I am salaried – one of the perks of my job is not having to deal with billing or prior authorizations. Occasionally I’ll have a nonformulary request form to complete but generally I have much less to put up in terms of that type of paperwork than my peers in private practice.
I’ve never heard of it, but am always skeptical of “fix-it” therapies for developmental disorders, especially those as wide ranging as ADHD, Asperger’s, and Dyslexia.
And Purple Scottie, I’d like to extend my appreciation to you for spending the time you have giving thoughtful answers to the questions posed here.
I have an appointment next week to talk to somebody about my suicidal thoughts…Any general advice?
I feel badly for not pulling up citations for all the studies I’m vaguely referencing but most of my journal article library is saved on my work drive and I’m posting for home. Another way to consider this question is if there are reasons why some individuals may show more resilience than others when exposed to trauma. There is evidence to support level of support in the environment as being a major factor but also some interesting (again relatively early studies) looking at genetic differences among patients who experience trauma and whether they go on to develop PTSD (i.e. studies on different polymorphisms on a specific serotonin transporter gene).
Another perspective on situations is that individuals who have undergone severe trauma in early life may have difficulties with boundaries and on some level knowing where they stop and the other person starts. Hypersensitivity to rejection can occur in many different conditions but a pattern of highly dramatic unstable relationships is frequently seen in individuals with either borderline personality disorder or strong borderline traits. As humans, we often continue to repeat the same patterns over and over, whether they are helpful are not, so a person who has difficulties with boundaries, a poor sense of self, and perhaps never has seen stable relationships may not realize that not all relationships are so dramatic or that they may deserve to be in a healthy relationship.
I do think the patients with these chaotic patterns suffer…
Be honest is the best advice and try to not worry about being judged. I think a lot of times patients may worry if they admit that they have had suicidal thoughts that they are automatically going to be locked up. There are times when psychiatric hospitalization may be necessary and may unfortunately be necessary under involuntary status but generally the goal is to provide care in the least restrictive environment possible.
I ask every patient, every time I see them about suicidal thoughts. If they say they are suicidal, that’s not the end of the conversation. I want to know more about what the thoughts are like – are they new or have they been struggling with them for years? Is it really a desire to end one’s life or a desire to escape from a particular stressor? What type of plans, if any, have they made about harming themselves? Have they rehearsed the behaviors? Do these thoughts occur when using alcohol or other drugs? Do they have impulses to burn themselves or cut themselves without meaning to kill themselves? If they do, how does that injury make them feel (some patients who engage in self-injury try to experience physical pain to relieve emotional distress). Are the suicidal thoughts ego dystonic (distressing) or ego syntonic (non-distressing) – does the patient feel safe knowing that they have an “out” clause if things worsen?
Please try to not worry about being judged as being “crazy” or “weak” for having suicidal thoughts. Also, be sure to ask about crisis lines (often billed as suicide prevention lines but I tell patients they don’t have to wait until it gets that bad to call).
I am not familiar with it; generally I am less up to date on therapies for conditions generally considered to be more in the realm of child/adolescent psychiatrists or developmental pediatricians.
Too tense perhaps?
Oh, and I’ll get to the question about treatment resistant depression soon…
Well, Michael Swango certainly got long-term legal punishment, if three consecutive life sentences in 23-hour-a-day solitary confinement in the highest-security prison in America with no possibility of parole is long enough for you. But I think there’s a pretty gigantic difference between Swango and someone like Nidal Hasan, the Fort Hood shooter.
Hasan committed a one-off burst of mass violence, motivated by a combination of religious extremism and some form of mental breakdown. Up until then he was, by all accounts, a normal and well-adjusted man.
Michael Swango, from the time he was a small child, was absolutely enthralled by death and by the idea of disaster and violence. All throughout his medical career, his co-workers observed that he was fixated on death and violence, that he was obsessed with incidents of mass murder and would make scrapbooks full of news clippings on same, and he was charismatic enough that he was able to continue working even with this bizarre persona. His obsession with death and his need to cause death was deeply ingrained into his mind and into his entire identity. It was like he was hard-wired to be a natural predator.
I’m actually kind of surprised to hear you use the term “evil,” as that is just a word that we invented as a way of explaining certain kinds of behavior that are consistently detrimental to the greater good. But what causes these behaviors? And is there any possible way that they can be harnessed towards something productive, or are people with these impulses irretrievably “broken” forever and destined to be killed or permanently imprisoned once they have been found out? Is it a chemical imbalance in the brain, or something else?
Thank you for the excellent, detailed reply, and for the time you’re spending on this thread. You seem like an excellent psychiatrist - perfect attitude towards patient care.
Of your patients that start medication, what percent experience significant reduction in depression?
Purple Scottie, thanks, but I don’t quite understand your answer.
Perhaps some background to the question would clarify things. I asked this very question here, in an earlier thread. The question “do borderliners suffer more or less from relationship drama then a average person would, seeing that borderliners create/suffer so much more relationship drama?” .
The discussion emerged because I stated that a borderliner would typically be less upset by relationship drama, not more.
I suppose my own personal reason for asking this question is that I hate relationship drama and the people who create it, and as borderliners do that, I wonder how much I should pity them.
If I understand your answer, Purple Scottie, you say that
a. there are general differences in stress tolerance between individuals, that may or may not have a genetic basis; a borderliner may or may not have a high stress tolerance;
b. Borderliners may have a drama pattern to their relationships because of that is what they are used to. While that is a drama in itself, wouldn’t that mean that a borderliner finds relationship drama deep down reassuringly familiar? Or should we see each new relationship drama as the tearing open, again, of a deep wound that never healed well in the first place?
In your experience, does Lexapro give just about everyone horrific nightmares/lucid dreams/really intense dreams?
If so, do you know why it does that?
Purple Scottie, I’m going to impose on your generosity and ask a couple more questions. I can see you’re getting bombarded, so feel free to defer these, especially since I’m “double dipping” 
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Do you, and psychiatrists in general, find the term “shrink” offensive? I tend to use it, since it’s shorter and doesn’t seem to carry the stigma that the less enlightened members of the population attach to the word “psychiatrist”, but I always feel bad, especially if I slip up and refer to my doctor as that in his presence or when talking to my GP. Or is it like the n-word, where it’s okay “within the community” but not when an “outsider” uses it?
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I’ve been through the mill with literally dozens of kinds of antidepressants. I’m not asking for personal advice here - I’m already seeing a very good p-doc. But, part of me thinks the whole thing is “smoke and mirrors”, a case of emperor’s new clothes. That there is no “there” there. I’m not trying to impugn your profession - I know psychiatrists go through some of the toughest training there is, and it must be an extremely challenging job; these are my demons. It’s just that, like a lot of Dopers, I tend to lean towards a scientific, logical positivist viewpoint, so it troubles me that all this is so subjective - it’s not like (as you said) one can take a culture and objectively determine which antibiotic will do the trick. There doesn’t seem to be a convenient instrument to measure serotonin - you can’t stick a thermometer-like instrument in someone’s ear and conclude, “aha…it’s a serotonin problem, rather than glutamate or dopamine, so I’ll need to use drug X”. And even if there were, the only way to know if it’s working is the patient’s self-reporting - you can’t objectively measure “a sense of wellbeing” or happiness, like you can measure blood pressure or white cell count.
It just seems so subjective - the doc will ask, “So…have you been feeling better since we last met?” And I really have no idea - it’s hard to “average out” one’s mood into a single scalar value like that. Part of the problem is that as a lifelong dysthymic, I have no baseline for feeling well adjusted and happy - it’d be like asking you, “Have you felt more or less like a woman this month?” [assuming you’re male - if not, please reverse the question]. Of course there are those “depression inventory” questionnaires, and one can keep a “mood log”, but that is also totally subjective. Filling out those questionnaires feels more like those surveys in tabloid magazines to figure out “if he really likes you” and so on. I do come from a very working class, "what’s all that shrink nonsense? " type background, so I’m sure that’s a factor.
It doesn’t help that a lot of the double-blind, placebo-controlled studies are funded and carried out by the drug companies themselves, who are obviously far from impartial, and that there have been cases of them suppressing studies showing drugs performing no better than placebo (kind of a file drawer effect).
Sorry for rambling. I guess my question buried under all this is, how do you deal with the “skeptical”, scientifically-minded patient, and in general with the subjectivity of the whole field? Feel free to ramble back at me in return
What do you think of Alyssa Bustamante, the 15 year old emo girl in Missouri that killed her 9 year old neighbor to see “what it felt like?”
She has dysfunctional parents, hospitalization after a suicide attempt, significant self-harm, dark fantasies,and a fascination with death. She’s been diagnosed with major depression and borderline personlity disorder, but it’s been suggested that the symptoms of BPD are similar to actual psychopaths. I got interested in this case because I have a similar background to her, yet I never acted on my fantasies, or apart from suicide really thought seriously of doing so. So I’m kind of wondering it it’s chance that she acted out and I didn’t, or if there’s something f—ed up in her head above and beyond her official diagnosises. For what it’s worth I have a friend who’se also BPD who’se been in trouble with the law, but in that case it was slugging a cop at a traffic stop when she thought her friend was being treated too roughly.
Also in your experience does Seroquel help with depression and BDP? I’m on that now in part because it’s one of the few psychotropic medications I can tolerate, but I know it’s not really labeled for that purpose.
I’d like to hear the answer, too. Evidence based practice in mental healthis such a young field. I often think the future will see a more person-specific, and more effective treatment of depression, rather then the trial and error-with a bit of expert’s intuiition thrown in.
Another side to **DarrenS’**s question is that I imagine that any practitioner has to employ the placebo effect to the fullest. That can mean playing the all knowing Doctor with one patient, and talking medical odds and clinical literature like equals with a more critical patient.
Thank you for this thread! I wake up with a horrorshow list in my head of things that did/are/might/will go wrong in my life, and what I should have done/can do/might possibly do to avert them. WHY? I’m not without resources, I’m not stupid, but life feels like a big boot hovering over an insect the minute I wake up in the morning. I always feel “this bad thing has got to come someday, it’s gonna be my turn”. So…what should I do?
Salinqmind, does googling generalized anxiety disorder help you any further?
Well, I know what it is. I was hoping for a one-sentence miracle cure from Purple Scottie, like ‘meditation and deep breathing is more effective than any pill or $200 an hour therapy’.
In case you thought I took some offense at your first answer, don’t worry, I didn’t. As my answer indicated, I’m well aware of people’s perceptions, partly because I’m the same way myself. I’d guess that we’re all hardwired to avoid people who are acting out of the ordinary, no matter how out of the ordinary we are ourselves.
But thanks for elaborating. It must be difficult in your field to leave the job at work. And I’ll add my kudos to you for starting this thread.
I can vouch that it doesn’t give EVERYone nightmares or really intense lucid dreams. 
I had rather wild dreams when I was on citalopram, which is basically diluted lexapro that costs $4 instead of $100 a month. Tweaking chemical levels in the brain does odd things.
Hi Purple Scottie, I am 50 years old and was diagnosed BP when I was 35. Symptoms first manifested themselves in my early teens. It was never noticed as a disorder because I was a high achiever with a very chaotic schedule. With money and success, my behaviors became self destructive. Lots of thrill seeking types of things.
The Doc that diagnosed me put me on Paxil, no mood stabilizer. I loved the stuff, it felt like I was taking speed. I got hit with a pool cue as an innocent bystander, and witness of a barroom brawl. It was then that I discovered how violent I could be. I beat the crap out of several guys and a couple cops. It took 6 cops to subdue me and get me into a car. They took me to a hospital instead of jail. My Doc changed my meds to Lithium and an anti-seizure med, whose name I cant remember at the moment. I crashed hard.
Every other cocktail I tried over the next several years made me feel like a zombie. I eventually went off meds and and away from doctors. I had a big bottle of seroquel that I would take when I felt like hypomania was getting out of control.
As I have aged, the hypomania has become very infrequent. The depression seems to be seasonal, and very intense. It got bad enough that I was starting to look at doctors again. It was about this time that I started having orthopedic surgeries. Arthroscopies, knee replacement and a joint fusion. I scheduled all of them for the months I had the worst depression. I have not had an intense depressive episode in 3 years. I assume its because I was using opiod pain meds. I have cold tukeyed the meds twice, I can still get 20 pills a month if I want them. I only use them for pain occasionally, maybe 2 or 3 times a month. If this coincides with a depressive episode it knocks me right out of it.
I know this is not a therapy that any psychiatrist is about to endorse, but is there anything out there that is so effective without such drastic side effects?
Two other things I’ve always wondered …
What is the difference between having a spiritual experience with some kind of deity vs. being crazy?
(And I would thank anyone so inclined to not jump in and threadshit and imply that anyone religious IS crazy, kthx.)
Do schizophrenics in, say, Saudi Arabia (or some other predominantly non-Christian country) hear from Jesus, or do they think it’s Allah telling them to jump in front of that train? Mainly I’m wondering if crazy people who think a deity is telling them to do wacky stuff tend to hear from whatever deity they’ve had the most exposure to, or does it pretty much seem to always be Jesus doing the talking?
Offshoot of the previous question – who do atheist schizophrenics hear from? If someone’s schizophrenic and an atheist and thinks God is talking to them, are they somehow able to go “ok, this is definitely just in my head, I don’t believe in any kind of god so I am not going to obey that voice?”
(And yes I’m aware that not all schizophrenics have auditory hallucinations, and not all of those who do are hearing from any kind of god; I’m just referring to those who do have them and do think some kind of higher power is communicating with them.)