The Canvas

     Kelly, fifty-six, came in with a new tone. Whereas before she had trouble talking about what was on her mind, in this recent session she came in  listing her stressors: her elderly father, missing her mother, her difficult daughter, her unsatisfying relationship. I said “it seems like you have a lot of complaints.” She responded, a bit angrily, “isn’t that what I am supposed to do when I come here?” “You certainly can, if you want to, but you do not have to,” I respond. “What do you mean?” She asked. ” I thought I was supposed to tell you all my problems,” she continued. “I thought I was making progress, because before I could not identify my problems, and now I am talking about them.” “Yes, I can see that you have changed in that way. I also see our time together as a canvas, and you are painting a picture of your life. Today, your picture includes a laundry list of your problems,” I said. “What else would I do?” She asked. “You could come here telling me how things have changed for you because you are taking yourself more seriously. You could try to focus on one problem. You could say how much you were looking forward to coming here so that you could release some of your inner tension.” I say. She looked at me in a perturbed way.  I continued, “I am not criticizing you, but I am noticing how you are presenting your issues. You are numbering your problems. ” Kelly calmed down. “I am going to have to think about that,” she said.  Kelly’s session went from her expressing herself in a new way, to interpersonal tension between us, to a moment of pause and deep thought.  The image of a therapeutic session as a canvas rescued the session from  a tone of  frustration to a new tone of self-reflection.

Family Medicine: Anyone Need A Refresher?

http://www.cme.ucla.edu/courses/event-description?event%5fid=1296214

Thursday, May 27, 2010
7:00	Continental Breakfast
Minicourse: PSYCHIATRY FOR THE PRIMARY CARE PHYSICIAN
7:30	Eating Disorders Shirah Vollmer, MD
8:10	Approach to the Patient with Depression Andrew F. Leuchter, MD
8:50	Women’s Life Cycle: The Role of Psychopharmacology Shirah Vollmer, MD
9:30	Questions/Answers

Getting From 20 to 30

  

                                       

                     Huey, twenty-one, is really scared of failing his economics class. He graduated high school, went  away to a four-year college, and “messed up.” He “partied” too much, hung out with his friends, never spoke to his parents, and eventually failed out of school. He came back home, started  a community college and then transferred to another four-year college, while still living at home. . He has kept up his grades, but his parents have told him that if he fails a class, he will be kicked out of his house. Although at the time that Huey failed out of college, he had no conscious guilt about the experience, with the pressure of this economics class,  and with maturity, he is now beginning to feel guilt, three years later, for the time he “wasted.” Huey’s world has become tense.

     Marcy, twenty-eight, went to college, did well, graduated, and now she feels like all her friends “have adult jobs and adult lives” yet, she is still trying to find “her way.” Marcy cries as she says that she cannot imagine that she ever be happy. She cannot foresee that any job or career could keep her happy for a sustained period. Marcy’s world has gone black.

     Stacy,https://shirahvollmermd.wordpress.com/2010/03/21/you-mean-my-kid-does-not-have-to-go-to-college/, now twenty, never wanted to go to college, but her parents made her. Her parents felt strongly that without a college degree, Stacy would not be able to “succeed” in the world. Stacy went, failed, and then she was torn between going to a community college to make her parents happy, or pursuing her dream of working in the fashion industry. She has decided to go to community college, but she has no enthusiasm. She is going to “make herself” do it.  Stacy’s emotional tone has gone flat.

     Huey, Marcy and Stacy, all remind me of the struggles of youth. On the one hand, Huey Marcy and Stacy all have bright futures ahead of them. They are healthy and they have opportunities. On the other hand, internally, they wrestle with making a life for themselves which at this moment looks painfully uncertain. They wrestle with making their parents happy, finding out what makes them happy, and living with past mistakes. Their friends are also trying to make their way, such that it is hard for Huey, Marcy and Stacy to talk to their buddies since it brings up issues of competition and inadequacy. Psychotherapy helps, since they want to talk about their feelings. They want to have a place where someone is not telling them how lucky they are to grow up in relative privilege. They want to grow up.  The road map is not clear. I will keep you posted.

Wellbutrin

     Peter, sixty-four, the subject of two earlier posts entitled “Seeming Sad” and “Seeming Scared”   https://shirahvollmermd.wordpress.com/2010/02/28/seeming-sad/ https://shirahvollmermd.wordpress.com/2010/03/09/seeming-scared/  says “I just cannot get over what that Wellbutrin has done for me. I am now comfortable socially. I feel so much better. I do not have the same kind of anxiety. My memory is better. I am just amazed.” Despite my twenty years of private practice, I am amazed too. The mechanism of action is not clear. Wellbutrin increases the amount of dopamine in the brain. Dopamine seems to help people with focus, motivation, and feeling pleasure. Yet, Wellbutrin does not have this effect on all players. Some people experience headaches, agitation, and an itchy rash. Why did Peter get such a positive response? I wonder. Maybe it is placebo, meaning that Peter really wants to believe that the medication can change his life and so he has changed his life, thinking that it is the medication, but it is really that Peter has changed his attitude. That is possible; it is hard to know. Wellbutrin can cause seizures, rarely. Consequently,  I do not prescribe it lightly, especially in older (meaning over sixty) adults. I could stop the Wellbutrin and see how Peter feels, but the risk/benefit ratio is relatively low, such that I do not feel compelled to see how Peter would be if he, as a patient of mine once put  it, “flew solo.” For now, I am pleased that Peter is doing better, feeling better, and believing, rightly or wrongly, that Wellbutrin has been “surprisingly” helpful. I am glad I have tools, however imperfect, to help people.

The Vortex

      Dawn, sixty, a long-term patient,  suffers from crippling anxiety, seemingly unrelated to any external stress. When I ask her about her childhood, she repeats  three stories from her childhood. They are interesting and poignant tales of parental insensitivities. I hear these stories, not as the child who had to endure inappropriate parenting, but as stories which Dawn holds on to to prove to herself that her pain is valid. It is as if Dawn is trying to convince me that she had a lousy childhood. One session, I respond to her story “I think it is terrible how you were treated, but I wonder why I hear only three stories. I wonder about all the other stories from your past. Maybe you do not tell me other stories because you are not sure how I would respond to them. Maybe you do not want to explore your childhood in more depth because you are afraid that there would be no way back.” Quickly, Dawn replies “the vortex; I don’t want to go there.”

      Exploring the past is a scary journey. Looking backward with an adult lens could create fear, sadness, anger and/or resentment. Unpleasant feelings could bubble up to the surface, leaving Dawn with greater anxiety and tumult. Dawn’s three stories of her childhood are like old friends; she knows how she will feel after she tells them. She knows how most people respond to them. There is a security in the repetition. There is the feeling that she will have convinced her listener that she came from “utter chaos.” A new story, an untold story, could cause her audience, in this case me, to perhaps feel bad for her mother, or worse yet, it could cause someone to minimize her pain. My look,  or my twisting in the chair, in response to a vignette might make her feel like I do not think she had it “that bad.” In order to avoid this uncertainty, she holds on to three childhood tales.

     Dawn’s guardedness lets me know how much pain Dawn suffers from. Behind those gates, I suspect that there are a lot of feelings of deprivation which are hard to articulate.  She cannot allow herself to relate her current crippling anxiety to her past. At the moment, she cannot entertain the possibility that the past relates to the present. The fact that she responded to me so quickly with the word “vortex” let me know that she is aware of how scared she is to open old wounds.  This was a hopeful moment. Identifying the vortex allows us to reframe it as a pit; one that is deep, but one that she can climb out of.  As she climbs out of the pit, her crippling anxiety will transform into a self-confidence that she has never experienced before.  I hope.

Is it Severe ADHD or is it Asperger’s? The Case for a Good Assessment

Charlie is seven years old. He hates school; he has no friends. Charlie is aggressive and angry most of the time, but particularly when his parents set a limit. A pediatric neurologist diagnosed him with Asperger’s syndrome and told the parents that he was an “odd duck.” Charlie was then evaluated in a tertiary care setting (a medical school). They agreed. Charlie was put on Risperdal, an antipsychotic. Charlie got “better” according to the parents, but he still did poorly in school and he still had no friends.

Charlie’s parents were reluctant to pursue educational testing. Not only was the price high, they did not want Charlie to think that his entire life was about going from one medical appointment to another. I understood that, but I said this is the most important step you can take in terms of understanding Charlie’s brain. Reluctantly, the parents agreed. Meanwhile, I explored the family history. Charlie’s dad, Tony, never did well in school either. Now, he works as a fire fighter. Charlie’s mom, Gaby, was a good student, as were her six siblings. I wondered about Charlie’s attention span. Gaby explained to me that “he could never sit on the circle, like the other kids could in preschool. He was always running around.”

The neuropsychological evaluation confirmed my suspicion. Charlie had severe ADHD. He could not focus; he has no frustration tolerance. Hence, he could not engage in a dialogue with other children, so he had no friends. He could not wait his turn in games. He blurted out what he was thinking. He had no ability to inhibit his thoughts, so other kids found him to be a “a bit strange” according to Gaby. I stopped the Risperdal, gave him a stimulant (Concerta), and within days, he was doing his work at school, he was no longer a behavior problem and he was getting along with other children. As Charlie said “that medicine really makes my friends nice to me.”

Social skills are dependent on attention. In order for Charlie to make friends, he has to be able to listen, wait, and think before he speaks. If his ADHD makes it so that he has no control over his brain, he will come across as odd, intrusive, and uncooperative. On the other hand, if he takes a stimulant, he will then be able to ponder his next move and thereby prevent the embarrassing moment of saying something that other kids will laugh about. In other words, he will have a space between thought and action. This space is critical for social success.

Untreated ADHD looks like Asperger’s Disorder. That is a simple, yet often missed, truth. The treatment for ADHD is stimulants. The treatment for Asperger’s Disorder ranges from special education to antipsychotic medication. These are very different paths. Diagnosis is essential. A comprehensive approach to assessment demands that the clinician consider all conditions, factoring in the statistics which reinforce the obvious; common diseases are common. ADHD is one out of twenty kids. Asperger’s is hard to pinpoint, but it is roughly one in a hundred kids. Those numbers alone make it so that ADHD should be a leading contender in the mystery of Charlie’s behavior. Adding on, Charlie has a potential family history of ADHD, as his dad might have it as well. This data, combined with the neuropsychological testing, combined with Charlie’s long history of hyperactivity makes the diagnosis straight-forward.

Charlie’s parents have gone through what so many parents suffer from. Charlie has behavior problems. Who should he see? A pediatrician? A pediatric neurologist? A child psychiatrist? Who should pay? Insurance? Out-of pocket? Should they go to a University for an “expert” opinion? There is no road map for these questions. Parents are understandably confused. Child psychiatrists are the experts at diagnosing behavior problems in children, yet the public does not understand that; pediatricians do not understand that either. Universities can be very helpful, but because the patient sees someone in training, there is variability in quality. Once again, the fault lies in my profession. We have not presented our expertise to the public in such a way that it is clear how we can be helpful. Shame on us for not helping more kids like Charlie. Shame on us for putting families through multiple evaluations with confusing answers.

Child psychiatrists need a public relations firm to announce our skill set. We should use the money from our dues in the American Academy of Child and Adolescent Psychiatry  Association to pay for this public education.  Maybe we can figure out a way to make it happen. For the sake of our “children” we must.

See also….https://shirahvollmermd.wordpress.com/2010/01/24/adhd-is-it-a-thinking-problem-or-a-personality-problem/ and https://shirahvollmermd.wordpress.com/2011/09/19/adhdwho-should-treat-it/

Weak Ties

     Alan, fifty-seven, was enjoying his life. He had friends, he had a creative job, and he had good relationships with his family. Then, Alan had a car accident and he suffered multiple injuries including a broken arm and a broken leg. He could no longer drive, dress himself, or go to work. He did not know how long his recovery was going to be. He needed a lot of help to take care of the basic aspects of his life. His friends and family helped in the first week, but after that, they grew tired of helping him. “They had to get back to their own lives,” he said. Alan was massively disappointed; not in them, but in himself. The accident made Alan realize that although he loves the people in his life, he really did not feel that close to them. Hence, he could understand why no one “stood by” him in his time of need.

   I said “it sounds like your accident illuminated the fact that your relationships are what sociologists call weak ties” “Sadly, yes” he says. “Weak ties help people feel more connected in the world, but they fall down when  dedication is needed,” I say. “Weak ties tend to work well if there are few demands on the relationship,” I continue. Alan looks sad. “Yea, it hurts,” he says. “Maybe you can use your accident as a springboard to developing deeper relationships,” I comment. “Yea, maybe something good can come out of all of this,” Alan replies.

Impersonal Parenting

     Karly, twenty-nine, Korean American, describes how her parents want her to marry a Korean man. She said to them “just because he is Korean, does not mean we have things in common.” Karly reports “they did not seem to understand what I was talking about. The fact that he was from a nice family, he was close to my age and he was single was all they cared about.” I said ” you mean that you don’t feel like your parents know who you are, so to them, any man from the same cultural background, from the same generation, should suit you just fine. It seems like you feel that if your parents took the time to get to know who you are as a person, they could not possibly suggest that you date this man.” Karly starts to cry. “You are sad because you so desperately want to be understood,” I say. Karly continues to cry.

    I feel for Karly in that she is reflecting on the fact that throughout her childhood, she feels that her parents ignored her personality. They cared about her schooling, her clothes, her manners, but they never seemed to care about her unique qualities, such as her love for intellectual discourse. As such, they cannot imagine why she would not be interested in someone who comes from such a similar family. Her pain is palpable and understandable. Karly yearns for connection to her family of origin; the type of connection where she would understand them and they would understand her. She feels she does not have this. In this way, she feels like an orphan. She is mourning the parents that she never had. Understanding her needs; understanding how she feels her needs went ungratified is a first step.  It is a tough journey. Karly is going to get through it, step by step.

No-Obstacle Parenting

        Sienna, fifty-one, told me “the thing I am most proud of in my parenting is that I did not get in their way. My parents, with all of their problems, luckily, did not get in the way of my being a good parent to my kids, so I learned that kids develop on their own and a parent has to learn how to stay out of the way.” “You mean that it is really important not to insert your own agenda on your child” I say, thinking that I am stating the obvious. “Yes” she says, “but that is not an easy thing to do.”

     Sienna has four children, two from her first marriage and two from her second. They are ages 30, 28, 17 and 15.  They have all had major struggles in their lives, including behavior problems, drug problems and learning problems. Despite the tremendous anxieties that she has had while raising her kids, she feels “very close” to them. Her oldest, Rachel, is getting married to a “wonderful” man. Sienna and Rachel are really enjoying planning the wedding. Sienna cries as she describes the intimacy she feels with Rachel. “Rachel raised herself” she says. “She knew she wanted to get married and have kids from a very early age. I told her to follow her dream and now it is working out. I am so happy.”

     Rachel did not finish high school. She was with a “bad crowd” and then she dropped out. She had a bunch of odd jobs, before she landed a good job in a medical office. Sienna, a professional, accepted  Rachel’s path. Some of Sienna’s friends were critical that she did not force Rachel to go back to school, but Sienna felt that Rachel would make her own decision about that. As Sienna reflects on that time in Rachel’s life, Sienna believes that she made the right decision. Rachel is very happy now and they have a good relationship.

   I see Sienna’s point. Some kids have a way of knowing what they want out of their lives and they find a path that gets them there. For these types of kids, a parent has to “stay out of the way.” Other kids need  guidance. The trick is to understand your child such that you make a wise decision whether to intrude or whether to stand back. Therein lies the art of parenting.

The Break-Up

    Mel, twenty-eight, really enjoyed his single life between the ages of twenty-two and twenty-seven. He had lots of single friends. He went out every night. He enjoyed cultural events. At twenty-seven, Mel met Hanna, age twenty-five. They fell in love. They spent all their time together. They met each other’s family and friends. Mel was happy; he did not miss his single life. After nine months, Hanna called it quits. She said she no longer enjoyed being with Mel. Hanna explained to Mel that she felt that Mel was too demanding of her time, and she wanted her “life back.” Mel was devastated. “I am crying like a baby,” he said. “Yes, that is exactly right,” I replied. “Maybe you feel like a baby who needs a lot of  love and attention, given how bad you feel right now.” I continue “maybe you are giving yourself permission to feel the loss of love, something that you need quite a bit. Maybe, even though you were happy through those single years, you walled off your desire for connection, and now the flood gates have opened and years of feeling lonely and yearning for connection are now coming up to see the light of day.” “Maybe” he says.

     “Well, I am not drinking” he asserts. “That’s good” I reply, “but what are you doing to help yourself, other than coming here?” “I don’t know how to help myself in a healthy way. That was never modeled for me. Both my parents are alcoholic. ” “So you never saw someone work through their pain” I asked. “Right” he says. “So, we have entered into foreign territory here” I say. “Yes, I would have loved for my mom to go to therapy, but she never would” he says. “Therapy might have helped your mom work through her struggles and that would have helped you be able to work through yours as well.” I state the obvious. “Yep” he says.

     I find Mel’s sadness to be a hopeful chapter in his life. I see that Mel will reconfigure his internal world such that he will embrace his need for connection and dependency. He will come to see that although things did not work out with Hanna, the pleasure he found in being with her, makes searching for a relationship worth the effort and potential pain. At the same time, I feel sad for Mel that he is going through a hard time. His “endless” tears point to the depth of his  suffering. The present is tough. The future is bright.