Great question, and thanks for the laugh 
What is your take on Michael Swango, the doctor who administered lethal doses of drugs to somewhere between 30 and 60 of his patients (as well as poisoning his co-workers with arsenic-laced donuts and “extra-spicy chicken”) ?
This was a guy who was intelligent enough to get into medical school and become a doctor; intelligent enough to continue getting jobs as a doctor in multiple hospitals by concealing his past and assuming new identities; and yet he simply could not stop killing people. And I think he was also quite addicted to the position of power that being a doctor provided, as he was absolutely relentless in his quest to get re-hired at hospital after hospital, whereas most people in his situation would just be glad that they got away with it and go into hiding or find a less conspicuous occupation.
Beginning from the time he was a small child, Swango religiously kept a scrapbook of news clippings relating to disasters, car accidents, plane crashes, mass murders, serial killers and all kinds of violent death.
What would you say to someone like this? What does society do with people like this?
What is your opinion on the use of psychedelics in treating patients?
Have you ever read the writings of Paul Lutus? What do you feel about his contention that psychology is unscientific and is slowly being replaced by neuroscience?
I wanted to highlight this question in cased you missed it the first time. I think this is a fascinating question and would love to hear your answer. Thanks.
Ideally, most patients with mood or anxiety disorders will be able to have a combination of therapy and (if needed) medications, either through the same provider or in split therapy with the psychiatrist and the therapist working closely together.
This question is not as applicable for the particular area I practice in; our hospital does have a clinic where patients are followed long term but the outpatients I see are either in the emergency room (crisis intervention) or are being seen for initial one to three visits before they are assigned if needed for longer term follow-up in one of the mental health clinics or a plan is developed for them to receive follow-up care with their primary care provider.
Regarding not making progress, it depends on how progress is defined. Usually in medicine, it is the eradication or control of a disease. One of the favorite populations of patients that I enjoy working with are individuals who have dementia, which except for a small number of possibly reversible causes, will eventually get worse and really can be considered a fatal disease. In the context of treating patients with moderate to severe dementia, I see progress being made if we are able to help alleviated distress of the patient, if we can reduce caregiver distress and support them, and (if at all possible – this is why I wish every one would complete a iiving will or other documentation stating what type of care they want if terminal… or if they become unable to speak for themselves due to dementia) to provide a caring environment and treatment within the context of their preferences. While the dementia still progresses, if we are able to improve sleep in a patient who has been suffering from insomnia, I count that as a win.
I also enjoy working in hospice settings and my hospital has an inpatient hospice unit where i see patients. Terminal delirium is quite common and while it is unlikely we can eradicate it, if we can reduce the patient’s distress and if possible increase lucid and hopefully pain free periods, I think that also counts for something.
It depends. I think medications are a valuable tool but they aren’t always the right, best, or only tool needed. During some evaluations, it becomes fairly clear early on that a medication may be helpful; on other times, I will have a few visits to help clarify diagnosis.
Also, sometimes depressive or anxiety symptoms may be due to a medical problem so I like to make sure we have current labs; generally CBC (complete blood count - anemia can contribute to fatigue, red blood cells that are too large may be a clue to explore further alcohol use issues), a chemistry panel (electrolytes, renal function, liver enzymes – partly to help with safe prescribing; also abnormal lab values in these values may be a clue to a medical condition causing the symptoms) , TSH (screening thyroid test), B12 and folic acid levels, urine drug screen, urinanalysis (especially in older hospitalized patients as urinary tract infections can often manifest as confusion), and RPR (screening for syphilis). RPR used to be a routine screening lab in many areas of the country; my state continues to have a high rate of infection so it makes sense for us to continue to screen and we see several cases of neurosyphilis a month. Depending on the patient age and medical co-morbidities, I may request other tests and I encourage all patients who have never been tested or do not have a recent test to be tested for HIV. I also try to screen for symptoms of obstructive sleep apnea and refer for sleep study if the patient is at higher risk to have this condition; many patients with OSA who are successfully treated with CPAP may have resolution of their mood symptoms without needing any other intervention.
If I do feel a medication may be helpful, I discuss this with the patient as well as the other options such as watchful waiting and the risks/benefits. Studies have shown a high rate of individuals choosing not to take medications prescribed to them and I believe a bottle sitting on a shelf unopened won’t help any one, so I really try to sense if the patient is ready and willing to take a medication. For a depressed patient for example (let’s say mild depression), an antidepressant might be helpful but a course of psychotherapy is also reasonable. If the patient is not interested in medication but therapy, I will help set them up with a therapist in our system and if the symptoms worsen or the patient changes their mind, they can come back and be re-evaluated.
I also tend to recommend stopping medications fairly frequently or discussing other alternatives with their primary care provider (i.e., changing from one blood pressure medication to another). The patient population I see tend to have a high rate of medical co-morbidities; the outpatients generally have several other active medical issues such as chronic pain, diabetes, heart disease, etc.
[quote=“picunurse, post:32, topic:612161”]
Can dyslexia be mistaken ADHD? My husband was dxed with dyslexia as a child, but as an adult with ADHD. Could he have both, or was is misdiagnosed as a child?/QUOTE]
As an adult psychiatrist, I have much less knowledge about learning disabilities. I see a fair number of patients with ADHD. In getting an initial history, I always get at least a brief educational history such as overall type of grades, favorite subject, “hardest” subject, history of failed grades, behavioral problems. These answers may clue me in to look further if there is a learning problem. If a patient tells me they hated English and history because they had problems reading or other clues, I will discuss the case with a neuropsychologist and obtain neurocognitive testing. Even if testing does not support a learning disability or ADHD, it may be helpful in outlining a patient’s strengths and relative weaknesses.
This is a tough one and depends on the patient’s history and preferences. One of the best things to do, however, no matter what the treatment plan is to schedule VERY frequent follow-up with psychiatrist and therapist in pregnancy and post-partum period and to work, if needed, with a high-risk ob-gyn. A patient with a strong history of bipolar disorder or who has had severe post-partum depression in prior pregnancies will be in a different risk category than one with a milder depressive disorder.
Additionally our data about the effects of the drugs in pregnancy/breast-feeding is obtained by reports afterwards of individuals who had problems after exposure. A prospective study (group A of moms exposed and control group B of moms not exposed) is not ethical. We know some drugs are probably safer than others.
Breast-feeding is another tough one. Some women will work with psychiatrists and choose medications with shorter half-life and do “pump and dump” at the time blood levels are presumed to be highest after taking that day’s medication.
What is known though through all of this is that a healthy mom is important to having a healthy child.
Depends on whether I’m their psychiatrist or running into them in “real life”
I know there are several more questions to answer and I’ll try to respond later today.
Originally Posted by PandaBear77
What is the difference between having a personality disorder and simply being an asshole?
Originally Posted by Purple Scottie
Depends on whether I’m their psychiatrist or running into them in “real life”.
If I may chime in as a psychologist, Pandabear’s question is a very good one. And one I have given a lot of thought to. The terms “asshole” or “patient” say little about the person they apply to, but much about how much understanding and leeway the speaker is willing to give.
Many friends and relatives of a person with a personality disorder are torn between these both viewpoints. When they are hurt and need to vent and want to protect themselves, the “asshole” perspective feels good. When they want to have more involvement (or more effective involvement) with the patient, the medical perspective is more useful. Going from one perspective to another can take a long time and is very typical in the therapy of people who have to deal with a loved one with a personality disorder.
A good outcome would be it they can see that the personality order is real, that it is not their fault, nor entirely the fault of the sufferer, and that they can still hold enough emotional distance to have the contact they want.
Based on god knows how much books I read, I came up with the following statistic on everyday evil.
In any given situation, your odds of running into a reasonable, kind, person is about 85 %. I’m not making that up, that number appears in many studies on how many people will, for instance not try to cheat the system in for instance unstaffed self-checkouts in supermarkets.
Your odds of running into the opposite, an unpleasant person, commonly known as “asshole” is 15 %.
Two-thirds of those 15 % people are the ordinary kind people described above who just have a bad day. They cut you off in traffic, or snark at the telephone because they are themselves stressed, tired, victimized, annoyed, etc. Just like you do when you have such bad days (or bad years) yourself. We are all temporarily assholes to other people. This is the category where a firm remark: “Stop acting like an asshole” may help, at least after the asholle has cooled down a bit. It is also the category where changing the circumstances (group standards, chance of being caught) has a large impact.
The last 5 percent are people who make life consistently difficult for most people around them and for themselves (well, except for the ones with anti-social disrder, who have no social conscience. They only make trouble for other people). Many of them have a personality disorder. This category includes the Sadistic or Narcisstic boss, the (paranoid or obsessive compulsive) Neighbourhood Nut, the criminal, and the Crazy Hobo. You can call them assholes, but it won’t do you much good besides venting.
It seems like if I found out I had a patient with a PD, I’d drop them like a hot potato because I’d think I’d be wasting my time. They are so hopeless. And I’d also be concerned that they are so messed-up that they would be hell to deal with. Stalking me, calling me up at night threatening suicide, yelling at me during sessions, etc.
I’m curious why my therapist hasn’t fired me yet. Maybe it’s because schizoids generally aren’t stressful patients? But my therapist told me she can’t empathize with many of my problems. This would stress me out, if I were her. I wouldn’t want to deal with someone who I couldn’t understand. And it also makes perfect sense why she can’t empathize. She wouldn’t be a very good psychotherapist if she were anything like me.
As someone who works with people dealing with anxiety in a hospital, would you have any advice for me? I am phobic of hospitals and physicians, quite badly. My record was 15 minutes for my best friend when she had her c-section, to see her and the baby afterwards. Afterwards I threw up, and spent about two hours working off the shakes, and then had nightmares for the next few nights.
For what it’s worth, it is limited to hospitals - I can go to my rustic doctor’s office quite well, only needing small concessions like keeping doors open, keeping all clothes on at all times, and sitting in a chair instead of on the exam table. I think it helps that my primary phys is about 150 years old and super sweet. I also had fairly limited problems (in comparison) with my CT scan, which was not in a hospital.
I have never been brave enough to admit this problem to my actual therapists - I’m afraid they’ll write it down somewhere and it will go in my medical record, and in my time of need the hospital doctors will see the notation and take advantage of me. (Yes, I know that’s not rational. Thanks for the insight.)
I have considered getting a medical alert bracelet that says I’m a crazy person, but I don’t know that it would help.
(I’m also broke, so that’s a consideration also.)
You beat me to it. I was going to say, The difference is in perception. To me, I have personality disorder. To others, I’m an asshole.
You might not have been working long enough to answer this question, but in the current economic times, have you noticed an increase in people who need help mentally?
Well, going by what I’ve read so far, I think this question is probably from waaay out in left field with respect to your experiences and focus so far, but what the hell, it’s acute for me at this time …
When I am romantically interested in or deeply attracted to someone, I seem to be completely unable to be cool, smooth, in any way inscrutable, or to act casual. It’s like that joke about God telling Adam he was getting a penis and a brain, but only enough blood to use one at a time. (except of course, that I’m a girl.) Seriously, when I’m in that state it’s like I am suddenly wretchedly, abjectly stupid.
I have never figured out how to play things close to the chest (no pun intended) and just be, you know, cool about it. Because “Captain Obvious” just isn’t a successful strategy.
Any suggestions?
Doctor… ya gotta help me! Sometimes I think I’m a wigwam… other times, I think I’m a teepee! What’s wrong with me!!!
Well, going by what I’ve read so far, I think this question is probably from waaay out in left field with respect to your experiences and focus, but what the hell, it’s acute for me at this time …
When I am romantically interested in or deeply attracted to someone, I seem to be completely unable to be cool, smooth, in any way inscrutable, or to act casual. It’s like that joke about God telling Adam he was getting a penis and a brain, but only enough blood to use one at a time. (except of course, that I’m a girl.) Seriously, when I’m in that state it’s like I am suddenly wretchedly, abjectly stupid.
I have never figured out how to play things close to the chest (no pun intended) and just be, you know, cool about it. Because “Captain Obvious” just isn’t a successful strategy.
Any suggestions?
Yes, don’t worry about it. It is a positive thing. You are advertising what you want without having to spell it out loud.
Yes, people do notice that you are blurting and blundering a small part of the time, when he is around. And like blushing, most see and notice it exactly for what it is: a very sincere compliment. They will probably talk about it amongst themselves, because it is a cute and juicy piece of gossip. And so The Boy will hear that a you are usually less of a stammering klutz and b: you are into him. So people will do your matchmaking for you!
Stammering and klutzing around a guy you are attracted to tells him in no uncertain terms that yes, you are deeply attracted to him. It tells him that even better then if you would act all smooth and cool, because then, he doesn’t know if you like him or if if you are just that smootha and cool and way out of his league. The rest is up to him. If he feels the same about you, you’ve saved you both a lot of trouble. If he is not into you, he’'ll let you blunder, which in a way is less painfull then a flat out rejection. If he is a jerk, he will be jerkish about it, which tells you all you need to know and makes him look worse then it makes you look.
You’'ll return to you usual self eventually in the relationship. Think about it: what would you prefer: be Miss Super Cool and watch The Boy go and date somebody more approachable, or having a relationship with The Boy and returning to your original state of Your Usual Moderate Cool after a couple weeks?
There is a reason shyness in a girl is considered a positive trait. Not in boys though, but this is a case where a girl shouldn’t judge herself with a standard only applicable to men.
A useful book.
I have got a question for Purple Scottie.
Does emotional harm (selfishness, abuse, retaliation, abandonment, etc) feel worse for someone with borderline then a “normal” person, or do they feel it less, as they often get/invoke so much of it?
From my reasonably uneducated outsiders perspective, I would think that early abuse (say in their teens or younger) would be even more devastating for someone suffering from borderline. They are emotionally much less equipped to cope, and far more likely to take the shame and hurt and agression out on themselves.
On the other hand, by the time a girl with borderline is in her twenties, she will have gone through so many cycles of destroyed relationships that, crude as that may sound, I think she may simply be used to the drama and heartbreak in love or friendship or mentorship. It can’t be as devastating the fifth or tenth time as it was the first time, can it?
Most borderliners do, in fact, jump from one relationship to the next. The “normal” mourning of such relationships isn’t visible much; I don’t know what shape if any, it takes with the BPD-er herself.
Thoughts, anyone?
THank you every one for the great questions. I apologize for being so slow to respond to them all and I am trying to not miss any (unless my subconscious is working against me)…
My initial response to the question was not the greatest and I think the answer by PandaBear77 was very good. What I think I was trying to convey is that eventually when I am just out and about, I have to turn off parts of my “Shrink Brain” or I would end up crazy! My non-psychiatrist self tends to believe that much of the difficult behavior I see in public may be due to transient stress and I try to not get too worked up looking for hidden motivations.
In my personal life, I have learned to be very good with boundaries. I am lucky that no one in my family has a raging personality disorder; however, when I am beginning a new relationship (friendship or romantic), if I begin to see a lot of “pink flags” suggesting a possible personality disorder, I am not very likely to pursue it further. I need a little drama in my non-work life as possible!
First of all, please know it is not uncommon for people to have anxiety and even phobias about various aspects of medical care whether it is about hospitals or specific tests like MRIs. No caring physician or other medical provider will think you are crazy or label you in any way if you acknowledge this fear and if they do call you “crazy” or otherwise give you less than the best care, you need to find and deserve a better provider!
Interventions our team uses depends on the severity of the phobia and its extent. For an individual with claustrophobia who severe difficulty tolerating MRIs, a low dose anxiolytic is often very appropriate and helpful when given before the procedure. I saw this done more when I worked on a child and adolescent unit but we would frequently order a numbing cream (EMLA) to be administered to the skin prior to a blood draw; use of the numbing cream along with a good phlebotomist who is both good at doing the “stick” and also distracting the patient can help. Our specific service also has a psychologist who is an excellent teacher of relaxation techniques and diaphragmatic breathing and we often work together on managing anxiety in the hospital.
It helps to remember that personality disorders are to some extent very exaggerated or particularly prominent displays of traits that many of us may regress to in less dramatic form when under duress. Also, the personality disorders that are usually best known (because of their portrayals in the movies, such as Fatal Attraction) are the cluster B personality disorders (borderline, antisocial, narcissistic, histrionic). Generally, individuals with prominent cluster A or C traits do not “bring the drama” so to speak.
Currently, I’m not in a practice situation where I would see patients diagnosed with a personality disorder for long-term therapy but I have many psychiatrist and psychologist friends who actually really enjoy working with this population. It helps to think of it more like a chronic illness like diabetes. Plus, some patients really do make progress. In residency, in addition to our formal training in DBT by therapists, we had a couple of individuals who had been diagnosed with BPD and had been utilizing DBT for several years also give a couple of sessions about how they used it and how it helped them – seeing that individuals can get relief of suffering helps alleviates the feelings of hopelessness that may arise at times working with individuals with personality disorders.
Also, being stalked by patients is not a common every day experience. I do not want to be too specific but there was one incident during my training where a patient who had in addition to an axis I disorder a personality disorder diagnosis begin to follow me to my house and intentionally started to attend my church. The patient had a history of similar behavior with prior psychiatrists (including joining houses of worship of different faiths – i.e., the patient was Christian and began to attend the mosque that the psychiatrist attended). I had great supervision from my attending psychiatrists on how to address the situation and it resolved itself fairly easily. I did change churches (same denomination but different congregation) however.
I cannot prove the subconscious is real in the same way that I can see certain regions of the brain light up on scans when patients are given specific tasks but it is at least a good concept to help explain some of our behaviors that may be self-defeating.
Currently, to my understanding it is not legal in the US. If there is appropriate research done demonstrating it is safe and effective and it becomes legal, then i would want to become more educated about the use and when it may be helpful. Since many of my patients may be acutely medically ill or have severe chronic medical problems, even if proven to be safe and effective in a healthy (physically) patient population, it may not be for mine.
Personally, I believe evil exists. One of the responsibilities of being a psychiatrist (or any type of physician or provider) is to recognize there is an inherent imbalance of power in the patient-psychiatrist relationship and that to abuse this power (whether in extreme form or subtle boundary violations) is unethical and immoral. Whether considered just out and out evil or individuals with antisocial personality disorder, these people may be drawn at times to our field and it is the responsibility of all psychiatrists to call out and condemn not only these severe behaviors but the more subtle ones. He definitely deserves long term legal punishment and of course loss of license and any professional memberships he has.
Another example, but one that has been more difficult for my patient population, is the psychiatrist at Fort Hood.
Wow, I know I still have many questions to answer – I can’t access SDMB at work (plus I have a full calendar of patients) but I promise to keep coming back and will catch up as I can. I appreciate all the thoughtful questions.
What’s your rate? 
Purple Scottie (or other psychiatrists or psychologists who’d like to chime in)–what do you think of the Dore program for treating learning disabilities?
The research on ketamine is very exciting. The idea that we may soon have a safe, effective, rapidly acting medication we could give IV in the emergency department for treatment resistant depression… it makes this psychiatrist swoon to think of it! I actually have lined up on my next CME a review of the current state of literature on ketamine and depression so hopefully I will be even more up to date as soon as I hit the books (actually the ipod, it’s a podcast CME).
In my residency, we frequently used low dose methylphenidate (ritalin) as an augmenting agent for treatment-resistant depression. What surprised many people is that often the best responders to the treatment and the most appropriate candidates were our geriatric patients with medical co-morbidities. We could see very rapid response (within days) and at the low doses of methylphenidate used rarely had difficulties with insomnia or appetite supression. There is also some evidence to suggest it may also have some benefit in augmenting pain control in patients receiving opiates for malignant pain so it was often a good choice for a patient with severe depression and cancer. I use it less frequenly in my current practice setting, mainly because the internists are not as familiar with its use, and I need them on board but working with some of the oncologists we have had good response.
Choosing which medication to start is a bit of science and bit of art. Unfortunately, depression is not like a bacterial infection where we can draw blood, grow out a culture, and then determine to which antibiotics the bacteria is susceptible.
My general thought process in a medication naive patient (first trial of any psychotropic medication) goes along the following – and to make it a bit simpler, let’s stipulate the patient has a diagnosis of major depressive disorder, moderate severity, no psychotic symptoms and no history of mania. One of the first things to look at is the patient’s other medications and their other medical problems. My patient population (including the outpatients) tend to have multiple chronic medical problems and are frequently already on several medications. I want to of course avoid medications that will interact with drugs they are already on; additionally, if drug A and drug B are both reasonable options but drug B in general has more drug interactions, drug A may be a better first choice.
The antidepressants that are generally best known to the public are the SSRIs – Prozac (fluoxetine), Paxil (paroxetine), Celexa (citalopram), Lexapro (escitalopram), Luvox (fluvoxamine), and Zoloft (sertraline) – and the SNRIs – Effexor (venlafaxine) and Cymbalta (duloxetine). These medications have significant serotonergic activity so if a patient is already on medications that are hitting the serotonin receptors pretty hard there is a risk of serotonin syndrome; generally, this would be patients who take Ultram (tramadol) several times daily or require frequent use of triptans for migraines. There are times where it may be appropriate to cautiously use two serotonergic agents together but there needs to be close monitoring and strong education of the patient about sign/symptoms of serotonin syndrome.
The other two “front-line” so to speak antidepressants are Wellbutrin (bupropion) and Remeron (mirtazapine). Bupropion tends to be more activating and more weight neutral and may help with smoking cessation but it lowers the seizure threshhold more than the other antidepressants so if a patient gives me a history of seizures or has a condition like bulimia that predisposes them to seizures, I rule that medication out. Bupropion and Remeron both have the advantage of being less likely to cause sexual side effects. (I tend to be very upfront from the get go about risk of sexual side effects with my patients along with informing them that if they do develop them on treatment we will work on finding strategies to reduce them). Remeron, however, has side effects of tending to promote weight gain and being sedating; those side effects can be great if a patient is losing drastic amounts of weight and has severe insomnia. It’s not so great when a patient is dealing with weight gain from depression or has medical co-morbidities like diabetes or is sleeping too much.
There are other antidepressants as well that are very effective – the tricyclics and the mono-oxidase inhibitors. I still use these with patients but generally not first line because they tend to be “trickier” for the patients. With TCAs (tricyclics) there may be more problems with constipation, dizziness, weight gain and I avoid them in patients with certain cardiac conditions; since many of my patients are older or have multiple medical problems they are less likely to be a good candidate for a TCA.
MAO-Is are effective but generally require a patient to follow dietary restrictions (low tyramine diet); I have used them with success in patients but generally after patients have not responded to other medications and if the patient is highly motivated to follow the diet.
So after considering drug-drug interactions, medical contraindications to use of certain medications, I’ll start to consider whether there are any of the “side effects” that can be used for good so to speak, such as using Remeron in a patient with severe weight loss and insomnia. Ease of use for the patient is also important – patients are more likely to be willing to take a medication that is given once a day rather than two or three times a day.
When I sit down with the hypothetical patient above, I will tell them we have several good options but that I do not have crystal ball to know which one is going to be the right one for them. I usually discuss a plan A and a plan B; if I do strongly favor A more than B I will tell them that. I will also let them know we will keep working at it even if it takes us to plan Z to get it right. Sometimes a patient may request initially for a trial of Prozac (fluoxetine) because a family member has taken it and if it is appropriate (no drug interactions, etc), I will tell them that it is a reasonable choice and go with it.
Okay, I know that was rambling… but it comes down to that I don’t usually just go, a-ha, it’s Monday, so it is prescribe Drug X day. I can honestly say I have never met with a drug rep, do not use drug pens or other swag, and tend to when I get journals rip the drug ads out and don’t like pharm-based CME or and don’t do pharm based dinners.
Slightly tangental, but about not being able to draw blood and know the right antidepressant… well, that some day may change. There is a lot of research in psychogenomics. Basically, it is looking at different versions of the enzymes in our livers that process certain drugs. Some patients may be “rapid metabolizers” at a specific cytochrome, suggesting that they may need higher doses of a drug metabolized by that enzyme. Some patients may be slow metabolizers and more likely to get side effects. It’s still in the early stages and may be a while before it becomes clinically relevant to the average patient but it is exciting. (Some of this research helped lead to the knowledge that women on Tamoxifen should not be prescribed Paxil due to the drug interactions at a specific enzyme leading to higher risk of breast cancer recurrence).
Of course antidepressants aren’t the only drugs I prescribe… there is a similar process though with other medications, basically weighing risks and benefits. Additionally, if a patient has had prior trials of medications, that affects the thought process as well.
I realize I’m very behind on responses but will hopefully will be able to catch up as the weekend goes on…