Turning 30

Nina is about to turn 30. She is happily married with two small kids and she enjoys her job as an engineer, but turning thirty is “stressing me out,” she reports. “What about turning thirty stresses you out?” I ask, wondering what thirty means to her. “I feel like I am losing my looks. I used to get a lot of attention and I notice that it is fading away. I used to flirt with men, innocently, of course, but now that is getting harder and harder. Mostly, I feel like I am entering into a new phase of life and I am not ready for that.” Nina reports, not in an unhappy way, but in a scared way. “You sound anxious, but also a little excited that this next phase might bring some surprises.” I say, pointing out the feeling in the room that the road ahead may deviate from her past road, but that could be good and bad. “I just don’t know what to expect,” Nina says in a youthful and somewhat calmer tone. “That’s the fun part,” I say, highlighting the adventure of life, but still recognizing and acknowledging her fear of the unknown. In the end, we laugh with each other. “Birthdays can be hard,” I say. “You got that right,” she quickly responds.

 

See also….https://shirahvollmermd.wordpress.com/2011/06/30/turning-50/

Zoloft Magic

Carol, seven years old, was easily aggravated. She worried about middle school even though it was four years away. She worried her parents would die, even though they were both healthy. She worried about being upstairs in her house alone, even though she had lived in the same house for her entire life. She worried when she was separated from her mom, be it at school or at a friend’s birthday party.  Carol tried play therapy and behavioral therapy. She enjoyed both experiences, but she still had her worries. As a last resort, Carol and her parents came to me. After much deliberation, we decided to give Zoloft a try. Both parents had histories of anxiety and both parents had positive responses to SSRIs in the past. Carol started on Zoloft and within a week, she was more “fun to be around,” according to Carol’s mom. Separation was no longer a problem. Carol reported that her worries “went away”. Carol had no side effects, only the positive benefit of not worrying all the time. Success-at least, for now.

See also…..https://shirahvollmermd.wordpress.com/2010/11/17/zoloft/

Therapeutic Ambivalence

  Maria, https://shirahvollmermd.wordpress.com/2010/01/24/i-dont-like-it-when-you-look-at-me/, thirty-three, comes to her monthly appointments “confessing” how she changed her dosages of medication. Her sister is a primary care physician, so she often “consults” with her and then changes her pharmacology accordingly. “You have problems trusting me,” I say, making her instantly uncomfortable. “I come here for a long time. I could get my medications from my internist, but I choose to come to you,” Maria says, bringing up some good points. “Yes, but at the same time, you feel the need to make your own decisions about medications, rather than discuss the issues with me. Both are true: you put a lot of faith in me, and you don’t want to be dependent on me, so you work independently.” I say, showing her the layers of her mind. “I guess I should go back up on the medication,” Maria says, as if I am concretely telling her to return to the dosage I prescribed. “The dose is not the important thing here at this moment. The important aspect of our conversation is your ambivalence in our relationship, which might reflect on how you have ambivalence in other relationships as well.” I say, trying to highlight the underlying issue of communication versus unilateral decision-making. I am trying to talk about her mixed feelings in our relationship which manifest themselves by her adjusting her dosage,  independent of my opinion. Maria looks like she wants to think about what I am saying. She leaves with some agitation, but she also looks like she appreciated the challenge to her thinking. Doing psychopharmacology, like in all doctor-patient interactions, bring up the issue of relationships, bringing to the forefront issues of communication and trust. Once again, the notion that a psychiatrist can “just do meds” is ill-founded. Understanding dynamics is critical to all relationships which are so loaded with deep underlying issues. Maria and I have work to do-psychodynamic work, that is.

The Guilty Betrayer

   Max, eighty-five, just cheated on his girlfriend Beatrice, age eighty-seven. Max says “I just love Sophie (age ninety), so I had to let Beatrice go.” The guilt in Max’s voice is palpable. “Beatrice really loved me,” Max tells me, with what seems like is a mixture of uncomfortable feelings. “It seems like you have never found a woman that meets all your needs,” I say, referring to the fact that Max has never had a monogamous relationship. “I guess that is true,” Max says, with a sad and thoughtful tone. In this interchange, Max becomes sympathetic. He did not set out to hurt Beatrice, although he did hurt her very much. Max is trying to make himself feel whole, and in so doing, he has betrayed Beatrice. Max believes that Sophie is more suitable to him, even though in his lifetime, he has never found anyone who he felt was a good fit. On the one hand, Max gets a lot of credit for trying, despite his advanced age, to find his soul mate. On the other hand, after all these years, one might hope that Max could be more honest in his relationships. Max seems to understand this. He seems both proud of himself for finding a new partner and angry with himself for letting down Beatrice. It is too simple to say that Max is a “bad person” even though he has been consciously hurtful to others. His long life has shown that he repeats the pattern of falling in and out of love, humiliating the previous girlfriend each time. His awareness of his pattern brings up a stew of feelings which makes him alternate between elation and guilt. Max has children, but his love life dominates his mental existence. Maybe Sophie will be the one, he hopes.

See also..https://shirahvollmermd.wordpress.com/2010/05/05/the-guilty-road/.

Senior Center-Yay!

    Primary Care Physicians need to learn psychopharmacology; they also need to learn how to help people enhance their lives through behavioral change. This is the old saw: nature and nurture. The medications address the nature, the environmental change targets the nurture; both are important, at every stage of life. Consequently, I have taken a new route to training Family Medicine Residents to guide patients towards healthier, happier lifestyles. A physician recommendation is powerful. A friend or family member may suggest to their loved one to pursue a community resource, yet when this same suggestion comes from their doctor, there is often more impact.  Further, when a physician has seen the resource themselves, they are more likely to explain the benefits in a way which is compelling. So, Monday mornings are now consumed with what I jokingly refer to as “field trips,” but more seriously refer to as “community medicine”. The Culver City Senior Center was our focus. My residents and I were overwhelmed by the scope and accessibility of all that they had to offer. There were computer classes, trips to museums (they were going to the Getty Villa that day), Tai Chi, and a knitting group. Lunch is offered, requiring a voluntary donation of a nominal amount. The physical, mental and social stimulation available was really exciting. My group bemoaned the fact that we did not make their age cut-off. If one patient a month follows through on the recommendation to expand their world by joining the Culver City Senior Center ($10.00/year), then I have done my job, both in terms of helping residents understand community resources to improve mental health, and in terms of helping patients improve their physical and mental well-being. My “field trips” are win-win-win. I “win” because I expand my world of social services. The residents “win” because they are shown experiences which can’t really be described, they have to be seen. The patients “win” because they are given recommendations which can potentially improve the quality and the duration of their lives. A triple gain-not bad! Sometimes nurture is underrated.

 

See also….https://shirahvollmermd.wordpress.com/2010/04/07/growing-old/

‘I Trained You’

“I trained you,” my seventy-year old patient, Eleanor says, referring to the fact that I saw her in my training and we have “grown up together” as she continues to say. “I trained a few others, but I stuck with you,” she reports, referring to the fact  that she had seen many trainees, but she followed me into my private practice, allowing us to have a long relationship. “You seem rather proud of that. I agree that you were certainly there in my formative years as a professional.” I say, joining her in her assessment that her role as a patient was pivotal to my growth as a psychiatrist. “I am proud. You were just a young thing when we started, and now you seem more sure of yourself,”  Eleanor says, continuing in her role as my teacher, almost as if she is my mentor. “That is interesting that you see change in me and that you comment on that,” I say, highlighting that she is both observant and direct. “I think I did a good job,” she says, enjoying our repartee. “I am glad you think so,” I say, proud that I give her satisfaction, but also  noticing the upside-down quality to our conversation. For a few moments, the doctor-patient relationship has flipped. We are going to return, but this was an interesting interlude.

Diagnosis Dilemma

Child Psychiatry Rant….

  Dr. X,  A notable child psychoanalyst, from a notable academic institution says “I am OK with putting kids on Risperdal, because if it controls his symptoms, then I can do my work better.” My rage explodes internally. Putting kids on Risperdal is a major decision. There are long-term side effects which range from increasing cardiovascular risk factors to permanent movement disorders. There is no way that a self-respecting child psychiatrist can be carefree about prescribing atypical antipsychotics. Sure, some kids really need it so that they can stay in school and achieve academic and social success. Sure, some kids can go on Risperdal for short-term treatment, thus mitigating the long-term concern. Still, prescribing these medications come with serious consideration,  which we, as child psychiatrists, need to join to say that we are focused on both short-term gain and long-term pain. Getting a child better is one thing, but we must also be concerned for the future of that child. We must think about prevention as well as symptom relief. Sometimes, I feel lonely in that regard, but I also remind myself that speakers often posture; they say things they don’t believe, to be both provocative and interesting. I bet that was true for Dr. X. It worked.

Controlling To Combat Anxiety

  Van, thirty, never lets me get a word in. She talks incessantly and when I try to interrupt she takes offense. I become assertive, “I think you need to control this situation since it makes you anxious when I speak, since you are never certain about what I am going to say.” Van starts to cry and then she gets angry. “You always criticize my behavior. Now, you tell me I am controlling.” Van says with that combination of hurt and anger. “Anxiety is an interesting phenomena, and everyone copes in a different way. Sometimes you cope by trying to control the situation, in this case the psychotherapy. I don’t see how that is a criticism. I see it as an observation which might be something useful to think about.” I say, realizing that observations can sound critical at first, but with some time and distance, those observations become important ideas to bat around. “I know you always think about what I say, but I also know that your first response is to feel like I am judging you in a negative way,” I say reassuring her that we have been through this cycle before and so I trust that my words will stick in her head, but she also wants me to know that she is hurting now.

  Understanding and explaining, Heinz Kohut, taught us. Those two words stick in my mind. First, I try to understand Van’s reaction, and then I try to explain it to her. “I am sorry I got so mad at you,” she says. “No need to apologize. This is our work and we are working hard,” I say, with conviction that we are going deeper, but the waters are treacherous. “OK, I will think about what you say,” Van reassures me. “I know that.” I reassure her. Giving up control is hard. For Van, deep anxieties lie beneath her need to be in charge. She protects herself from feeling those anxieties by being controlling. Taking away that protection is a slow and delicate process. The pay-off for Van will be deeper relationships. We proceed.

‘I Thought You Were Going To Yell At Me’

 Luke, https://shirahvollmermd.wordpress.com/2011/10/04/why-do-i-want-to-see-you-everyday/,cheerfully tells me the tale of his weekend. “Multiple hook-ups” he says. By that he means that he “made out” with many girls, most of whom, he met for the first time. I look at him, but I stay silent. It feels like he is waiting for me to talk about how his life is unsatisfying because he avoids deep relationships. We have talked about this many times, but this time, I know that he knows what I would say if I were to speak. Concluding the session, he looks at me with deep curiosity. “I thought you were going to yell at me,” he says, almost as if he is disappointed that he did not get his maternal fix. “I did not have to say anything because you already know how your behavior leads you to feeling empty inside,” I say, agreeing with him that I did not engage in my typical way of challenging his social decision-making. “Well, I know, but it was a fun weekend,” Luke says somewhat defensively and somewhat wistful that I changed our pattern. “Maybe I did not engage with you as I usually do because you can see for yourself how your relationships lead you down an emotional path which thus far has been unsatisfying.” I say, trying to slightly alter our dynamic in which our sessions become confessions. Luke leaves looking very confused, still cheerful.