One last psychiatry rant

So, I felt the need to get on my soapbox one last time after reading this post over at mudfud. After this, posts will relate to medicine only. I have purged myself.

There will never be such a thing as a biologic marker for depression. Even if it existed, of what use would it be? If I felt fine but had some biological marker that indicated I had depression, should I take medication? Why? What would be the point? Likewise, if someone feels horribly depressed but doesn't have the marker, should we not treat them? Of course not.
I guess you could use it for screening, but what's the point of screening for depression? The point of screening is to treat illness before it becomes symptomatic. But depression, by definition, cannot be asymptomatic. So, why screen for it?
There may be other conditions out there (i.e. hypothyroid) that secondarily cause depression. And there may very well be biological markers to test for these diseases. But for a biological process to cause no other physical symptoms except for those associated with depression? I suppose it's plausible but, I think, highly unlikely.
How do the patients in these studies get their diagnoses anyway? The DSM. Diagnosing psychiatric illness isn't at all like diagnosing hypertension, anemia or diabetes where a simple number gives you the diagnosis. It requires people to make a judgment call, in every case, as to whether the DSM criteria apply. And how often do psychiatrists agree on whether the DSM criteria apply? Depression is one of the most reliable DSM diagnoses and it is only about 80% reliable. Psychiatrists agree on whether or not a given individual is depressed about 80% of the time. And unlike diabetes or hypertension where a diagnosis is either correct or incorrect there is no higher authority to say who made the "right" psychiatric diagnosis. Therefore, since the diagnosis itself is only 80% reliable, any biological marker we found could only be at most 80% reliable.
Ok, let's say that you believe the DSM only approximates these "biological" illness and you believe that with biology and genetics we will finally be able to make the "true" diagnosis. The DSM becomes obsolete. Schizophrenia, for example, is found to be a heterogeneous group of illnesses each with it's own abnormal proteins produced by their own abnormal genes. Schizophrenia is no longer a psychiatric diagnosis but a neurological diagnosis. I once had a professor who said that one day, there will no longer be any psychiatrists but only psychologists and neurologists. I agree. But, while neurology might grab a few, I think psychology is going remain in control of the vast majority of current psychiatric diagnoses.
Soapbx disengaged.

Grand rounds: edition 27

Grand rounds are up at Over My Med Body. Check out some interesting posts from various medical bloggers.

The Fat Man

So, I was scheduled to begin medicine today. Little did I know, my psych rotation had been extended one more day only, the setting had been changed to Dr. Levin's outpatient internal medicine clinic.
It was the last patient of the day. I was starting to get into the swing of things, relearning how to use my stethoscope - I basically hadn't touched a patient in 6 weeks except to shake hands. This lady was skinny with long, gray hair looking much younger than her stated age. When I called her from the waiting room she was helping a lady in a wheelchair get her feet propped up properly.
"Someone you know?" I asked.
"No, but she needed help."
She happened to be a nurse, and so was completely aware that our conversation was going to have very little bearing on her treatment but was quite happy to talk to me anyway. And talk. And talk. She described symptoms of chronic fatigue and headache, casually slipping in that she had recently discontinued her antidepressants. She'd also had multiple CAT scans and MRI's, some for neurological symptoms, some for her chronic sinusitis. The longer I talked to her, the more doctors her story introduced me to: neurologists, psychiatrists, gastroenterologists, otolaryngologists, another general practitioner who "didn't take her symptoms seriously." I did my best, but this was all a bit much for me to handle on my first day of medicine. I reigned her in, and did a thorough neurological exam - which she really seemed to appreciate. "I'm so glad you're examaning me. Your exam has reminded me, I noticed that one of my pupils was bigger when I looked in the mirror last week." I added this, newest complaint, to her HPI.
I explained all this to Dr. Levin. He listened patiently and intently before we went to see her. Maybe it was just the luck of the draw but, after having worked with some pretty shady and self-absorbed psychiatrists, I was all set for Dr. Levin to completely brush the patient off, start her on some new antidepressant and tell her (in so many words) not to come back. He did start another antidepressant, but didn't brush her off in the least. He listened to what she had to say, looked at her MRI and answered her questions. During the interview, she expressed fear that he would drop her as a patient after discontinuing her meds. He had no intention of dropping her - unless she wanted to be dropped, which she didn't. It was a good match.
I see now why Dr. Levin's office is so full of gift baskets from all his patients. At the end of the day, he gave me a bag of muffins because there was simply too much food around. Dr. Levin is the character The Fat Man from House of God. He knows his medicine, says what's on his mind and patients absolutely adore him. I'm excited about this preceptorship.

My political persuasion

Apparently, I'm a liberal. Who knew?

Thanks to orac for posting the link. Please, send me a trackback if you decide to take the quiz yourself!

Dr. Lin threesome

So, I was checking the url's referring to my site - as us bloggers do - and I found something a little strange. On 3 separate instances and from 3 separate ip addresses, someone searching Google for "Dr. Lin threesome" was referred to my blog. The question who whether my blog has anything to say about "Dr. Lin threesome" aside, why the hell would anybody be searching for "Dr. Lin threesome" in the first place? Who's Dr. Lin? And what does she have to do with threesomes?
Anybody? Anybody? Bueller?

Reverse date rape?

I'm a horny guy. I'll admit to it. There was an M4 on psych rotation with us - the most voluptuous Indian girl you've ever seen, with an ass that follows behind her like the trailer on a semi. Whenever she turns a corner, her ass remains in plain view. She sat in front of me to take the psychiatry shelf exam today, wearing black pants that failed to contain the entirety of that ripe peach which she rested gingerly upon the chair, exposing almost a full inch of intergluteal cleft as she leaned forward. I finished the exam as quickly as I could and rushed immediately home to masturbate.
The point of telling this story is, I'll match my horniness up against anyone's. But, that being said, I very much resent what seems to be a social expectation of horniness whenever our significant other happens to be in the mood. Skye was in town this weekend. We had some great fun together but, there are occasions during which I am very tired and would rather just sleep. What does one do in the event that one finds oneself being kissed and groped just as rapid eye movements are pleasantly settling in? Does one say "no?" I've said "no" before; usually I'm met with various combinations of sobbing, confusion and anger - depending on who I'm with. At that point, I reluctantly give in. Ok, so it's not really against my will. I am a willing participant. But 'no' should mean 'no.' I should be able to say 'no' without feeling guilty about it.
Here's the problem, the message that men have consistently received from our society is: "You'd better be horny all the time because your girlfriend is only going to be horny some of the time. You wouldn't want to waste an opportunity." Women are used to being pressured for sex and so it's become perfectly culturally acceptable, and even encouraged, for women to say "no." This engenders a culture where, when women do decide they are willing to put out, the expect - even, feel entitled - to have someone out there who will want them and they will feel rejected as all get out if this isn't the case. You see the position we're in? It's not easy to reject someone like that. It's much easier to acquiesce and give them what they want.
My point is that the passive, subtle ways that women have of pressuring men for sex are every bit as coercive as the more overt, forceful ways that men have of pressuring women for sex. And they're both BAD! So don't do it. If you're a guy, the solution is simple - just don't force yourself on anyone. If you're a girl, there's no need to cry if your boyfriend says "no." You're not undesirable. Just wait till morning. Unless you have hair around your nipples or below the navel in which case, it may be that he finds you undesirable.

The Antipsychiatry Movement

"Only more powerful people can call less powerful people schizophrenic and get away with it safely." Thomas Szasz said this at a conference in 1984. He believed that schizophrenia and depression are not diseases but "social fictions" used by more powerful people to treat less powerful people against their will. He compared the label of 'schizophrenia' to the counting of blacks as 3/5 of a person in the U.S. Constitution - useful to the rest of society, but not useful to black people themselves.
Szasz and other authors, such as R.D. Laing and Peter Breggin, were the subject of a Psychiatry Grand Rounds given at school today entitled The Rise and Fall of the Antipsychiatry Movement. The resident who gave the talk - and most of the faculty members in that room, for that matter - would like to believe that the so-called "Antipsychiatry Movement" has indeed fallen. But he acknowledged that, because treating mental illness is inherently different than treating medical illness, there will always be a certain sector that questions what psychiatrists do. From the little I've learned about Thomas Szasz, I think he makes some excellent points. He believes that psychiatry is ok, as long as it happens between consenting adults. If you want to try medication for your illness or if you think that, as a patient, you would benefit from hospitalization, fine. But, according to him, hospitalizing people against their will is always wrong - preventing suicide in someone is not sufficient justification for taking away their rights and homicidal people should be delt with by the police. Here's a fascinating transcript I found from a 1998 debate on the question of: "Is depression a disease?" Szasz and 5 other psychiatrists participated. I've always agreed with those who say it is not. Depression is a constellation of symptoms with no identifiable cause. This is not to minimize the suffering of depressed people, but to say that it is a mental and spiritual process and not a brain illness or a biochemical disorder.

One of the psychiatrists in the audience of today's Grand Rounds, Dr. Butz, in the course of blasting Peter Breggin and the rest, brought up Ernest Hemingway. Hemingway was a psych patient at Mayo Clinic shortly before his subsequent suicide. Dr. Butz had happened to be in Minnesota at the time and had happened to run into the intern who was following Mr. Hemingway's case. Although, the official story is that Hemingway got between 11 and 15 ECT treatments, Dr. Butz claims to know different. Apparently, they had declined to do ECT on him fearing it would stifle his creativity. To this day, Dr. Butz believes that ECT would have saved Ernest Hemingway's life. What do you guys think? If Michelangelo had been suicidal, would you have cut off his hands in order to keep him from killing himself? I think ECT would have only driven Hemingway to suicide faster.

Mrs. Katz got her ECT after all - treatments began today. She had signed the "consent" form over the weekend. This morning she asked me, "Is there a risk of brain damage with this procedure?" My answer,
"Well, technically, the procedure is brain damage."

Grand rounds: edition 26

Sorry for the delay in posting. Skye was in town this weekend so I was a little, um, preoccupied. This week's grand rounds can be found over at The Well-Timed Period. Submit posts for next week to Graham at Over My Med Body. Today was my last day on psych rotation. I promise to post a good wrap-up tonight.

Ethical Dilemma Theater: Part III - Informed consent? I've got your informed consent right here!

It was time to present my new patient this morning. I had called Mrs. Katz on the phone last night in order to get the rest of her history. She was a 68 year old lady with an 8 year history of depression. She had been managed as an outpatient up until this point, but her condition had acutely worsened when her regular psychiatrist decided to stop her TCA (tricyclic antidepressant) about 7 months ago. She had tried several medications in the interim, but nothing had helped. Finally, her regular psychiatrist decided he'd had enough and referred her to our hospital for ECT (shock therapy). I asked Dr. Beck about restarting her TCA. His response was, "She won't get better because she'll complain about the side-affects." Well, ok sure, that's possible. This lady was pretty ill. And if Dr. Beck - the attending psychiatrist - thinks that ECT has a better chance of helping her, why not give it a try? - as long as she's amenable to it.
The problem was, she wasn't amenable to it. She wouldn't sign the consent form. But Dr. Beck wasn't about to let a pesky detail like "informed consent" get in the way of pursuing what he thought was the best treatment option. In a flash, Dr. Beck had the patient's daughter on the phone and for a solid 30 minutes Dr. Beck, the psych resident, the social worker and the patient's daughter did their darnedest to harangue Mrs. Katz into signing the consent form. Each member of the team had his own strategy. The social worker tried to convince her that it was in her best interests and that she'd feel better. The psych resident tried to explain why ECT was best option in terms of a risk:benefit ratio. And best of all, Dr. Beck's strategy was to put on his most excellent used car salesman face, shove a fancy pen into Mrs. Katz hand and say, "Come on, just sign it. See?" tapping the dotted line, "Just sign right there. We just need a signature and then we can start getting you better." I thought I was going to be physically sick.
She didn't end up signing, but Dr. Beck put her on the schedule for Monday anyway. He's hoping the daughter will be able to convince her mother to sign when she visits in person this weekend. I left a patient handout on ECT along with a couple of articles on the subject with Mrs. Katz, hoping it will help guide her and her daughter in making an informed choice.
Personally, I think it would be worth another trial of her TCA. What's the worst that can happen? It doesn't work, in which case ECT is back on the table. Suicide is always a concern because TCA's are fatal in overdose. But she has been asked multiple, multiple times about suicide ideation and has consistently denied it. She also has no history of suicidal behavior and no previous psych hospitalizations. In the end, whatever treatment option we pursue doesn't really matter as long as it's what the patient wants. I don't think giving in to high pressure salesmanship really counts as informed consent. It will have to come from her.

Work from home

We released our hostage today. The patient had signed his 5 day notice 1 week (5 business days) prior to my first day on service. That meant we had to either release him, or go to court to justify keeping him. The court date was set for 3 days later and when the court date came, as has become standard procedure, they issued a continuance (postponed making a ruling) for 1 week. That one week was up today - 17 days after the patient had originally requested to be discharged. And he hadn't gotten any better. In fact, he had gotten worse. His delusions were more elaborate and his blood sugars were running in the 400's. But, in order to keep him, we would've had to go to court yet again. The 3 med students looked on this morning as the nurse, social worker and psychiatrist all looked at each other saying, "I think he's better, don't you?"
"Oh, yes. Much less agitated than when he came in."
"Yep, definitely calmer. See, he's not clenching his fists anymore-"
"This is probably his baseline anyway."
They called the patient in and said, "Congratulations! You're free to go."
I'll miss pt J.J., always asking for his diet 7-up. He asked so often that the resident finally wrote an order: 1 diet 7-up qShift. If I'm ever in the hospital, I'm going to ask the resident to write an order for 1 foot massage q6hrs PRN.
Note to any mentally ill people who might be reading this: if you're not suicidal or homicidal, think twice before signing yourself into a hospital - you may be there longer than you had planned.

There was a new admission last night. I went to do the history after getting back from lecture but she was tired and in no mood to be talked to. But I didn't have any other clinical responsibilities today. And I didn't fancy waiting around until my patient had had her nap. So I went home and called her this evening. It was great - I just finished writing it up. Makes me wonder why I ever need to go into the hospital at all!

Sex toys: the silent killer

You'll never see any two people with more discrepant personalities than Ryne and Ned. They're both in my M3 class and on pediatrics rotation now. Ryne is 30, skinny, dark hair, glasses and extremely even keeled. To even contract his facial muscles into the form of an expression would be considered an emotional outburst for him. Ned, on the other hand, is 24 and somehow managed to work his way into medical school despite his, apparently undiagnosed, ADHD. I think it was pure Taoism that got him in.
The subject of today's lecture was pediatric AIDS. When the subject of transmission came up, vertical (mother to fetus) transmission was obviously at the forefront. But we explored the other modes as well: unprotected sex, IV drug use, and blood transfusions. Naively believing we had exhausted all the possibilities, we were rudely awakened from our delusion as Ned asked, "What about vibrators? You know, like, with lesbians. If one has AIDS and she shares her vibrator with her partner...can it be transmitted that way?"
The class broke into an uneasy laughter. Our course director chuckled and said, "Yes, I suppose that's a possibility too."
But the class really exploded when Ryne raised his hand and, in all seriousness asked, "Is that specific to vibrators or does it extend to other toys as well?"

Moral: Write letters to your respective congressman - the government needs to start providing clean sex toys to all lesbians in order to help curb the spread of AIDS. Republicans need to realize that this moralistic policy of denying lesbian access to free sex toys is a public health disaster. Pretty soon it won't be just a lesbian problem anymore, but bisexual females will spread the disease to straight males and the AIDS epidemic will spread out of control in this country.

Visitor

Skye is coming to visit this weekend. I'm...excited. I guess. I don't know. I really do want to see her. Although, if she knew what was good for her, she'd probably forget about me and start seeing someone else. I don't understand why we can't both just be adults with regard to our relationship. I won't ask what she does while she's in California, she won't ask about who I'm doing over here and then, when one of us visits the other, we can play like we're in a real relationship. Is that so hard? But no, she has to define our relationship. And there are all these rules like: we can't have sex unless we're going to be exclusive with one another. It's all so immature.
I think life would be a lot easier if I were gay.
Which, I AM NOT.
Not that there's anything wrong with that.

Grand rounds: edition 25

Orac has done a nifty job with Grand Rounds this week. Check it out here.

Public airwaves

I'm beginning to think I have a problem. The hours I spend each evening - motionless, pupils dilated, neurons firing like mad - I've lost 85% of my productivity. Sometimes I even indulge well into the late-night hours. I'm addicted to PBS and NPR. It all starts with Car Talk followed by The What Do You Know Quiz and This American Life on Saturday morning and progresses to Prarie Home Companion and Selected Shorts on Saturday evening. Sunday morning is reserved for brunch and by the time I part ways with the rest of "The Intelligencia," we're already into Wait, Wait, Don't Tell Me, Le Show with Harry Shearer, Shadenfreude the mental massaging of Joe Frank and, of course, Ken Nordine's Word Jazz.
My weekday routine is also a sad story of servitude to the airwaves. I come home from the hospital, jog my frustrations away and plop down in front of The News Hour and, inevitably, PBS has me hooked with some interesting special event or documentary. Tonight it's a concert program featuring stars from the 80's. I'm not remotely gay but GOD, Freddie Mercury is HOT!
Are there any support groups out there for this kind of thing? Somewhere where I could go - I would stand up and say, "Hi, my name is T.J. And I'm addicted to public television and radio."
"Hi T.J.," everyone would say in unison.
They could give me a sponsor named Bill. The group leader would say to me, "Next time you get an urge to watch PBS or listen to NPR, I want you to call Bill instead."

I'm not really sure where I was going with this post. The point is, I need to tear myself away from Mick Jagger and Tina Turner and do some reading.

Ethical dilemma theater: Part II

Dr. Solomon is a big name in the field of psychoanalysis at our institution. I walked into 8am "Dr. Solomon rounds" on Friday morning and sat next to an older, white-haired gentleman wearing a tan sportcoat and conservative tie. He immediately began asking me questions - "Are a you a student?" "What rotations have you done so far?" "Where are you from?" "What do your parents do for a living?" I answered his questions for awhile and, at about 8:15, he got up and walked to the front of the room to begin rounds. I had been talking to Dr. Solomon.
What happens at "Dr. Solomon rounds" is this: a psychiatry resident presents a case and Dr. Solomon comments on it from a psychoanalytic perspective. Today's case involved a Hispanic lady with complaints of depression who had one story of abuse after another to tell her therapist. The resident who presented her had so far done about 3 months worth of therapy with this woman.
I learned on Friday that countertransference is an important part of psychoanalysis. Analysts look at how their interaction with the patient makes them feel and this is supposed to reveal something about what is going on with the patient. Dr. Solomon listened patiently for about an hour before asking the psych resident, "Yes, but how did all of this make you feel?"
The resident admitted that she had been sympathetic at first, but had subsequently become annoyed with all of her sob stories. What is the proper response to this feeling of annoyance? According to Dr. Solomon, there is a school of psychiatry out there which advocates that the therapist be totally forthcoming and honest with his feelings thereby making himself more emotionally accessible to the patient. "If you're annoyed, you should tell the patient you're annoyed. If your patient is a model and asks you 'Do you find me attractive?' you tell them 'Yes, I find you attractive. I get an erection just thinking about you.'" Is this level of openness acceptable? What should proper doctor-patient boundaries be? If a patient asks you to go to a basketball game, is it alright to accept? Some psychiatrists have lunch with their anorexic patients believing that it's therapeutic. One could argue that, if the patient doesn't have many friends, attending the basketball game together will offer therapeutic benefit by providing him with emotionally validating experience. What if having sex with your patient is somehow therapeutic for them? It's not inconceivable. Sex is often therapeutic. (I think this question will be explored on an upcoming episode of House - I can't wait!).
I haven't really formulated my own opinions about this issue yet. I'd love to hear some opinions while my mind is still pretty clay-like.

Mindless fun

Ok, Ethical dilemma theater: Part II is going to have to wait. In the meantime, vicarously live out your sadistic tendencies though some great pencilmation.

I can't take credit for the following, but neither did the original author. So, here it is. Enjoy! Back with an original post tomorrow - promise!

DICTIONARY FOR WOMEN'S PERSONAL ADS:
40-ish...........................49
Adventurous..................Slept with everyone
Athletic..........................No tits
Average looking.............Ugly
Beautiful.......................Pathological liar
Contagious Smile..........Does a lot of pills
Emotionally Secure.......On medication
Feminist........................Fat
Free spirit......................Junkie
Friendship first..............Former slut
Fun.................................Annoying
New-Age.......................Body hair in the wrong places
Old-fashioned................No BJs
Open-minded.................Desperate
Outgoing.......................Loud and Embarrassing
Passionate.....................Sloppy drunk
Professional....................Bitch
Voluptuous...................Very Fat
Large frame....................Hugely Fat
Wants Soul mate............Stalker

WOMEN'S ENGLISH:
1. Yes = No
2. No = Yes
3. Maybe = No
4. We need = I want..
5. I am sorry = you'll be sorry
6 We need to talk = You're in trouble
7. Sure, go ahead = You better not
8. Do what you want = You will pay for this later
9. I am not upset = Of course I am upset, you moron!
10. You're certainly attentive tonight = Is sex all you ever think about?

MEN'S ENGLISH:
1. I am hungry = I am hungry
2. I am sleepy = I am sleepy
3. I am tired = I am tired
4. Nice dress = Nice cleavage!
5. I love you = Let's have sex now
6. I am bored = Do you want to have sex?
7. May I have this dance? = I'd like to have sex with you
8. Can I call you sometime? = I'd like to have sex with you
9. Do you want to go to a movie? = I'd like to have sex with you
10. Can I take you out to dinner? = I'd like to have sex with you
11. I don't think those shoes go with that outfit = I'm gay

No voices this time

I had lunch is one of my classmates today. She's a petite, Korean girl - probably weighs about 85lbs, dress size '0.' I had the small chef salad and a skim milk. She had a cheeseburger and a Krispie Kreme doughnut. Life just isn't fair.

Part II of ethical dilemma theater to be posted tonight...
Plus, a bit of good news. My paper on medical futility as a justification for DNR orders is going to get published by a student publication out of California. Yes! Few people know this about me but, while I have the more immediate goal of becoming a doctor, I'd eventually like to become editor-in-chief of the American Journal of Bioethics or some similar publication. I then plan to use that position as a springboard, launching myself into a series of bloodless conflicts after which I find myself in a situation where I happen to be ruler of the free world. It's all part of the 75 year plan which, so far, appears to be right on schedule :)

Ethical dilemma theater: Part I

The following is a real ethical dilemma involving a real patient at our hospital. The details have been changed to protect the innocent. And the guilty.

Dr. Bradshaw holds rounds in a small conference room on the inpatient psych unit. There are 4 medical students on his service, a resident and a social worker who takes care of things like discharge planning, court hearings, setting patients up with social services - in other words, 90% of all the useful things that happen on the psych ward. Lynne was the medical student who had been on call the previous night and she had admitted a new patient to Dr. Bradshaw's service. She began presenting the patient to the team, "F.P. is a 55 year old male with a history of bipolar disorder and alcohol abuse..." This is the part where most of the other medical students fall asleep before arousing once again to present our own respective patients. But something in Lynne's presentation caught our attention. She went on, "Patient denies anhedonia and feelings of worthlessness or hopelessness. He says he often feels guilty because he killed 2 people in 1978, no suicide ideation or homicide ideation..." The rest of us looked at each other. Had we heard correctly? Had I fallen asleep briefly and had a hypnogogic auditory hallucination? When she was done, Dr. Bradshaw asked,
"What would you like to do?"
Lynne's answer came out as casually as if she had been ordering a turkey sandwich at the deli, "Restart his mood stabilizer at it's previous dose, give 100mg of trazodone to help him sleep at night, put him in touch with social services so he can start collecting disability and call the police."
This prompted a very long and emotional discussion of patient confidentiality vs. duty to protect, vs. justice. No real consensus was achieved.
Luckily for us, the law is pretty clear. We're never allowed to violate patient confidentiality except in some very specific circumstances (i.e. suspicion of child abuse, elder abuse, the person poses an immediate danger to someone, the reporting of certain infectious diseases and in some states, parents must be notified if a minor is having an abortion). This patient hadn't made any specific threat. What would you do?
Here's what we did - we called Legal Affairs (read: copped out). They were out to lunch. We're still waiting for them to return our call.

Shock therapy

You thought maybe this went out of style during the McCarthy era? You thought that this is kind of stuff that can only happen in movies like, A Beautiful Mind or One Flew Over the Cuckoo's Nest? You'd be wrong.
Medical students at my school are required to attend at least one session of ECT (electroconvulsive therapy) in order to pass their psychiatry rotation. ECT is mainly used today to treat intractable depression. It's done a little more "humanely" that it once was, but the principle is still the same. The patient is sedated using something like thiopental or ketamine, a tourniquet is placed on an arm or a leg and succinylcholine (a paralyzing muscle relaxant) is given. The tourniquet is to keep the succinylcholine from reaching that limb so we can verify that the patient is having a seizure. The succinylcholine is mostly for our benefit - so we don't have to watch the patient flopping around. Two electrodes are placed - one on each temple - and a charge is administered. Somehow, out of the 3 medical students observing, I was the one that had the dubious pleasure of holding one electrode while the shock was given. The patient's facial muscles tensed violently for about a second, the current was stopped and the prototypical rhythmic jerking of a myoclonic seizure was seen in the tourniqueted left foot. This lasted about 25 seconds.
Alright, I don't care what the literature says, the idea that inducing a seizure can somehow be therapeutic is just plain crazy to me. If there were studies showing that kicking someone in the balls repeatedly improved their depression, would you do it? How many times would you do it? If the patient didn't improve after 10 kicks to the groin, would give him another 10 kicks? Another 100? It's insane.
So, that's my biased, uninformed opinion. I'm going to read some articles on the subject now. Maybe it will change my mind completely and I will recant everything I said in this post. But, I doubt it.

Grand rounds: edition 24

Check out this week's Grand Rounds. Thanks to Hospice Guy for hosting. My own contribution is here. Submissions for next week should be sent to Orac at Respectful Insolence.

Welcome to the psych ward - you can check out any time you like, but you can never leave

My new resident on the in-patient psych unit is tall and lanky, wears a scruffy beard (the goatee portion is one length and the rest is another) and wears his fiery red hair in a long pony-tail. I imagine him having studied something like philosophy as an undergrad. A little eccentric but, if you saw him walking down the street, you probably wouldn't look twice - certainly not in an urban setting like ours. Seems like a perfectly acceptable style for a psychiatry resident, but does anyone know any neurosurgeons who present thusly? Anyway, I like him. He seems like a really smart guy.
At rounds this morning, his attending decided that one of the patients on our service - a 65 year old man with bipolar disorder and an acute exacerbation of his manic symptoms - was not fit to leave the hospital. The man had signed himself into the hospital voluntarily when his caseworker found he was having delusions of having won the lottery and making plans to rent a hall for a party to which he was going to invite 75 people. He was otherwise very much intact - having some trouble sleeping but no signs of depression, suicidality, homocidality or other psychotic symptoms. His biggest complaint was being upset at not being able to leave.
Here is a disturbing fact I learned today: In our state, if you're hospitalized in a psychiatric ward and decide you want to leave, the hospital can keep you for up to 5 days before being obligated to come up with a justification for keeping you. There are only 3 such justifications - 1. you are mentally ill and a danger to yourself or others, 2. you are mentally retarded and a danger to yourself or others, 3. you would be unable provide for your own basic needs if discharged. This means that (as happened in this case) some people who come into the hospital voluntarily will be forced to stay involuntarily! WTF?! If the person was competent to sign themselves in and their condition hasn't deteriorated since coming admission how is it that they are not also competent to sign themselves out?
Well, apparently this patient wasn't competent to sign himself out based on criterion #1? #3? The resident totally disagreed with this assessment and I think he was right. He racked his brain for awhile, thinking about what he was going to write on the certification form. The patient wasn't agitated. He hadn't made any specific threats except for the threat to sue for $5 million for every day that he couldn't leave. The resident wrote down some B.S. about the delusions in the chart. Ethics can be so pesky sometimes.

Psychotic symptoms due to reduced glucose intake

I think I’ve got the upper hand in the ongoing calorie war now. I came home to my parents’ house for dinner tonight. We ordered Chinese food. When my mom, my dad and I order Chinese food, we always get 2 orders of egg rolls. There are 2 egg rolls in an order, making for a total of 4 egg rolls. My mom eats one, my dad eats one and I eat one. Inevitably, I’m offered the left-over egg roll, and inevitably I can’t resist it. This has been going on for years.
My dinner tonight would consist of the following:

½ of a small order of curried chicken with some white rice
4-5 spoonfuls of vegetarian fried rice
1 egg roll
12 ounces of carbonated water (I love that stuff)

Don’t think I wasn’t tempted by that last egg roll. It stared at me from the communal serving dish. I stared back at it. It begged me to eat it, tempting me with its crispy, fried outer shell. It said, “Take me, or someone else will take me first!” I ignored it. “Don’t be a fool,” it refused to be ignored. “Eat me now! You may not get another opportunity to eat Chinese for weeks!”
“No!” I said. “Stop tormenting me, damnit! You can’t control me, so just shut up.”
My mother put down her fork which had frozen midway between plate and mouth. “Who were you talking to?” Whoops. My mouth, tongue and larynx had just conspired to form words that I had meant to say only in my head.
“You heard me. I said, shut up and stop trying to control my life.” I hadn’t actually been listening to what she had been talking about while I had was having my private diatribe with the egg roll, but odds were at least 1:1 that it was something critical about the way I run my life.
“I’m sorry.” She looked down at her plate. “I know you are capable of making your own decisions. I won’t say anything more about it.
Phew – that was a close one! I wiped my mouth, wiped my brow and excused myself with both appearances and will power in tact.

A 20 year old man came to our clinic the other day. The referral form from the screening clinic downstairs said, “Bipolar disorder with psychotic features and a history of ADHD since childhood.” He had been given a prescription for an antipsychotic. His answers to my questions about depressive symptoms and manic symptoms raised suspicions in me as to whether his diagnosis of bipolar disorder had been incorrect. I went on to try and flush out these “psychotic features.”
Q: Do you ever see things that aren’t there?
Ans: No.
Q: Do you ever see things that other people don’t see?
Ans: Yes, I see things that other people don’t see. But those things are actually there.
Q: What kinds of things do you see?
Ans: Ghosts. Spirits. Some of them are people I recognize, others I don’t know.
Q: Do you ever hear voices?
Ans: Yes.
Q: What kind of voices?
Ans: Voices of people I knew when I was 5.
I pursued this further. It turns out he was involved in this awful childhood experience at that age where he and 6 friends were kidnapped and held in a basement for 2 days where they were given drugs and were sexually abused. 4 of them were murdered but he and 2 others escaped. It’s their voices that he hears, voices of the ones who died. They ask how he’s doing. He talks back to them sometimes, as long as no one’s around. I asked if he’d ever talked about this experience with a doctor before. He hadn’t! I couldn’t believe it. Having been treated for psychiatric illnesses since childhood you’d think it would have come up at some point. The upshot is, Dr. Wilson was also unconvinced by the previous diagnosis of bipolar and we lowered the dose of mood stabilizer that he was on. The hallucinations? My guess is that he has subclinical PTSD. He believes that spirits really do appear to him. In the absence of any other psychotic symptoms, who are we to say different? Maybe spirits really do appear to him. Either way, I don’t think my own personal beliefs about the spiritual realm (or lack thereof) have any place in determining what a patient’s treatment should be. If a psychiatrist is an atheist, should he give his Christian patients Haldol to make their belief in God go away? Of course, what if God is telling the patient to hurt people, or to throw herself in front of traffic? Luckily, we didn’t have to worry about those kinds of things with this patient. His “hallucinations” were entirely undistressing to him. I think not “treating” them was the right thing to do. We discontinued the antipsychotic.

As for the egg roll, I think my brain just needs time to adapt to the new diet. Before too long, those neurons will be metabolizing ketones like nobody’s business.

Diagnosis: evil

I always love the lecture on personality disorders. It's my favorite part of psychiatry. Also scary, as we identify traits in ourselves that are associated with various pathological personality types. I don't meet the DSM criteria for having a personality disorder. But, if I did, I'd probably be a Cluster C - avoidant, dependent, obsessive/compulsive. Here's what an online quiz had to say about it:

Disorder	Rating
Paranoid:	Low
Schizoid:	Low
Schizotypal:	Low
Antisocial:	Low
Borderline:	Low
Histrionic:	Moderate
Narcissistic:	Moderate
Avoidant:	Moderate
Dependent:	Low
Obsessive-Compulsive:	Low
-- Personality Disorder Test - Take It! --

The discussion of personality disorders, particularly antisocial, reminded me of an article I read a few weeks ago (abstract here) about whether there are people who transcend our diagnostic acuity and are just plain evil. I've satisfied myself that the question of whether someone is evil is between that person and god and that there's really nothing else for the rest of us to say about it. It has nothing to do with the heinousness of the act, but everything to do with the individual's culture, his own moral beliefs and his psychological state.

I kind of forgot where I was going with this post. The only other relevant thing I can think of at the moment is: don't ever date someone who's borderline. Or, if you're female, stay away from those antisocial types.

Please welcome...God

Please welcome, the first ever guest writer at Blog of the Anonymous Clerk, God

I hope you're not too down today. I realize your visit to the clinic didn't go quite as you had hoped. Try to realize that they mean well. But, like you and like everyone, they are imperfect human beings. They want to help, but sometimes they let their own agenda get in the way. But don't tell them about our conversations, whatever you do! If you do, they'll think you're crazy. And you're not crazy. You're enlightened. They haven't seen the light and until they become Born Again Believers like you, they won't understand. Putting those dark days behind you was the right thing to do. Since you've found me, there's no need to speak of those days anymore. Talking about this past gives life to what should not be remembered, let alone spoken of. One day, they will believe as you do and they will understand. I will help you through these days. We will talk and I will help you cope. These people can't help you now. If you tell them, they will only think you are crazy and they won't help you. They'll hurt you like the others did. But that young man in the short white coat really does want to do his best for you. Try not to hold it against him - he just hasn't seen the true reality yet. You have. You are saved.


Inspired by this post at intueri.org.

A short trip to Hypoglycemia

When you enter our medical school as a first year student, you are paired with an upperclassman who is designated your "big sib." My little sib happens to live in the apartment directly above me and she is cute! Today was the first time I had an excuse to knock on her door. It was our annual "big sib dinner," and I thought it would be nice for us to walk over there together. We had Thai food. I gave some big brotherly advice. Midway through the dinner, my own big sib showed up. She had just come from the OR - she was on plastics and they were replacing a patient's jaw with his fibula. So there we were. 3 generations of sibs. Pretty wild stuff.
It was my turn to volunteer at the homeless shelter tonight. This is the part where upperclassman teach the underclassman how to do a focused history and physical and how to write a good note. I hope I wasn't completely useless to my underclassman tonight. My mind just wasn't there. As you can probably tell from the quality of this post, my mind really isn't here either. It's because I'm on a diet now - restricting my caloric intake. Not enough glucose to the brain.