Judy Garland

 

Thinking about Judy Garland, having  just seen “End of the Rainbow” http://articles.latimes.com/2013/mar/16/entertainment/la-et-cm-tracie-bennett-end-rainbow-20130317, with fellow psychiatrists, we engaged in a heated debate about the nature of her suffering. ?Bipolar, ?ADHD, was the launching pad for the discussion, and yet my thoughts turned to her horribly sad childhood in which, she made money for the studios, and in the process, she was fed prescription drugs to keep the “machine” going. “Trauma,” I said firmly, in trying to understand this icon. She seemed robbed of a time in her life to “play” even though some might say that acting is a form of playing, Judy Garland had to play like she was told and so, by definition, this was not the kind of play in which she could make up her own rules, and have a time in her life in which her activities were inconsequential. This left an inner emptiness, a “zombie state,” as a colleague of mine says, in which she could never experience the sensation of being alive, but rather she enlisted her superego to do what she “was supposed to,” thereby leaving her feeling without satisfaction or fulfillment. She never had a chance to experience her ego, as her superego was running her life, from such an early age. Her many husbands, it seems to me, provided this superego, until one of them tired of the emptiness. She never seemed to know herself, to know her ego, and as such, she could never find a path towards happiness. As Ray Bolger, her co-star in the Wizard of Oz, succinctly stated, “”she just plain wore out.” Like a machine, the gears could no longer turn. Sad, sad, and sad. There is no diagnosis, as far as I can see, but only an incredibly talented woman who never developed a sense of herself. What do we call that? I call that child abuse.

Health Care Apps

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In the “adapt or die” mode, part of moving into the next wave of health care changes is using applications to help patients understand and treat their ailments. Knowing which application to recommend to patients will be an important tool in the ever-expanding toolbox of treatment modalities. This application, pictured above, helps patients learn diaphragmatic breathing by showing a man lying on the ground with a book on his stomach, demonstrating that the book rises and falls with each deep breath, but not with shallow breathing. Deep breathing soothes anxiety, and is a relatively simple means of coping with stress in very powerful moments, such as learning about the Boston Marathon. Teaching people to breathe is that simple, elegant, intervention in which there are no negative effects. The smart phone allows people to teach themselves deep breathing in the privacy of their own space, along with the value of repetition, if need be. There is no doubt, that the smart phone will serve as both a health care passport, in which patients travel with vital medical information, along with serving as a  treatment tool, particularly for stress-related disorders such as anxiety or insomnia. This advanced technology thrills me beyond words. Only in my wildest dreams did I imagine such useful patient information to be so incredibly handy and useful. In this way, medicine is in an exciting era.

Paranoid-Yes: Dementia-No!

Diagnosis, particularly psychiatric diagnoses, are history based. We have no objective tests. We have no imaging studies. We need to listen, pay attention, gather a history, and pursue collateral information. Yes, you have known me to say this for a very long time. Now, I will tell a fictional story which illustrates my point, since the fire in me pushes me to say it again. Diedre is a 70 year-old longstanding patient who has a long family history of mental illness. Her mother was bipolar. Her father had issues with alcohol. Her mother’s mother also had bipolar illness. Both her mother and her maternal grandmother had a history of long stays in psychiatric hospitals. Diedre, although high-functioning, has, what seems to be a more mild version of her mother’s illness. She does have a history of psychiatric hospitalization, but her mental illness manifests more in paranoia than in mood swings. She has long periods of time where she is quite agitated that institutions, such as the police department, want to hurt her. As a result, I have her on an antipsychotic medication, which, as she reports, makes her “much calmer”. Diedre also has a severe alcohol and prescription drug abuse problem, which she denied for many years, but she knew that I knew that this was an issue. Over a long holiday weekend, her drinking caused a change in mental status, leading to her boyfriend calling 911, and then a subsequent psychiatric hospitalization for delirium. The psychiatric team took her off her medications and she detoxed in the hospital. Although the patient told the team to talk to me, that communication never happened, so even as her mental state cleared, where she returned to her baseline paranoid ideation, the team did not re-start her antipsychotic. Instead, they interpreted her mental state as the beginnings of dementia. They administered one test of functioning, which, by her report, she was too paranoid to cooperate with the questions, so she “failed” the test and was diagnosed with dementia. This resulted in a report to the DMV stating that she was unsafe to drive. This also resulted in them insisting that she transition to a skilled nursing facility, at the cost of many thousands of dollars out of pocket, since the team did not feel she was safe to go home. When she was discharged she returned to me. I told her to re-start her antipsychotic, to return to her previous living situation, and to get private cognitive testing in order to have documentation for the DMV. As expected, she has no evidence of dementia, and although the hospitalization was very helpful in starting her on a sober life, the increase in paranoia was tragic to observe. Histories take a long time to understand. Quick diagnoses are not only wrong, they are harmful. There is a fire in my belly.

Is Everyone Bipolar?

This blog is part of my series entitled The Couch in Crisis: The State of Psychiatry

Last night at dinner I was having a conversation with a mental health professional. She told me that she was seeing so many patients diagnosed with bipolar disorder and then getting better on the medication. In typical fashion, I wanted to scream. The diagnosis of bipolar disorder should NOT be made based on a response to a medication. Our mood stabilizing medications make a lot of people feel good. They feel calmer and more in control of themselves. This positive response to medication does not imply that they suffer with a major psychiatric illness called Bipolar Disorder.

Bipolar Disorder occurs in 1% of the population. This is a psychiatric diagnosis is defined by the presence of an abnormally elevated mood, referred to as mania. The onset of full symptoms generally occurs between 15 and 25. Bipolar disorder used to be called manic-depressive illness. This term was coined by the German psychiatrist Emil Kraeplin in the late nineteenth century.

There is no blood test to confirm the diagnosis. This means that any doctor can say a person has it. A clinical diagnosis depends on the clinician. Herein lies the dilemma. In my mind, doctors are overdiagnosing this condition because physicians want to label a condition as opposed to seeming uncertain. It is this need for certainty which I feel we need to change. Many people will respond to mood stabilizers and not have bipolar disorder, so we need to tell them that we do not know their diagnosis, but we do know how to treat it. Although this may be unsettling, often times this is the truth. As a profession, we need to see how labels can hurt people and as such, it is sometimes better to remain uncertain in the diagnosis instead of prematurely labeling someone. To put it another way, if we do not embrace uncertainty, who will?