Mind/Body

The Hypochondriac

Lacey, fifty-seven, insists that no physician can determine the cause of her multiple somatic complaints. Lacey, a physician herself, no longer practices medicine, as she feels disabled by her symptoms which she struggles to explain to others. She is not exactly tired, she says, but she does feel fatigue. She does not have headaches, but she does feel discomfort in her head. Her stomach is not quite right, although she eats a healthy diet and she maintains a healthy weight. She has consulted multiple tertiary care medical centers, all of whom, express confusion over her symptoms. She comes to me, not because she considers her symptoms secondary to her mental state, but because she is despairing that no physician can give her a diagnosis. George Vaillant MD in his article entitled “The Beginning of Wisdom is Never Calling a Patient a Borderline,” speculates that hypochondriacs need to be understood, in terms of their subjective suffering, and through this understanding, their personal trauma will eventually unfold, yielding a platform in which to work through childhood pain. In essence, primary care physicians need to entertain the notion of a hypochondriac as someone who is crying out to be heard, but patience and empathy must be present for a long time, before this will pay off with insight and symptom relief. Psychiatrists often cannot be helpful, as the hypochondriac will feel further dismissed and thereby get more angry. My job with Lacey is to work with her and her primary care physicians, mostly to help her other physicians understand how to work with her. My direct work with Lacey is to help her deal with her frustrations, while cracking the door open, that her symptoms, indeed very distressing, might be as a result of a painful internal mental state which reaches back to childhood trauma and the need to be heard and understood. Sad as it is, Lacey acts as if the only way people will listen to her is if she has medical complaints. It is as if she believes that if she were to say she were sad, anxious or scared, then she would be ignored, but if she insists that she has a serious medical problem, then her friends and family will attend to her. This pathological belief, likely stems from a childhood in which only physical problems yielded nurturing, whereas emotional issues were neglected. Maybe Lacey will come to understand that, but for now, the job is to give her the space to feel heard and understood, with the sensitivity to know that the slightest suggestion that her mind is producing these bodily complaints, will be heard with anger and despair.

Neuroscience Comes Alive!

 

http://www.latimes.com/news/science/la-sci-transparent-brain-20130411,0,313957.story

Social Isolation Is Not Good For Your Health-Proving What We Know Intuitively!

http://www.latimes.com/news/science/la-sci-social-isolation-health-20130326,0,7160788.story

Without connection, we die sooner. So, today’s article in the LA Times, tells us, as it reports from a published study in the Proceedings of the National Academy of Sciences. Sure, we want science to support what makes sense, so sure I support the study. I just hope it comes as no surprise. Emotional needs, like physical needs, are needs, and as such, when deprived, poor mental and physical states ensue. Without nutrition we die. Food is life-sustaining, and so are friends and family, if one feels that these friends and family can provide reciprocity and respect. This latter comment, is, of course, speculation. The study only shows in a gross way, how important people are to other people. I speculate further, that the interactions necessary to sustain life are those which bolster self-esteem and worthiness. Without these, the mind tells the body that life is less important and so there is less of a push for self-care. In other words, as we age, this mind/body connection is even more important, as the body becomes more vulnerable, the need for the mind to “fight” for the body’s survival is more critical. This “fighting mind” is fueled by feeling loved and valued by people deemed important. Some would argue that elderly people in communal living situations live longer because the support of the community helps them wake up each day and look forward to seeing their “friends’ whereas elderly folks who live alone have less incentive to push themselves towards activities. All this to say that “behavioral medicine,” as some call the specialty of mental health, really promotes the obvious-friendship. As I say many times in my posts, the answer is easy. The difficulty is in the execution.

Sleep, Memory and The Brain: Science Validates Common Sense

Do you want to learn new material? Go to sleep. I knew that in college. An awake mind is more efficient. Do you want to do well on a final exam? Go to sleep. I knew that too. Sometimes  I think that my college success was based on knowing this principle and thereby shunning the notion of an all-nighter. It felt to me that I had better retention with more sleep, so sleeping was my tool to academic accomplishments. Yesterday, Matthew Walker MD said the same thing, http://psychology.berkeley.edu/faculty/profiles/mwalker.html at UCLA Psychiatry Grand Rounds. The hippocampus, the part of the brain responsible for memory, is more responsive after sleep, be it a nap or a night-time rest. He had pretty brain pictures, randomized controlled studies, and a videotape of a Harvard University undergraduate trying to get a thirty page paper done on no sleep at all, demonstrating that sleep changes brain function for the better.

Now, although he was a wonderful speaker, I felt like I already knew what he was saying, when of course, the science of it all, is brand new. The lecture became more engaging as he said we not only sleep to learn, we also sleep to “forget” the emotional association of memory. Sleep, he says, often strips the emotional aspect of the event, while still preserving the narrative memory. “What about PTSD, I asked my colleague/audience neighbor?” Almost immediately, as if he heard me, he said that “in PTSD, one is unable to strip the emotion from the memory, and hence the sleep in PTSD is characterized by nightmares.” Wow, that makes sense to me. The adage that “time heals all wounds” is mostly true, because as we sleep every night, the emotional aspects of memory fades, except in extreme trauma, where the emotion can persist for years and years after a devastating event. This was the most intriguing part of the lecture. Sleep not only refreshes the learning aspect of our brain, it also refreshes our baseline emotional state-most of the time. My take-away was that the value of sleep trumps almost everything and although sleeping medications are a last resort, getting people to sleep can be a key intervention for mending mental health. I knew that. Now, I have science to back me up. Thank you, Dr. Walker.

 

http://www.youtube.com/embed/giKIFuw5fy“

Psychiatry Residents: Thinking About Psychoanalytic Training

This is not the group I spoke to today, but the picture gives you an idea of psychiatry residents, physicians who decided sometime in their medical career to specialize in psychiatry. These folks, graduates of medical school,  have decided to spend four years doing adult psychiatry training and they can then decide to add-on another one to two years to do child psychiatry training. At a noon-time talk, we discussed why I did psychoanalytic training and whether it makes sense for them. “I felt when I finished my adult residency and my child psychiatry fellowship that I needed more psychotherapy training.” I said to astonished faces. “After all this training you did not feel competent?” One resident asked me. “First, you have to remember that I trained in the eighties where we had a lot of psychotherapy training in residency and we did not have as many psychopharmacological tools, which means that we did not have psychopharmacology clinics like you have now.” I say, emphasizing that doing psychotherapy in residency made me appreciate the depth of knowledge necessary to do deeper work, such that more training seemed mandatory to me.

On the one hand, I understood that from their perspective, they are about to graduate from ten years of education, many of them saddled with substantial debt. The idea of further education must seem both financially and academically absurd. On the other hand, the work of a psychiatrist/psychotherapist can be so deep that training is never finished. This is a field of ongoing in-depth analysis of the human mind, which requires expert consultants, ongoing study, along with group training experiences to fully appreciate the nuances of motivation. “The end of residency is not the end of learning,” I say to a group that continues to look stunned.

I am left to reflect on my own classmates in residency. We knew that psychoanalytic training was in our future. We accepted that as part of our professional development. Psychopharmacology was a nice addition to our tool box, but it was no substitute for studying how the mind navigates a complicated world. I fear that my cohort is a dying breed. “The one thing I am sure about is that I cannot be replaced by a computer.” I say with confidence. “Oh yes, you can” the residency director  says. “One day a computer will study your every move and then be able to do exactly what you do, except that you keep learning and the computer cannot do that,” he corrects himself with a good point, supporting my point. Psychoanalytic training, as a lifelong process, makes my work deepen with time. Each patient adds to my experience and my wisdom, along with consultation with colleagues and study groups, such that replication of my work is nearly impossible. “I work in a personalized way and I am grateful for that opportunity,” I tell the residents. “No one else thinks like I do, and so I bring something unique to each session,” I say, without modesty, emphasizing the privilege of being a psychiatrist. I am not sure these residents will be able to say the same thing, but I sure hope they will.

Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa

        “The young woman is looking for some sort of control over her life,” I say to fourth-year medical students, as a way to help explain the self-destructive behavior that might underlie Anorexia Nervosa. “What does she say when you ask her about how it feels to have control over her life by not eating,” an eager, soon to be primary care physician asks me. “Well, she would deny the experience. She would say that she does not have a problem; that her parents are overly concerned and they always have been. Her denial of her problem, stimulates a question about what is going on, on a deeper level of her brain. This leaves us, the clinician, to speculate that it is possible that on an unconscious level, there is a positive affirmation in her starvation, in her ability to control her bodily urges.” I say, wondering if these future physicians are looking at me glassy-eyed because they are tired or because I am not explaining the unconscious very well, or both. “So, what is a primary care physician supposed to do?” Another eager and enthusiastic fourth-year medical student, interested in Internal Medicine, asks me. “Well, as with so many complicated diseases, the primary care physician, needs to shepherd the patient through the health care system. The patient will need monitoring of her electrolytes, her weight, her blood pressure. She will also need to see a nutritionist, along with, a mental health provider. The primary care doctor needs to coördinate care; provide the patient with a “medical home,” the new buzz phrase. The student looks at me with recognition, maybe a little embarrassment that the answer was obvious, and yet because we are dealing with mental health issues, the clarity of the situation gets blurred.

      I am back to wondering my age-old question. Do medical students, our future physicians, need to understand human behavior? If so, what is the best way to teach them? If not, should their psychiatry curriculum be limited to psychopharmacology? My answer is clear. A major challenge in being a physician is to help people, help themselves. Understanding how patients get in their own way is critical to helping all patients stay on a good path. This seems both obvious and neglected.

Medical Aggravation

  Lew, thirty-three, has a rare genetic disease requiring pre-authorization for a very expensive medication which he takes by mouth once a month. He switched insurance companies because his wife lost her job, and so now that she has a new job, Lew has new insurance. Consequently, Lew had to find a new primary care physician. This physician has to connect with Lew’s insurance company to state the reason Lew needs this medication, even though Lew has been taking this medication his entire life. Doctor Lippe, a male, newly trained primary care physician, is quite personable and seemingly sensitive to Lew’s needs. Yet, the authorization does not go through and Lew begins to experience vague, non-specific complaints of fatigue, joint pain and headaches. Lew believes his insurance company is to blame, but upon further research, he discovers that his physician never filled out the needed paper work. “You need to get another primary care physician,” I tell Lew, with uncharacteristic directness. “You need a physician who will be your advocate and follow-up with the details of medical work.” I say, sharing Lew’s frustration and aggravation about this critical, although not life-threatening, delay in care. Lew has a hard time understanding my point of view. “He is so nice,” he repeats. “It is hard for you to see that Dr. Lippe might be nice in his office, but the lack of follow-through could be a bad sign for more urgent matters down the road. ” I say, forcefully and unequivocably. “Yes, it is hard for me to see that a physician might be lazy, or not motivated to help his patients, or inattentive to details,” Lew says with uncharacteristic naiveté. “Well, they can be,” I say, with such  obvious frustration about Lew’s poor medical care. “I have to think about this,” Lew says, with agony, partly because he is without his medication, and partly because of our intense discussion. “One issue is that because you did not get your medication, you are in a compromised position to advocate for yourself.” I say, understanding and articulating that medically vulnerable people are doubly hurt because first, their bodies betray them, and second, they are less able to defend themselves against incompetency and unnecessary delays. “Yes, it is hard for me to think straight right now,” Lew says, understanding his vulnerability. “I am so sorry about that,” I say, again feeling the frustration of the health care system.

Irritable Bowel Syndrome

    Shawn, twenty-one, always felt “inferior” to his older twin brothers, Timothy and Albert. They are both attending  Harvard Law School; they were both the best in their class, “in just about everything,” Shawn says. Shawn does not focus on comparing himself to his older brothers, but every major step in his brothers’  lives (e.g. getting into good colleges, doing well on the LSATS, winning lots of awards) is associated with Shawn having “terrible diarrhea and intestinal pains”, he says. Shawn went to a seasoned gastroenterologist who, after doing a series of diagnostic tests,  according to Shawn concluded “you need to be on major psychotropic drugs and go into major therapy,” “What did you think of Dr. Hertz’s assessment?” I ask. “Dr. Hertz has taken care of our family for three decades. I really trust him,” Shawn replies. “So you think that your mind is in distress and that is being expressed by your bowels?” I query.  “Yep,” Shawn replies, “but I don’t know what to do about it. I don’t belong in my family,” Shawn continues. “What do you mean?” I ask, thinking I know what he means, but I am curious how he is going to express his feelings in words. “I come from a family of high achievers. Both my parents are law professors. I don’t even like to read.” “You mean that you feel like an outsider in your family and that terrible feeling causes your intestines to be erratic?” I wonder aloud. “Well, I am not sure,” Shawn says, “all I know is that I really respect my parents. I respect Timothy and Albert. I just don’t feel like I belong with them. I am not that ambitious. I don’t know what I want to do with my life. I think in another family, that may be OK, but in my family, they think I am really strange.” “You mean to say that you don’t feel strange when you are with your friends, but you do feel that way around your family?” I wonder aloud again. “Sometimes I feel strange with my friends who seem to know their path in life, but when I am with my friends who are just as confused as I am, I am totally comfortable,” Shawn replies very clearly. “There is something very comforting about sharing anxiety about your future with your friends who are in a similar boat, huh?” I ask, knowing that anxiety likes anxious company. “Absolutely,” Shawn replies. “I wonder if your intestines work more regularly when you spend more time with your anxious friends,” I respond. “You know, I am going to have to try to track that,” Shawn says,  sounding curious about the relationship between his bowels and his feeling “strange”. Mind/body, at work, yet again.