pursue active lifestyles (when accountants start claiming adult ADHD in large numbers, we'll know something is fishy).

4. I have found humor in psychiatry to be a funny thing (so to speak)--okay that wasn't very funny. As one would expect from human nature, psychiatric humor does go on, and widely, but so far as patients are concerned it is behind the scenes, surreptitious. Because of the long and lamentable chronicle of the stigma and mishandling of the mentally ill, psychiatric humor is sort of like racial humor, practiced above board only if one is of an appropriate ethnicity and patienthood. That is how it should be--respect and professional ethics demand it. And yet...as compared to other professions, those in psychiatry (and I include here nurses, therapists, etc.) see more than their share of the absurd, which, human nature being what it is, provokes involuntary amusement. It is a stressful profession at times, and, well, we creatures need to find humor in situations, if we're not allowed to find it in people.

So I mention this vignette not for the sake of any unseemly humor, but only as a break from my endless harping on ambiguity in psychiatric diagnosis...

Well, I started to write a full vignette, but even with details removed, it ain't right, for this venue anyway. Suffice it to say though that if you have been psychiatrically hospitalized twenty times, if you store your feces in your freezer, if you bear said feces to church (freezer being full, presumably), and, having been hauled to the emergency room, become extremely agitated and transform your room there into a scene of scatalogical mayhem, then we can safely leave diagnostic subtlety behind and say, ladies and gentlemen, we have a diagnosis. I appreciate the symbolism and possible psychological meanings of what the fellow was doing, but he really, really, really needs to stay on some medication this time.

7 comments:

Dr X said...

During my first inpatient clinical training experience, I was introduced to a young man who stored hundreds of feces samples in baby food jars in his bedroom. This worried his parents.

From a distance, this sort of thing might tempt one to cast the patient in the role of persecuted visionary who merely colors outside the culturally-approved lines. But, only from a distance.

neuronarrative said...

Out of layman's curiosity, why is Xanax the benzo where you draw the line? Dependency potential?

Novalis said...

Yes, due to the short half-life, dependence and potentially severe withdrawal with sudden discontinuation (which can happen when someone's supply is "lost" or "stolen," which occurs frequently).

Anonymous said...

While we're on the charming topic of faeces...

Maximum security inmates (not necessarily mentally ill), who've been stripped of everything --including their dignity and self-determination--quite commonly use their own faeces as weapons of last resort to regain some kind of psychological ascendency over their predicament, and prison officers. With their privacy completely invaded, and even their bodily functions regulated by authority figures, they rebel by creating a physical barrier of such repugnance, so that the deepest part of their untouched psyche--their essential being--might remain unviolated.

Do you think that's what scatalogically obsessed mental patients are trying to do(apart from the obvious symbolism and violation of social norms)?

Anonymous said...

....or sometimes a piece of shit is just a piece of shit...

Novalis said...

Well, whatever the case Novalisette (doesn't really work, does it?) who was working the ER that night didn't sound that happy about it in her 3 A.M. email. It sounded like the Haldol and Ativan were flowing freely and interpretations were kept to a minimum.

flawedplan said...

Hoarding poop is a classic behavior in advanced Alzheimer's; I was a direct care worker for years and saw it daily. One explanation has to do with the unstoppable regression toward infancy; the smell and texture stage, smearing it on walls like paint. But to others turds were like nuggets of gold, hidden treasure; and in case the turd was wrapped in foil and eaten like a sausage, a simple, common example of mistaking one thing for some other thing.

And yes, I nearly shit. (Sorry, couldn't resist!)