Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for February, 2010

Maple Center-Take II

Posted by Dr. Vollmer on February 17, 2010

Monday,  March 1, 2010….Medicating Kids, What’s Up With That?

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“My Mom is Always Yelling At Me”

Posted by Dr. Vollmer on February 16, 2010

 

            Alan, the subject of my earlier blog, http://shirahvollmermd.wordpress.com/2010/01/23/stop-yelling-at-me/, comes in happy, and relaxed. I told him that I was thinking about our last session, a week ago, where he told me that his mother is always “yelling” at him. He says, “yes, that is still a major problem. ” Alan reports that his mother is always serious, negative and “uptight”. I asked Alan how that affected him. Alan says “I don’t like it.” I marvel at how the tables have turned since that visit a few months ago.

        I first saw Alan as a ten-year old boy, then I did not see him for many years; more recently, I saw him in a very agitated state. Now, a few visits later, I see a calm, secure young man, who is complaining that his mother is experiencing her world in the way that Alan presented to me a few months ago. Does anxiety run in their family? I wonder.  Did the mom’s agitated state put Alan into an agitated state? I wonder. Should I suggest that the mom enter into treatment? I wonder that too.

      I bring Alan’s mom into my office with Alan. We discuss their family life. We all agree that everyone in the family could be happier. I suggest that there might be a heaviness at home, which could improve. I am nervous saying this since I do not want the mom to think that I do not understand her pressures. She works. Her husband works. Both parents are responsible for their respective elderly parent. Alan is about to go to college, so there is a major stress with this upcoming separation. Still, I think that if they focus on their family dynamics, they can learn to appreciate each other more. They could learn to laugh together and enjoy each other’s company in a deeper way. I remain anxious. Will Alan’s mom think I am criticizing her? I hope not.

     Alan and his mom begin to fight  in my office.  The accusations are the same. Alan says his mother is  “negative”.  Alan’s mom, Sonia, screams “I am not negative”.  She continues to shout at Alan  “you are perceiving things so negatively”.  The session is almost done. I do not want to end on a tense note. I gently try to wrap up. I feel optimistic and I share that with the two of them. I do not know why, but they both  leave smiling. I will see them together next week.

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Hypersexuality: DSM 5, Are You Kidding?

Posted by Dr. Vollmer on February 15, 2010

                                                                                                                    

   As stated in this link, http://wellness.blogs.time.com/2010/02/10/dsm-5-hoarding-binge-eating-and-hypersexuality/, “hypersexual disorder would be added to the new version of the DSM as a diagnosis for people who, for a period of six months or longer, meet at least four of five criteria, including engaging in sexual fantasies and behavior as a response to depression and anxiety, or repeatedly indulging sexual desires without regard for the emotional repercussions-for themselves or others.”

   My goodness. How bad do psychiatrists have to get with diagnoses until the field is buried?

    The DSM, or diagnostic and statistic manual,  published by the American Psychiatric Association, for a profit, is used around the world by clinicians, researchers, psychiatric drug regulators, health insurance companies, pharmaceutical companies and policy makers. The manual evolved from a system which collected a census of psychiatric hospital patients, developed by the US Army, but then it was dramatically revised in 1980 to be more symptom oriented. ICD-10, the international classification of diseases, version 10, produced by the World Health Organization has a chapter on mental and behavioral disorders. The two books are not revised synchronously, so there are different codes for the same disorder.

      Given that DSM is essentially the reference book to define a mental disorder, the diagnosis of hypersexuality disorder means, to put it crudely,  that if the patient has more sex than the doctor thinks is appropriate, then the patient could be labelled mentally ill. Surely, I am joking, my critic says. Yes and no, I respond. Behavior is subjective. How can we begin to draw a line in the sand about sexuality? The critic returns. He says, well what about alcohol use? How do we decide who is an alcoholic? I see the point, however we do have objective markers; the DUI, the elevated liver function tests, the alcoholic blackout. What are the objective markers with sexuality? Pregnancy and sexually transmitted diseases  are not the same thing.

   Does Bill Clinton have hypersexuality? Does that explain Monica Lewinsky? If so, do we really want a president with a mental disorder? Forget that he lied, should his “mental disorder” be grounds for impeachment? What about John Edwards? He had sex with a woman, fathered a child, told his aid to lie on his behalf , ran for the President of the United States, all while his wife, the mother of his three living children, and one deceased child, had metastatic breast cancer. What if we say that John Edwards has hypersexuality disorder? What if he gets “treatment”? Is he now cleared to run for President again?

      What about the treatment for hypersexuality disorder? Is the goal to ensure the patient have sexuality, but not hypersexuality? Do we, as the psychiatrists, tell our patients how many times  a day, a week, a month, with one, two or three partners? If so, do we then become religious leaders in the community? What is the difference between a mental disorder and unethical behavior? If the patient has guilt, then is it a mental disorder, but if he has no guilt, then is it unethical? Does the presence of guilt imply a mental disease, or is this, in fact, a positive sign for the presence of a conscious? I am confused.

     I have seen a number of patients who have a lot of sex with a lot of partners, but I am not concerned about their sexuality, I am concerned about their relationships. I am concerned about their ego strengths, their sense of themselves, and their management of their anxiety. Sexuality is an end-result of many complicated psychological mechanisms. We psychiatrists, need to look at the underpinnings of  behavior. That is our job. To only look at the last stop on the train is to short change the wonders of the human mind. I hope we do not do that.

    Finally, I fear that hypersexuality disorder is a back door into reconstituting homosexuality as a  mental disorder. Until 1974, gays were considered mentally ill. In 1974, DSM II was amended, and homosexuality was removed from the DSM. One bemused observer of the American Psychiatric Association’s annual meeting  labeled it ”the single greatest cure in the history of psychiatry.”‘http://www.nytimes.com/2000/01/15/arts/bigotry-as-mental-illness-or-just-another-norm.html?scp=1&sq=homosexuality 

   Hypersexuality disorder is not just a step backwards, it brings psychiatry into the world of judgment, religious principles, and potential persecution. Where did the love of the brain, married to the love of the mind go? Where did the deep respect for the doctor patient relationship go? Where did protecting the vulnerable go? I fear I will no longer be able to recognize my field; the profession which seemed to me to be so personal and so respectful of individual choices. We have lost our way. I hope DSM 6 can find it again. I really hope that.

Posted in DSM 5, Musings | 6 Comments »

A Kid’s Temper is Dysregulated? My Musings on DSM 5

Posted by Dr. Vollmer on February 14, 2010

                                                                                                                             

“Revising Book on Disorders of the Mind” http://www.nytimes.com/2010/02/10/health/10psych.html?em is a NY Times article by Benedict Carey, printed February 10, 2010 and Shari Roan in the LA Times, http://www.latimes.com/news/nationworld/nation/la-sci-dsm10-2010feb10,0,2650262.story, remind us that psychiatrists, to quote Mr. Carey, are creating a new line between “normal and not normal, between eccentricity and illness, between self-indulgence and self-destruction-and, by extension, when and how patients should be treated.”

In my previous blogs, I have discussed the floating away of the term Asperger’s Disorder http://shirahvollmermd.wordpress.com/category/musings/dsm-v/ and the arbitrariness of our diagnostic system. http://shirahvollmermd.wordpress.com/category/musings/dsm-v/. I have also discussed the diagnosis of gender identity disorders, and how this label should change http://shirahvollmermd.wordpress.com/2010/01/23/gender-identity-disorders-in-girls-a-plea-for-a-label-change/ and .http://shirahvollmermd.wordpress.com/2010/01/23/boy-or-girl-introducing-a-continuum/.

One interesting change is that DSM is moving from Roman numerals to Arabic numerals, presumably because the authors are anticipating minor changes in the future, so there will be DSM 5.1 and then DSM 5.2. http://www.latimes.com/news/nationworld/nation/la-sci-dsmbox10-2010feb10,0,7852958.storyI admit to my skepticism that part of the DSM world involves the money made from publishing the manual, so the idea that the authors expect future changes, to me, sounds like the movie makers who make Spiderman, knowing that the first movie will kick off a few series of films.

The draft of the document will be displayed for public comment from Wednesday until April 20 at www.dsm5.org, allowing for input from individuals and organizations who may feel they’ve been left out of the revision process. I wonder how this will fly.

In light of my upcoming presentation on “The Angry Child” I have been pleased to read that the writers of DSM 5 are considering adding a childhood disorder called “temper dysregulation disorder with dysphoria”. For the majority of kids with temper issues, this diagnosis makes much more sense than bipolar disorder. The hope is that this diagnosis will tilt doctors to recommend behavioral interventions before psychotropic medication, although I am not sure that changing the name will in fact change the treatment algorithm. . Further, as Edward Shorter, a historian of psychiatry, says “the bad news is that the scientific status of the main diseases in earlier editions of the DSM-the keystones of the vault of psychiatry-is fragile.”  For example, if a child is a victim of severe physical abuse, the child becomes angry, but if the assessment is not done carefully, that child will be labeled with “temper dysregulation disorder with dysphoria.” As with all diagnoses in psychiatry, the question is how much of the behavior is internally driven and how much is externally driven. When we give a child a diagnosis we are implying that the majority is internal. This is a slippery slope of blame, unnecessary medications and misunderstanding.

I want to go back to DSM II, published in 1968. This listed 182 disorders and was 134 pages long. Symptoms were seen as reflections of broad underlying conflicts or maladaptive reactions to life problems, rooted in a distinction between neurosis and psychosis. Sociological and biological knowledge was also incorporated in a model that did not emphasize a clear boundary between normality and abnormality. The DSM III, with Robert Spitzer MD, at the helm, published in 1980, was the watershed event in that it was 494 pages long and listed 265 diagnostic categories. Spitzer argued that “mental disorders are a subset of medical disorders.” The categorical approach assumed each particular pattern of symptoms in a category reflected a particular underlying pathology. The psychodynamic view was abandoned in favor of a regulatory model. Sigh!

The truth of the matter is that our diagnoses are by and large, not scientific. As scientists, we psychiatrists, need to admit this. We should stop pretending that we know what is wrong with people when we don’t. This post is yet another plea for humility. I can hope.

Posted in Child Psychiatry, DSM 5 | 4 Comments »

Persephone

Posted by Dr. Vollmer on February 13, 2010

    The little girl, Persephone, was taken from her mother Demeter, but then returned as an adult and powerful woman. Carol Gilligan referred to this Greek myth as a story of adolescent female development.

      Amy, a fourteen year old patient, was constantly yelling at her mother, telling her mom that she was “stupid.” Amy had been an ideal little girl. She developed normally, she had lots of friends, and she was a pleasure to be with. At puberty, Amy’s world changed. She continued to do well in school and she continued to have friends, but her relationship with her mom went South. She was impatient and sarcastic with her mother to a point where each time they had a meal together, a fight would ensue.

     Can I guarantee that Amy will follow the myth of Persephone? Will Amy come around and begin to show her mother some respect? Should I recommend  that Amy’s mother take the criticism? This is a two-track problem. First, the mom has to set limits with regards to Amy’s mean-spirited quips. Second, the mom needs to understand that Amy’s behavior is likely part of Amy’s development and separation from her own childhood. Amy is becoming a young woman and as such, she is struggling with maintaining a continuity from her childhood, versus venturing forth into a new adult world. This internal struggle is manifested in Amy’s surly attitude.

    I feel bad for Amy’s mom for having to endure a constant barrage of criticism. I also feel bad for Amy that she feels that she has to be mean to her mother in order for her to work through her developmental issues. At the same time, I think both Amy and her mom will evolve into a healthy adult-child relationship. My job is to keep the long view. I carry the flag for seeing the other end of this seemingly dark tunnel.The story of Persephone has a happy ending.  Sometimes, not very often, I think my job is easy.

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You’re Fired-II

Posted by Dr. Vollmer on February 12, 2010

    Teri, the subject of my earlier blog, http://shirahvollmermd.wordpress.com/2010/02/11/youre-fired/ had an in-depth personal relationship with her psychiatrist/psychoanalyst. The termination was crushing. Her sense of betrayal echoed my story  http://shirahvollmermd.wordpress.com/2010/01/24/betrayal/. What happens when a doctor patient relationship is less intense, but the psychiatrist walks away, seemingly without any thought or care?

    Theo, a  fictional character, a 22-year-old  schizophrenic patient, was seeing  Dr. G. three to four times a year. Theo was relatively stable, but occasionally he needed his medications tweaked. When Theo was an adolescent, his behavior became scary such that he required three hospitalizations over  four years. Dr. G followed Theo through these multiple crises. More recently, Theo had done very well. Dr. G resigned from his care. He did not give Theo any referrals. He did not give Theo an explanation.

    To get into Dr. G’s mind is a game of wild speculation, but with sudden changes, one is left to try to make a narrative. How does this happen? Is Dr. G unethical? Is there any recourse? How does Theo find another doctor who won’t do this? By way of conjecture, I propose that Dr. G was overwhelmed by Theo. When Theo was going in and out of crisis, Dr. G felt anxious, uncertain and ill at ease. Dr. G knew that in such a high acuity time, he could not leave the case. As Theo calmed down, Dr. G saw his exit plan. Leaving a patient when he is stable makes sense. The problem is that Dr. G is responding to Theo’s history, whereas Theo is looking at the present, thinking that he is doing well, so of course he is not a burden on his physician.

    Wait a minute. Doctors are supposed to take care of sick people, not healthy people, so why does Theo have to be well for Dr. G. to want to take care of him? It is a myth that doctors want to take care of sick people. I think that young doctors have ideals, but as  the physician gets older, has more personal problems, sees the finite nature of his own life, then he wants to have a life that feels good. Sometimes feeling good involves helping people, but when the person you are helping, also makes you worry, then it can be hard to cope.

   Dr. G. was cruel to terminate Theo without an explanation, without a referral. Dr. G. has to weigh his job satisfaction, his quality of life, against the impact of his termination on the patient.   This is not an easy determination, but I suspect that all doctors are faced with these dilemmas throughout their careers. Perhaps there should be more transparency in this process. Perhaps more transparency would create less shame, for both the patient and the physician. Relationships are hard. Some do not endure. It is a hard truth.

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You’re Fired

Posted by Dr. Vollmer on February 11, 2010

     Teri, a fictional colleague, came to me as a friend to discuss her problems with her shrink. At the age of 28, Teri was diagnosed with metastatic breast cancer; she was scared. She jumped into psychoanalysis with a well-respected training analyst affiliated with a psychoanalytic institute here in town. Teri started going to psychotherapy twice a week, but as she underwent chemotherapy, she started going four times a week since she felt she needed more support. Fifteen years later, Teri was still going to her analyst, but over the years, she cut back to three times a week and then to twice a week. Her cancer went into remission, she got married, she had children, and her psychiatric career was going well.

      Despite the successes in her life, her relationship with her psychoanalyst was very troubling. Dr. Miller, the psychiatrist/psychoanalyst, encouraged Teri to call him in between appointments. Dr. Miller did not want Teri to feel alone. Teri did reach out to Dr. Miller in between sessions. As such, their relationship was particularly intense. Teri came to depend on her “shrink,” as she called him, and when he took a long time,  more than 24 hours, to return her call, Teri would get angry. Eventually, Dr. Miller grew tired of Teri’s anger and rather than talk directly about her expectations, Dr. Miller, suddenly told Teri that he would no longer see her again. Dr. Miller said “don’t call me, don’t email me, that’s it”.

     Teri was devastated. She felt betrayed, angry, and punitive. She wanted to report Dr. Miller to the Medical Board for abandonment. Teri understood that she was a demanding patient, but she also understood that a psychiatrist/psychoanalyst has the tools to talk about the issues of entitlement. Teri felt that even though her behavior was “out of the box,” so was Dr. Miller’s in that he encouraged her to call him. Teri saw Dr. Miller as her lifeline. Dr. Miller seemed happy to oblige, at least for the first ten years of treatment.

      Teri called a colleague to see if she had grounds to report Dr. Miller to the board. Her colleague told her that she had no basis, since as a professional she is perfectly capable of finding another psychiatrist. Teri was not abandoned in the same way that a patient who is lying in the hospital is abandoned if his doctor does not show up. Teri understood, but she  wanted revenge. Teri felt helpless, a feeling which was  layered over  her helpless feeling of being a breast cancer victim.

     Doctors are not held hostage by their patients. If a physician feels that he no longer wants to take care of a patient, he has the right to transfer care to another physician. If the patient is relatively healthy and he has the means to find another provider, then the physician does not have to do the work of finding alternatives. Still, human kindness dictates that termination should be done with care. Long term relationships are hard to end and sudden endings are the most challenging.

    Like with a break-up of lovers, ending relationships is so challenging that sometimes people behave in undesirable ways. Doctors, and in particular, psychiatrists/psychoanalysts, are held to a high standard, as one assumes that they are sensitive to relationship transitions. As we  want to believe that all parents love their children, we also want to believe that all psychiatrists/psychoanalysts are careful when they want to extricate themselves from the treatment. Sadly, the consumer, the patient, cannot count on this.

    One can imagine that over the many years of a psychiatrist-patient relationship, the life of the psychiatrist changes. Children are born; grandchildren are born. Illness ensues. Many psychiatrists/psychoanalysts will not disclose these life changes and as such, the patient is left wondering what he or she did wrong to create the termination. Like a child who blames himself for the divorce of his parents, so the patient blames himself for being fired. Again, this blame is layered over the pre-existing bad feelings which brought the patient to treatment. I call this experience a sh.. storm.

    So, what did I tell Teri? I told her I was sorry. I told her I could help her find another therapist. I told her she deserved better. She cried. I cried. Some stories do not have happy endings. This is one of them.

Posted in Musings | 2 Comments »

Avoidance

Posted by Dr. Vollmer on February 10, 2010

Nancy, the subject of http://shirahvollmermd.wordpress.com/2010/01/23/friendly-fire/ came in, as she does every week, to talk about the love she feels from her children. Nancy has four kids, two from her first marriage and two from her current marriage. They all have their struggles, but Nancy feels so incredibly proud of them. She tells me how much each child has moved her in a particular way. She gets teary-eyed when she talks about how her adult children want to live near her. Her warmth and affection to them feels genuine and heart-felt. Yet, I ask myself, “why does Nancy come to therapy to discuss how much she loves her kids?” The short answer is that Nancy is avoiding talking about the more difficult part of her life, her marriage. Nancy has been married to Woody for ten years and for the most part, all ten years have been challenging. Nancy does not feel understood or appreciated. She feels that her work, both in the world and at home, goes largely unappreciated, especially by her husband. So, I wonder, why are we not talking about her marriage. I know the answer. If we begin to go down the road to discuss her marital problems, she will get scared that she will conclude she needs a divorce and she does not want to get near that path, so she comes to therapy to remind herself about all the warmth in her life.

Nancy used to view me as adversarial. In the past, she saw in me someone who wanted to take her down from her good feelings about her kids into the ugly world of a difficult marriage. After many years, Nancy has come to see that she has assigned me the role of wanting to make her feel bad by pressing her on the difficulties in her life. Now, she says with amazement that she sees me as trying to help her work through her problems. She marvels at how she used to believe that  I was trying to “take her down”.

Avoidance is a powerful defense. Nancy goes to the good things in her life to avoid the challenging things. For years, this was an unconscious process. Nancy had no idea why she would come to therapy to talk about how wonderful her children are. Now, she sees that just like a child who avoids doing his math homework  because he struggles in math, Nancy has avoided talking about the part of her life that needs work. Further, she used to feel that my wish to bring her difficulties to her attention was malicious. Fortunately, Nancy also knew that we had a long history of working together and although she felt in certain moments that I was trying to make her life worse, most of the time, she understood that I was there to help. Nancy’s mixed feelings allowed her to hang in there with me so that we could explore her avoidance behavior. Patience paid off.

Posted in avoidance, Musings | 5 Comments »

The Angry Child

Posted by Dr. Vollmer on February 10, 2010

Presentation to the UCLA Child Care Center Parents and Staff….Thursday, February 18th, 2010

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Teaching at NCP

Posted by Dr. Vollmer on February 9, 2010

Wednesday, February 10, 2010….Female Adolescent Development…..Psychoanalytic Psychotherapy Program

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