The Curious Psychology of “Disability”

December 28, 2011

I’ll start this post with a brief clinical vignette:

I have been seeing Frank, a 44 year-old man, on a regular basis for about six months.  He first came to our community clinic with generalized, nonspecific complaints of “anxiety,” feeling “uncomfortable” in public, and getting “angry all the time,” especially toward people who disagreed with him.  His complaints never truly met official criteria for a DSM-IV disorder, but he was clearly dissatisfied with much in his life and he agreed to continue attending biweekly appointments.  Frank once requested Xanax, by name, but I did not prescribe any medication; I never felt it was appropriate for his symptoms, and besides, he responded well to a combined cognitive-interpersonal approach exploring his regret over past activities as a gang member (and related incarcerations), feelings of being a poor father to his four daughters, and efforts to improve his fragile self-esteem.  Even though Frank still has not met criteria for a specific disorder (he currently holds the imprecise and imperfect label of “anxiety NOS”), he has shown significant improvement and a desire to identify and reverse some of his self-defeating behaviors.

Some of the details (including his name) have been changed to preserve Frank’s privacy.  However, I think the general story still gets across:  a man with low self-worth, guilty feelings, and self-denigration from his overidentification with past misdeeds, came to me for help.  We’ve made progress, despite a lack of medications, and the lack of a clear DSM-IV (or, most likely, DSM-5) diagnosis.  Not dramatic, not earth-shattering, but a success nonetheless.  Right?

Not so fast.

Shortly after our appointment last week, I received a request for Frank’s records from the Social Security Administration, along with a letter from a local law firm he hired to help him obtain benefits.  He had apparently applied for SSI disability and the reviewers needed to see my notes.

I should not have been surprised by this request.  After all, our clinic receives several of these requests each day.  In most cases, I don’t do anything; our clinic staff prints out the records, sends them to SSA, and the evaluation process proceeds generally without any further input from us (for a detailed description of the disability evaluation process, see this article).  But for some reason, this particular request was uniquely heartbreaking.  It made me wonder about the impact of the “disability” label on a man like Frank.

Before I go further, let me emphasize that I’m looking at Frank’s case from the viewpoint of a psychiatrist, a doctor, a healer.  I’m aware that Frank’s family is under some significant financial strain—as are many of my patients in this clinic (a topic about which I’ve written before)—and some sort of welfare or financial support, such as SSI disability income, would make his life somewhat easier.  It might even alleviate some of his anxiety.

However, in six months I have already seen a gradual improvement in Frank’s symptoms, an increase in his motivation to recover, and greater compassion for himself and others.  I do not see him as “disabled”; instead, I believe that with a little more effort, he may be able to handle his own affairs with competence, obtain some form of gainful employment, and raise his daughters as a capable father.  He, too, recognizes this and has expressed gratitude for the progress we have made.

There is no way, at this time, for me to know Frank’s motives for applying for disability.  Perhaps he simply saw it as a way to earn some supplementary income.  Perhaps he believes he truly is disabled (although I don’t think he would say this—and if he did, I wish he’d share it with me!).  I also have no evidence to suggest that Frank is trying to “game the system.”  He may be following the suggestions of a family member, a friend, or even another healthcare provider.  All of the above are worthwhile topics to discuss at our next appointment.

But once those records are sent, the evaluation process is out of my hands.  And even if Frank’s request is denied, I wonder about the psychological effect of the “disability” label on Frank’s desire to maintain the gains he has made.  Labels can mean a lot.  Psychiatric diagnoses, for instance, often needlessly and unfairly label people and lead to unnecessary treatment (and it doesn’t look like DSM-5 will offer much improvement).  Likewise, labels like “chronic,” “incurable,” and “disabled” can also have a detrimental impact, a sentiment expressed emphatically in the literature on “recovery” from mental illness.  The recovery movement, in fact, preaches that mental health services should promote self-direction, empowerment, and patient choice.  If, instead, we convey pessimism, hopelessness, and the stigma of “disability,” we may undermine those goals.

As a healer, I believe that my greatest responsibility and most difficult (although most rewarding) task is to instill hope and optimism in my patients.  Even though not all of them will be entirely “symptom-free” and able to function competently in every situation life hands them, and some may require life-long medication and/or psychosocial support (and, perhaps, disability income), I categorically refuse to believe that most are “disabled” in the sense that they will never be able to live productive, satisfying lives.

I would bet that most doctors and most patients agree with me.  With the proper supports and interventions, all patients (or “users” or “consumers,” if you prefer those terms) can have the opportunity to succeed, and potentially extricate themselves from invisible chains of mental illness.  In Frank’s case, he is was almost there.

But the fact that we as a society provide an institution called “disability,” which provides benefits to people with a psychiatric diagnosis, requiring that they see a psychiatrist, and often requiring that they take medication, sends a very powerful—and potentially unhealthy—psychological message to those who can overcome their disability.  To Frank, it directly contradicts the messages of hope and encouragement I try to offer at each visit.  It makes him dependent upon me, rather than upon himself and his own resources and abilities.  In other words, to a man like Frank, disability is anti-recovery.

I don’t have an easy answer to this problem.  For starters, changing the name of “disability” to something like “temporary psychological material support”—a substitute label, nothing more—might be helpful.  Also, rewarding recipients (e.g., not repealing their benefits) for meeting predetermined milestones of recovery (part-time work, independent housing, etc) may also help.  But the more I think about the life-affirming and empowering potential of recovery, and about how we allocate our scarce resources, the more I believe that the recovery-based—as opposed to disability-based—practice of psychiatry has much more to offer the future of our patients, our profession, and our nation, than the current status quo.  For the sake of Frank’s recovery, and the recovery of countless other men and women like him, maybe it’s time to make that happen.

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(Mis)informed Consent

December 20, 2011

Over the years, the practice of medicine has become less of an art, and more a process of crossing T’s and dotting I’s.  “Treating the chart” has become, in many ways, more important than treating the patient, and it seems that the pen—or, rather, the electronic medical record—has emerged as a more valuable tool than the stethoscope or reflex hammer.

For psychiatrists, one of the pesky little details of any office visit is obtaining “informed consent.”  Most commonly, this is the document—signed by the patient—stating that he/she has been fully informed of the reason they’re being prescribed a medication, the potential risks of taking said medication, and any possible alternatives.  Most private insurers and hospitals, and all Medicaid programs, require this documentation in the charts of patients seeing mental health specialists, and (at least in my experience) these documents are frequently sought in chart audits.

What do I mean by “pesky”?  Put briefly, the process of obtaining informed consent can be time-consuming, and some doctors worry that it might actually interfere with treatment.  In a 2004 survey, for instance, 44% of psychiatrists reported that “informed consent … increases patients’ anxiety.”  With respect to antipsychotics, nearly 20% of psychiatrists in the same study admitted “it is good practice to withhold information about tardive dyskinesia from some patients.”  As a result, patients are often poorly informed about the meds they take.  In a 2001 study of psychiatric inpatients in Scotland, fewer than half knew the reason they were receiving medication, the side effects of those medications, or even remembered getting an explanation from staff.  (But, according to the survey, far more than half were “happy to take all medications”!!)

I was recently asked for some suggestions on how to improve the medication-consent process in my outpatient clinic.  I must admit, the current process is atrocious.  Our forms are 10+ years old, with general descriptions of each class of medication (and, of course, they lack any drug introduced in the last decade); and they have that “photocopy of a photocopy” appearance, with faded margins and text at a crooked angle.  But hey, no big deal—they’re just papers to sign and stick in the chart, basically.  In the community clinic where I work part-time, the process is even more rudimentary: we have one generic form with no drug names or descriptions; the front-desk staff asks each patient to sign the form before each visit, and afterward I simply write in the name of the medication(s) I’ve prescribed.

In thinking of ways to improve the process, I’ve come to realize that it may provide an opportunity for some meaningful change in our treatment approach.

First of all, there’s no excuse for not describing the potential adverse effects of the drugs we use, but we must be cautious not to trivialize this process.  Most psychiatrists I know, for example, have a readymade “speech” about the potential for rash with Lamictal, or weight gain with Zyprexa, or sedation with Seroquel.  (See this post at Shrink Rap—and its comments—for more on this perspective.)  But if the patient hears this as just a “speech,” it’s less likely to be meaningful, just like the pre-flight safety lectures you hear on airplanes.  I advise my students and residents to pretend they’re prescribing to their spouse, parent, or child, and give all the information they would want to hear about each new drug.  (This includes how to stop the medication, too.)

Second, just as important as the potential adverse effects, I believe that patients need to hear more specific explanations of how the drug might actually provide some benefit.  All too often we give a feeble explanation like “this Prozac should make you feel better in a few weeks” or ” Valium might calm your nerves a bit” or “since you haven’t responded to your antidepressant, here’s some Abilify to help it along.”  We owe it to our patients (and to ourselves) to provide more detailed explanations.  To be sure, most patients don’t need to hear a molecular mechanism, complete with pKa values or details of CYP450 metabolism, but we ought to have this information in our heads, and we must know how we’re using this information to treat the patient in front of us.  When a patient asks how an antipsychotic might help their depression, or why an anticonvulsant might help stabilize their mood, we must give an answer.  (And if no good answer is possible, we need to rethink our treatment plan.)

Third, it is equally important to discuss treatment options with a patient.   When patients ask “is there anything else I can do or take?” the ensuing discussion might extend the appointment by a few minutes, but it always leads to a more collaborative dialogue (unless, of course, the patient is fishing for a Xanax prescription or a month’s supply of Seroquel to sell for cash).  A discussion of alternatives often gives an indication of what the patient wants, what the patient values, and how we can best promote the patient’s recovery.

Finally, the informed consent process really should be extended to non-psychiatrists who prescribe these agents.  Primary-care docs routinely prescribe antidepressants, benzodiazepines, psychostimulants, and mood stabilizers (and, of course, my personal favorite, “Seroquel for sleep”), without a discussion of risks, benefits, and alternatives, or (in most cases) a signed consent form.  Heck, even gastroenterologists prescribe Reglan, which is as likely to cause tardive dyskinesia as many of the antipsychotics we use in psychiatry, and pain specialists are fond of Cymbalta (an SNRI with some potentially nasty withdrawal effects) for “chronic pain.”  These providers should recognize the potential risks (and mechanisms) of psychotropics, just as psychiatrists do, and share them with their patients.

So even though we might look at obtaining informed consent as a “necessary evil,” we should instead look at it as a way to enhance treatment.  If nothing else, this would force us to think about what we do and why we do it.  It would enable us to honestly evaluate the true benefits and risks of what we prescribe, and maybe steer us in a different—and healthier—direction.


Is the Criticism of DSM-5 Misguided?

December 15, 2011

In 2013, the American Psychiatric Association will publish the DSM-5, the next edition of its diagnostic manual.  Public reaction has, thus far, not been favorable.  Critics decry the lowering of diagnostic thresholds in existing criteria; the conception of new diagnoses seemingly “out of thin air”; the radical overhaul of entire sections (like the personality disorders); and the secrecy under which many of the earlier planning stages were held.

Much of the criticism, including that from its most vocal critic, Allen Frances (lead author of the current edition, the DSM-IV), laments the expansion of diagnostic criteria.  They argue that this may increase the number of “mentally ill” individuals and/or pathologize “normal” behavior, and lead to the possibility that thousands—if not millions—of new patients will be exposed to medications which may cause more harm than good.

The American Psychological Association, the British Psychological Society, and the American Counseling Association have expressed their opposition publicly.  An online petition from the Society for Humanistic Psychology (part of the APA) has garnered nearly 9,000 signatures in fewer than 60 days.

I understand and sympathize with the critics, particularly against the DSM‘s emphasis on “user acceptability” over validity (and, in the interest of full disclosure, I did sign the petition).  But I wonder whether the greater outcry against the DSM-5 is somewhat misdirected. The DSM-5 may very well turn out to be a highly flawed document, but that’s all it will be: a document.  Whether it results in the “overdrugging and overdiagnosing” predicted by critics like Frances is not the primary responsibility of its authors, but of those who will use the book.  And this is where the outrage should be directed.

First of all, let’s just state the obvious:  it is impossible to write a comprehensive, scientifically valid catalog of all mental illnesses (particularly when some argue convincingly that mental illness is itself a false concept).  When we’re talking about conditions that have both biological and sociocultural origins (in fact, this has long been part of the distinction between “neurologic” and “psychiatric” disease), it seems clear that a diagnostic manual will never capture the full spectrum of psychiatric disorders.  Even if we included semi-accurate biological markers in the diagnostic criteria—a Holy Grail we’re far from attaining—mental illness will always, in the end, depend primarily upon the patient’s subjective experience.

Thus, the DSM-5, like all DSM’s before it, will be, almost by definition, incomplete or deficient.  It will be a descriptive tool, a taxonomy, a guidebook, featuring the authors’ best guess as to what might constitute a treatable condition.  For example, in real life there is no one thing called “major depressive disorder” as it appears in the DSM-IV (in fact, there are 1,497 variations).  Nonetheless, we use “MDD” to label all of our patients with these combinations of symptoms, because it’s the best fit.  But a good mental health professional doesn’t treat MDD, he or she treats the person with MDD.  Calling it “MDD” is only necessary for insurance billing, for drug companies to get FDA approval for new pharmaceuticals, and for patients and docs to give a name to (and, if necessary, demystify) their condition.

In other words, the danger lies not in the label, but in how we use it.  In fact, one might even argue that a lousy label—or a label that is so nonspecific that it applies to a broad swath of the population, including some in the “normal” part of the spectrum (wherever that may be)—may actually be beneficial, because it will be so meaningless that it will require the clinician to think more deeply about what that label is trying to convey.

As an example, consider “chronic pain,” a label frequently applied to patients and written in their charts.  (Even though it’s often written as a diagnosis, it is really a symptom.)  “Chronic pain” simply implies that the patient experiences pain.  Nothing more.  It says nothing about the origin of the pain, what exacerbates or soothes it, how long the patient has experienced it, or whether it responds to NSAIDs, opioids, acupuncture, yoga, or rest.  When a new patient complains of “chronic pain” to a good pain specialist, the doctor doesn’t just write a script; he or she performs an examination, obtains a detailed history and collateral information, and treats in a manner that relieves discomfort yet minimizes side effects (and cost) to the patient.

Perhaps this is what we can do in psychiatry, even with the reviled new DSM-5 diagnoses like “Attenuated Psychosis Syndrome” or “Disruptive Mood Dysregulation Disorder.”  Each of these new “diagnoses” suggests something about the patient and his or her behavior or experience.  But neither one should predict a course of treatment.  In fact, a vague diagnosis should actually prompt the doctor to probe more deeply into a patient’s symptoms and determine their impact on the patient’s well-being and functional status (which may actually help improve disability evaluations, too).  On a population basis, the heterogeneity of patients given a diagnosis might stimulate further research (neurobiological, psychological, epidemiologic, maybe even anthropological) to determine more specific subtypes of illness.

Will the new diagnoses be “overused”?  Probably.  Will they lead to “overdrugging” of patients—the outcome that everyone fears?  I guess that’s possible.  But if so, the spotlight should be turned on those who do the overdrugging, not on the document that simply describes the symptoms.  This may turn out to be difficult: official treatment guidelines might come out with recommendations to medicate, insurance companies may require diagnoses (or medications) in order to cover psychiatric services, and drug companies might aggressively market their products for these new indications.  And there will always be doctors who cut corners, arrive at diagnoses too quickly and are eager to use dangerous medications.  But these targets, ultimately, are where the anti-DSM-5 efforts should be placed, not on its wholesale rejection.

In the end, one could argue that the DSM-5 is unnecessary, premature, and flawed.  Unfortunately, it simply reflects our understanding of mental illness at this point in time.  But is it a “dangerous public health experiment,” as Allen Frances has warned?  Only if we allow it to override our eyes and ears, our hearts and minds, and what our patients truly need and want from us.   In the end, it’s just a book.  What really matters is how we use it.


Prove That You Need Me

December 11, 2011

I’ll confess, sometimes after I see a patient I ask myself, “was that really necessary??”  That’s not to suggest that the interaction was a complete waste of time, or that I regularly provide treatment that is excessive or harmful, but I am frequently reminded of an observation I first made many years ago:  we in psychiatry provide a lot of “care” that might be considered unnecessary and, in the long run, wasteful and inefficient.

(Note: I am specifically referring here to certain aspects of outpatient mental health treatment.  The same might occur in other medical specialties, but those aren’t my areas of expertise, so I can’t comment.  Furthermore, I am NOT referring to regular health-maintenance visits to one’s primary physician, pediatrician, or OB-GYN, in which the “care” consists of an examination and, if necessary, screening tests or preventive measures.)

Consider the following examples of wasteful, inefficient care in psychiatry.

I see many patients (particularly in the community setting) who have been “treated,” often irregularly and infrequently, by a variety of psychiatrists or other physicians who have doled out a half-dozen psychiatric diagnoses and a laundry list of medications.  When I see patients like these, their complaints are usually vague and nonspecific, adherence to past treatments has been questionable, and a substance-abuse component is often present.  While these patients may indeed suffer from mental illness (or, in many cases, simply face profound psychosocial stressors that the system allows us to call mental illness), it is unlikely that these patients will receive the resources they truly need from conventional psychiatric practice.  However, it’s convenient—for us as a society—to shunt them into the psychiatric juggernaut, where they often lose any hope for lasting recovery.

Another example is the patient living in difficult, stressful circumstances who is referred to a psychiatrist by a social service agency or by the criminal justice system “for an evaluation.”  Again, these individuals may face huge psychosocial stressors—and may indeed benefit from professional assistance of some sort—but psychiatric care?  It’s hard for a psychiatrist to say no.  Instead, we give a diagnosis, frequently an “NOS” diagnosis, which, in practice, means “he sort of looks like he might have depression or an anxiety disorder or psychosis, but we’re not sure yet.”  This may be justifiable at first, but unfortunately these diagnoses tend to stick—and, interestingly, patients are rarely undiagnosed—locking the patient into a neverending roller-coaster of medication trials and, not uncommonly, a lifetime of psychiatric “disability,” at great expense to all.

Finally, there are those individuals who see a psychiatrist at the urging of their primary doctor or a family member.  They may complain of very legitimate symptoms of irritability or mood lability, guilt or sadness over a recent loss, sleep disturbance or anxiety, or chaotic personal relationships—phenomena which we have all experienced to various degrees.  Sometimes these symptoms are incapacitating; sometimes not.  But we psychiatrists are good at making square pegs fit into round holes; through our DSM-tainted lenses, we give whatever diagnosis “fits best”—often the dreaded “NOS,” discussed above.  Furthermore, because many of us are loath to send a patient home empty-handed—and ill-prepared to do anything other than diagnose or prescribe— we give a medication which we think might “work.”  (And if it does, we see it as affirmation of our diagnosis, but that’s material for another post.)

These three situations are common in psychiatry.  I’m absolutely not saying that patients like these should be denied treatment, “shown the door,” and asked never to return.  As a mentor taught me many years ago, no one sees a psychiatrist when everything in his or her life is perfect.  But sometimes we fail to recognize that the psychiatrist may approach the patient and his or her complaints in the wrong way.

I believe that, when evaluating patients, psychiatrists should use the tools of scientific investigation:  an open mind (although we can use our past experience and intuition, as long as we search for data to support it, too), deep interest and curiosity, a systematic method of analysis, and, most importantly, the lack of bias or predetermined outcome.  A significant aspect of this “data collection” is an accurate assessment of the patient’s resources and ability to overcome his symptoms; if his resources can be augmented by psychotherapeutic intervention or by medication, fine, but if not (or if an accurate assessment of his strengths shows that such intervention is unnecessary), then we must have the willingness to say no and back out.

Let me emphasize once again, I am NOT saying that we should be skeptical of patients, or ignore their complaints.  But we need to acknowledge we are predisposed (as a result of our training, the nonspecificity of the DSM-IV, and the current treatment paradigm in psychiatry) to see “mental illness” where it may not exist, and prescribe drugs in response.  As a result, patients sometimes feel that their complaints “aren’t heard” or are “misunderstood.”  Alternatively (and worse, in my opinion), some patients may actually buy into the diagnosis (when in fact it may just be a figment of the doctor’s—or the APA’s—imagination) and use it as an excuse or a rationale for not taking other measures to engage in lifestyle change.  To provide truly compassionate and patient-centered care, we must act differently.

I know some psychiatrists will respond, “I always see my patients with an open mind, I’m fair and honest, and I give the patient the benefit of the doubt.”  Of course, there are exceptions, but as a product of psychiatric training within the last decade, I can attest to the fact that this approach is rare.

Psychiatrists are taught to look for pathology, not health.  And as they say, “seek and ye shall find.”

A more life-affirming and empowering strategy might be for the psychiatrist to (a) first evaluate a person’s strengths and assets, (b) carefully assess the patient’s goals or desires, (c) determine what prevents him or her from achieving those goals, and, most crucially, (d) determine whether the psychiatrist has the means to help the patient achieve those goals (not necessarily to “correct a symptom” or “treat a diagnosis”).  Then and only then can treatment commence.  Otherwise, we’re spinning our wheels, misleading our patients, wasting our time, and serving no one.


We Do Not Know What We Cannot Know

December 5, 2011

Who provides the best mental health care?  I’m not referring to the relative merits of psychiatrist vs. psychologist, academic center vs. private practice, or meds vs. therapy.  No, I’m referring to the actual individuals providing the treatment, and the background that they bring to the therapeutic interaction.  We like to talk about education and degrees, publications and professional designations, but to the patient, do these really count for anything?

Why do I ask?  Readers of this blog are aware that I do some part-time work in community mental health, and while I feel that I have a good rapport with most of my patients there, they couldn’t care less about where I went to school or how many publications are on my CV.  By the same token, I cannot relate with much of what they experience in their day-to-day lives.  The symptoms they report almost surely have a very different meaning to them, than the same symptoms would to me or to someone in my family.

I also work on an inpatient psychiatric unit where, again, we doctors are on a different plane than the patients we treat.  In fact, I’ve been impressed by the degree (and duration) of peer interaction, even in these acutely ill patients, and wonder whether this may be a significantly therapeutic component of their hospital stay.  I regularly see groups of two or three patients sitting together, discussing medications, family or relationship problems, legal issues, or—as I experienced just the other day—simply singing or dancing with each other.  It seems as if patients can trust their peers far more easily than their providers, who aren’t in their shoes.

And in the addiction field, “mutual support” (12-step meetings or other group therapy), in which the “therapeutic breakthroughs” come not from professional staff but from the influence of peers, provide the foundation of most of our treatment approaches.  Having had my own experiences as a patient, too, I can attest to the fact that my peers often “got” me far more effectively than those I was paying to do so.

Is this necessarily a problem?  After all, a surgeon doesn’t have to experience colon cancer to perform a bowel resection, an internist doesn’t need to be diagnosed with diabetes to understand its management, and a man can be an excellent obstetrician even though he’ll never give birth to a child.  Even in mental health, professionals can be quite astute and eminently capable, even without a history of mental illness themselves (even though we’re often accused by our colleagues as selecting this profession to cure our own problems!).

But it might be time to reevaluate this.  As a psychiatrist, I may understand the neuropharmacology of SSRIs and antipsychotics, the (supposed) biological basis of depression, and the foundations of cognitive behavior therapy more deeply than any of my patients, but in the long run, does any of this matter?  It’s bad enough that we lump together all sorts of symptoms as “major depression”; it gets infinitely more complex when we consider the vast range of circumstances that give rise to a person’s symptoms, and only the patient—or someone who shares the patient’s experience—can truly understand this.

Sometimes I feel like a fraud.  I’m expected to be objective and detached when, in fact, I’m dealing with subjective, emotional, and sometimes existential anguish that simply cannot be shared or felt by someone on my side of the couch (or desk, as it were).

How to remedy this?  For me, the best approach is not to view patients through the foggy and distorted lens of the DSM-IV, or with a narrow-minded focus on symptoms and medications, but rather to get to know them as I might wish to know a new friend.  I want to listen to their needs and desires, their intrinsic weaknesses and strengths (in a way, to not even see them as patients) and then provide whatever help or structure that they need—if I can.  Perhaps that type of engagement is not the standard of care, but patients seem to prefer it.

A very practical solution might be to rely on peer support more frequently than we do.  That is, ask patients to advise and connect with each other, rather than rely on ‘professionals’ like me.  (BTW, I’m not wishing my way out of a job; I truly believe that there will be a need for trained professionals to facilitate or oversee this process.)  We already know that the most effective non-pharmacological treatments for mental illness (e.g., the Soteria project) rely heavily on peer support.  The rise of social media has also empowered patients like never before.  Some of the most insightful (and respectful) information I have learned in this field comes from patient-oriented websites like Surviving Antidepressants, Beyond Meds, Holistic Recovery from Schizophrenia, and many others.  (In fact, I think it’s incumbent upon doctors to pay close attention to what’s written on sites like these—because these are the people who ask for our help!)

But maybe the most important thing we can do as professionals is to heed the advice shared by our patients and peers in the recovery community, which is to practice humility in our daily affairs.  We must acknowledge what we do not know.  And the most important information we do not have is what it’s like to spend a day in our patients’ shoes.  While we can share our expert knowledge with patients—and sometimes order treatments with which our patients disagree—we must ultimately respect the fact that our patients know themselves—and others like them—far greater than we do.


I Really Need To Lighten Up

December 1, 2011

Reading back over my last few blog posts, I realize I’ve done absolutely nothing to make psychiatry fun or interesting.  In fact, dear reader, you might think I’m a pretentious pedant, obsessed with irrelevant details that have nothing to do with what my patients really need.  And you know what?  You might be correct.  Treatment of depression by family practice docs?  BORING!!  A possible biomarker for cocaine relapseWho cares????  A new insomnia medication?  A real sleeper…

I realized today that I’m doing it all WRONG.  Not only can psychiatry be fascinating, but it can be cool.  As cool as a rap video.  Because that‘s what matters nowadays, right?  Don’t believe me?  Take a look at Steve Stahl’s DLPFC Rap:

No wonder I find psychopharmacology so dry.  It’s because I don’t realize how BADASS it can be!!!  I’m sitting here in my office, questioning antidepressant mechanisms, poring over datasets and p-values, and reading up on esoteric new interventions like concreteness therapy for mood disorders.  In the meantime, Steve Stahl and his NEI Global crew are partying on the beach in San Diego, rapping about the DLPFC.  It’s true.  I’m a loser.  Lame.  A real D-bag.

The DLPFC, for those “in the know,” is the dorsolateral prefrontal cortex.  I used to know it as Brodmann area 46, a cortical area responsible for executive function, planning, organization, and working memory.  But that’s boring sh*t for old farts like me, I guess.  After watching the NEI Global clip, I now know it as “all I need to know.”  That’s pretty tight.  It’s also “where the money is,” which is even more badass.  Dollar bill, y’all.

Why are those old, gray-haired APA dinosaurs spending all their time writing the new DSM-5???  Why do the guys in the journals recommend brain scans and genetic screens and personality tests and long-ass interviews???  Yo, get it together, Steve Stahl has already figured out that the DLPFC is responsible for “executive function, attention, concentration, impulses, emotions, obsessions, compulsions, motor [?], fatigue, ruminations, worry, pain, negative symptoms, guilt, and suicidality.”  What more do you need to know, bro???

So now, when a psych resident asks me what causes obsessions or suicidality, I can just answer, “Yo, homeboy, it’s the DLPFC.”  Then I can tell him to find a drug that acts on the DLPFC and say, “prescribe that sh*t!”  Even better, when a patient comes to my office and complains of pain or guilt or concentration problems, I can just whip out one of Stahl’s epic pix and say, “Chill out, sister, homey’s got yo back” and write a script for something that works on the DLPFC.  As the video says, “most of the symptoms are in the PFC!!!!”  Bitchin’!  Another satisfied customer!

Of course, I am kinda pissed off now because my med school profs and residency mentors made me study all that stuff about brain development, cognition, behavior, PLUS all that neuroanatomy sh*t not involving the DLPFC.  WTF???!!!!  Major waste of time, LOL!!!!!  ‘Cuz the DLPFC seems to be where it’s at (where’s this Beck Depression Inventory?).  All I need to do now is grab Stahl’s book or attend an NEI Global conference—or, better yet, look for drugs that affect the DLPFC—and I’m good to go!

Hey, mental illness is no laughing matter.  But learning about the part of the brain that causes mental illness can be LMFAO, can’t it??

[Thanks to the Neurocritic blog for the link to the DLPFC rap.]


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