Autism Apps

http://www.latimes.com/business/la-fi-apple-autism-20130430,0,2782344.story

Can an ipad application help autistic kids communicate? The answer is nobody knows and everyone, especially those at Apple, those in the educational community, and families with autistic members, would like to think so. There is no evidence to suggest that any app can be useful, and yet there are “a search for “autism” in Apple’s App Store brings up 1,449 apps for the iPad, and 1,259 for the iPhone. And Apple has even created a “Special Education” section of the App Store.

The range of these apps has expanded well beyond the initial focus of helping people with autism communicate and improve social skills to learning about emotions and delivering basic educational lessons in a format that’s better suited to autistic learners, Shih said.

The creators appear to be drawn by a mix of instincts to help others and the sense that there is potentially a sizable market for these apps since, according to the Centers for Disease Control and Prevention, 1 in 50 school-age children in the U.S. have been diagnosed with some form of autism, an increase of 72% from five years ago.”

So, are we looking at a market which is highly suggestible, or is this the next great intervention? My intuition tells me that for children and adults with social/communication issues, the ipad or iphone is a tool, which although could be useful, for the most part, it cannot compensate for face to face time of social interactions. We learn to be social through experience, and yes, virtual experience can serve as a rehearsal, but the bulk of cooperation and reciprocity is learned on the playground. I am excited about the notion of health-care apps, where folks can carry around tools at their fingertips which can remind them to eat better, exercise and breathe deeply, but as with all interventions, there does need to be scientific studies to guide us how we can use these tools to most effectively shore up our deficits. Right now, we seem to be working with, and selling, hope.

Is The ‘Self’ Lost in Psychiatry?

http://www.nytimes.com/2013/04/28/magazine/the-problem-with-how-we-treat-bipolar-disorder.html?pagewanted=all

Linda Logan talks says ” for many psychiatrists, mental disorders are medical problems to be treated with medications, and a patient’s crisis of self is not very likely to come up in a 15 minute session with a psychopharmacologist.” She goes on to say that non-medical professionals are taking on the task of understanding the self, but “new therapies and treatment philosophies, founded mostly by clinical psychologists and other practitioners who are not medical doctors, recognize the role of the self in people with mental illness.” This is my rant and so I will continue to both understand that my professional world is changing and, at the same time, attempt to push back and bring the “self” back to psychiatry, in my own way, through my work and through this blog.

Many in my cohort went into psychiatry because we felt that the patient had the disease, as opposed to our medical colleagues who treated patients like they were the disease. This personal aspect of psychiatry was the draw. The “liver patient in room one,” was the inspiration for leaving a field in which people were defined by what organ system failed, and not their social histories, their occupational histories, or their contributions to society. As psychiatry becomes more “medical,” patients are now a “disease” and there seems to be little value in understanding how the person copes with their illness, but rather the value, is in getting rid of symptoms. Clearly both are important. Moreover, it is important, in my mind, that one clinician be able to look at both symptom relief and coping styles. When these two issues are bifurcated, the patient is left to feeling misunderstood and frustrated, as Linda Logan articulates clearly in this article.

Of course there are exceptions, but the trend in psychiatry is towards this medicalization, which means towards a depersonalization of care. This trend crushes my soul. If we, as psychiatrists, do not carry the banner of knowing our patients, for the human beings they have worked hard to become, then who is going to provide comprehensive care to those with crippling neuroses and/or psychoses? Who is going to see the big picture of medication management within the context of defense mechanisms and family dynamics? Who is going to understand that to lean too much towards nature or nurture is to rob the patient of the complexity of their condition? We, as psychiatrists, must embrace both complexity and uncertainty. If we do not do this, then patients will suffer, and as they are, by definition, compromised, and hence  mostly unable to advocate for themselves. This is my rant, one which bears repetition, and so I will continue to post on this topic. Thank you, Linda Logan for triggering my continuous outrage.

New Yorker Entry….

“I told my husband I needed a new nest.”

Brain Stimulation: Literally Speaking

 

Deep Brain Stimulation (DBS), Transcranial Magnetic Stimulation (TMS), Electroconvulsive Therapy (ECT), and Vagus Nerve Stimulation (VNS) are all FDA approved treatments for neuropsychiatric disorders, heralding the new modality of treatment for psychiatric diagnoses. Darin Dougherty MD from the Division of Neurotherapeutics at a Harvard-affiliated hospital, presented his studies, demonstrating that when subjects were given active treatment, versus sham treatments, there was a high placebo response. To date, he has not been able to show the effectiveness of Deep Brain Stimulation, but he believes, that is because he has not determined where to place the electrode in the brain. Nevertheless, whereas drug companies used to sponsor most of the psychiatric research, now there is a lot of research sponsored by those who make these machines, such as Medtronics. Procedure-based psychiatry is the frontier, with hope of targeting a more specific area of the brain, moving us forward from ECT in which the entire brain has to seize in order to achieve the desired results. If we could localize the emotional brain, we could tickle it, and make folks feel better, or so the hope goes, for our future. In this way, this is an exciting time to be a psychiatrist, with the hope that like our medical colleagues, we hope to be able to offer our patients both pharmaceuticals and medical procedures which “fix” the underlying problem. Do I think this will put psychotherapists out of business? On the one hand, I would welcome the immediate relief that these procedures promise. On the other hand, I cannot imagine a substitute for working through difficult life decisions in a way in which one approaches junctures with thought and deep appreciation for the gravity of the decision. As always, I imagine these procedures could enhance psychotherapy by giving folks who are paralyzed by life’s traumas a way to move forward in psychotherapy so that they can navigate their world in a deeply conscious way. My work dovetails the work of those like Dr. Dougherty and so I welcome his neurotherapeutic  innovations.

Allan Arbus

http://www.nytimes.com/2013/04/24/arts/television/allan-arbus-mash-actor-dies-at-95.html?adxnnl=1&adxnnlx=1366824116-sVw9Zw5sh1end8MEUpK1KA

Years ago, a psychiatrist friend of mine were going to small theatre and we ran into “Dr. Freedman” from M*A*S*H*, and with great enthusiasm said “we are psychiatrists too.” It took a few minutes for us to realize the absurdity of our comment, and yet, we felt so comfortable with him, as a colleague. He was gentle with us, but, of course, we felt foolish. All these years later, Alan Alda is quoted as saying a similar sentiment about the late Allan Arbus. Moreover, to learn today that he was married to the talented, but tragic, Diane Arbus, is all the more riveting. I imagine his sensitivity was innate, making him a great actor, photographer, and, in my mind, a great listener, as well. It is so rare that my profession is portrayed well in the media. Thank you, Allan Arbus.

Crowd-Sourcing

 

You can evaluate your psychiatrist, as with any service provider, online. Drug addicts being told they can’t get refills can rant about their physician’s poor bedside manner and lack of empathy. Patient satisfaction evaluations are being used to determine physician salaries, as test scores are now tied to teacher’s pay in some school districts. Technology has made it such that the consumer has a voice, and although one does not know to trust the consumer’s opinion, in an uncertain world, internet evaluations through crowd-sourcing, give information which guides the client through the confusing maze of choosing a trusted professional. As Sandy Banks stated in the LA Times, yesterday, http://www.latimes.com/news/local/la-me–banks-yelp-backlash-20130423,0,7103175.column?page=2 , those with negative complaints tend to be more detailed and hence get put higher up in the algorithms, than those with flowery, complimentary feedback. Hence, negative reviews tend to float to the top, and in the case of businesses, if they advertise, then they can change the algorithm such that more positive feedback floats to the top. So, how much anxiety should a new psychiatrist feel when a patient calls and says “I was given your name by another doctor, but I googled you and found some negative reviews, so I am not sure if I should see you or not, but I thought I would give you a call  to see what you sound like on the telephone.” “The best way to see if I can help you, is to come in and meet me and form your own opinion” would be my advice to this young psychiatrist. The personal nature of this relationship makes it such that it is not “one-size fits all,” it is not “fungible”. As such, I would suggest this new psychiatrist say, “the question is not whether I am a good psychiatrist, but rather, the question is am I the right psychiatrist for you?” Crowd-sourcing has no way to address this “goodness of fit” approach to this very personalized service. On the one hand, this is terribly obvious, but on the other hand, it is hard not to flip out over a negative written evaluation, as the internet gives a certain permanence to words. Psychiatry is in transition. As such, psychiatrists need to cope with negativity on the internet. My suggestion-we all need to blog to remind folks out there that crowd-sourcing, when it comes to a psychiatrist, is out of  context. We need to promote this doctor/patient relationship without sounding defensive or paranoid. Once again, this is a new world for my profession. We are learning as we are going. The challenge of the internet continues. We, psychiatrists,  used to worry about protecting patient privacy, and of course, we still do, but now we also worry about protecting our privacy, as well. I think there is little hope for the latter. I can live with that.

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.

Friendship

Leadership

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.