Dr. X's Free Associations

Neuroleptic Malignant Syndrome

During my third year of graduate school, in addition my classes, I completed a 1-year diagnostic externship at a state hospital.  Most of that year was spent interviewing patients, administering tests and writing reports.  We did a little overnight ER duty, but not much.

Prior to that training year, I had only been on a psych unit twice before--once to drop something off to a classmate who was a tech at another hospital and once to visit a relative who was in an eating disorders program.

On my first day of the externship, as I was approaching the front double doors to the building where I was assigned, both doors abruptly flew open from the inside.  A couple of emergency techs were wheeling out a dead body on a gurney.

Inside the building, the staff was in an uproar, everyone making sure their own butts were covered, especially the neglectful non-clinical staff members who were mostly incompetent political patronage hires.

That was my introduction to Neuroleptic Malignant Syndrome.  Fortunately, that was also the only patient death during the year I worked at that hospital. The experience taught me to be on the lookout for NMS.

Emily Deans at Evolutionary Psychiatry wrote something I didn't know about the treatment of NMS:

(A rather unrelated aside - antipsychotic medications are well known for some pretty disturbing side effects. One of the scariest ones is called "neuroleptic malignant syndrome" where you get a high fever, stiffness, blood pressure spikes, and it can lead to kidney failure and death from muscle injury. One of the fastest treatments for NMS is electroshock therapy, believe it or not. What many people don't know is that schizophrenics institutionalized in the years prior to the invention of medication would suffer high fevers, stiffness, and death (it was called "malignant catatonia"). Now there is no question that the medicines cause NMS, but there is also an additional issue with the dopamine regulation in schizophrenia that could lead to autonomic dysfunction in a serious and fatal way. Just some food for thought.)

Fully Recovered

I returned to the gym this week and have already been there four times.  I took more than two months off, which is a very long stretch for me.  The pain caused by my shoulder injury subsided a while back, but normal sensation didn't return to my right hand until two weeks ago.  In a matter of days, I went from numbness and tingling to normal.  My approach now is to remain cautious--not pushing my luck with heavy weights. So far, so good, but I am very weak.

We're the Tea Party and We Don't Take Disaster Aid Like Those Black People

I received a viral email today from a person who considers himself a member of the Tea Party:

This text is from a county emergency manager in Minot, North Dakota Minot Daily News

WEATHER BULLETIN Up here in the Northern part of North Dakota we just recovered from a Historic event --- may I even say a "Weather Event" of "Biblical Proportions" --- with a historic blizzard of up to 25' of snow and winds to 50 MPH that broke trees in half, knocked down utility poles, stranded hundreds of motorists in lethal snow banks, closed ALL roads, isolated scores of communities and cut power to 10 ' s of thousands.

FYI:

Obama did not come. FEMA did nothing. No one howled for the government. No one blamed the government. No one even uttered an expletive on TV. Jesse Jackson or Al Sharpton did not visit. Our Mayor ' sdid not blame Obama or anyone else. Our Governor did not blame Obama or anyone else either. CNN, ABC, CBS, FOX, or NBC did not visit - or even report on this category 5 snow storm. Nobody demanded $2,000 debit cards. No one asked for a FEMA Trailer House. No one looted. Nobody - I mean Nobody demanded the government do something. Nobody expected the government to do anything either. No Larry King, No Bill O ' Rielly, No Oprah, No Chris Mathews and No Geraldo Rivera. No Shaun Penn, No Barbara Striesand, No Brad Pitts, No Hollywood types to be found. Nope, we just melted the snow for water. Sent out caravans of SUV 's to pluck people out of snow engulfed cars. The truck drivers pulled people out of snow banks and didn't ' t ask for a penny. Local restaurants made food, and the police and fire departments delivered it to the snow bound families.. Families took in the stranded people - total strangers. We fired up wood stoves, broke out coal oil lanterns or Coleman lanterns. We put on an extra layers of clothes because up here it is "Work or Die". We did not wait for some affirmative action government to get us out of a mess created by being immobilized by a welfare program that trades votes for ' sittin at home ' checks. Even though a Category 5 blizzard of this scale is not usual, we know it can happen and how to deal with it ourselves. (the email ends here)

A one minute search reveals:

Dec 23, 2009: Disaster Aid for 2009 North Dakota Floods Tops $150 Million

Seroquel: Softening the Black Box Warnings

Earlier this evening I saw a Seroquel XR commercial that promoted the use of Seroquel with antidepressants for the treatment of depression.  Either I've never seen a Seroquel commercial before or I haven't paid attention.

The narrator spends much more time listing possible adverse reactions than she spends describing the therapeutic use of Seroquel. But what most interested me was the way the narrator's tone of voice, the background music and the images worked together to hypnotically offset the negative impact of the script she was reading.

I searched online for the ad and couldn't find it, but this commercial promoting Seroquel for the treatment of bipolar disorder employs the same techniques.  I'm pretty sure they even hired the same woman for the voice-over work.

And is there any subject that hasn't been covered in an xtra normal video?  Probably not.

The Relational Context of Narratives in Psychotherapy

Cheryl Fuller:

Human beings are narrative makers. We remember ourselves and our lives in stories -- stories we tell our friends, family, strangers, ourselves. When a new patient comes to me, I say "tell me about yourself" and await the story of this person's life and how it has brought her to me. And if we work together for some time, that story will change so that the story she tells at the end will be recognizable as hers but different in some ways from the tale told at the beginning.

Do yourself a favor and check out the rest of Dr. Fuller's post.

Study Diseases or Cases?

From 1 Boring Old Man:

In another Residency in Psychiatry in the mid-1970s, there was a different way of learning. There were lectures and lots of articles, but they came from reading lists, and some were pretty old - "classics." There were lots of conferences where a Staff Psychiatrist interviewed a patient or supervisions where we presented our own cases. It was more about single cases rather than single diseases. I spent a lot more time in the library reading books rather than reading this month’s journals. It seemed like we stayed on the trailing edge instead of jumping at new things like in Internal Medicine. It fit better with the way I naturally think and I liked it.

Though I'm not a medical doctor, this reminded me of my graduate school training.  Yes, we read books and articles about "conditions," but for the most part we used this material to learn about different theoretical approaches to understanding and treating people without comparing them to diagnostic templates based upon symptoms.  And keeping up with the leading edge was far less important than developing depth in areas where depth already existed in the literature.

We spent maybe two classes (not courses, classes) in graduate school going through the DSM III and we didn't have to memorize any of it.  The classes were merely intended to familiarize us with the DSM.  At this point, I only have a pocket DSM IV-TR.  Rarely do I open it.

Away from the books and articles, the actual clinical training focused intensely on single cases.  We spent a great deal of time learning to listen, formulate and intervene without concern for diagnostic categories. The format for single-case presentations varied with the supervisor, but I learned from all of them.

There is much more to 1BOM's post than what I quoted above.  It's a good read for anyone interested in the radical transformation of psychiatry since the 1960s.  You can check it out here.

Adamscare!

This isn't a joke.  In 1798, John Adams signed into law a payroll tax on privately employed seaman to cover their health care which was to be provided in government hospitals.  An Act for the Relief of Sick and Disabled Seamen was also supported by Alexander Hamilton and Thomas Jefferson.

Rick Ungar writes in Forbes:

There are those who will continue to argue that these indications of how the founders viewed these issues in their own time do not necessarily resolve the issue as to how we may, Constitutionally speaking, proceed with reforming the health care system of today.

They may well be right.

But, at the least, can we not agree that the mounting evidence as to how men like Jefferson and Adams perceived the issue should bar the attempt to pin the objections to health care reform on the backs of the nation’s founders?

Or, notwithstanding claims to the contrary from the History Department at Glenn Beck University, can we at least agree that the founders were real human beings and stop treating them like hand puppets?

Guilt ctd

Neil Scheurich reacts to my post on (Tucson) survivor guilt.

The Packaged Animal

What if Wal-mart started running commercials with actual employees haggard from a typical workday, instead of spruced and smiley actors who would sell a kidney before working a grueling day in retail? You can think of thousands of similar examples, and they all beg the same question: what would our culture look like without the packaging? That's a hard question, and I'm not sure we want to find out. As idyllic as "authenticity" sounds, it requires an entirely different level of tolerance to accept. What if job interviews stopped being dances of concealment and started being transparent discussions. Imagine a job candidate saying, "Well, I left that firm because I couldn't stand being in the same room with my boss. He disgusted me, and to stay another day would've pushed me over the edge." Or the interviewer saying something like, "The main thing you need to know about this company is that we don't like liberals."  -- David DiSalvo

Packaging is an intrinsically human activity that arises from the slippery, multilayered nature of identity and selfhood.  Some of our self-packaging is conscious and intentional.  We are aware that we should present ourselves differently in varying social contexts.  But much of our packaging involves relatively seamless internal shifting to meet the world around us. Merely being in the presence of different people makes us feel and act differently.

City Notes

Must have been about 10 degrees when I left my office early in the evening yesterday.  Around 5:30 pm, Hu Jintao's motorcade drove by on Michigan Avenue while an inebriated homeless man who looked to be in his 60s was shouting, I'm a wino, I'm a wino.  He wasn't dressed adequately for the cold weather and I feared he would freeze to death if he fell asleep.  All I could think to do was give him the cup of hot coffee I was carrying.  Then a young guy wearing a suit gave him a sandwich.

The best thing that could have happened to him would be for the police to pick him up for drunk and disorderly, but I don't think they would do that unless he was harassing people, which he wasn't.  Later, while I was waiting for a train in the underground, I saw a cop step around the barrier at the end of the platform and take a walk into the tunnel.  I think he was looking for homeless people trying to escape the cold.