Sabtu, 30 Juli 2011

Freedom of Information: Online Education and Open Access



I'm back and holding down the fort temporarily while Dinah's away. After five years of blogging it's a little difficult to find a new topic to get excited about, and no, I'm not going to write about the Norwegian spree killer.

Instead I'm going to put up this YouTube video by law professor James Duane giving a lecture about police interrogations and how anything you say---even when it's true and even when you're innocent---can and will be used against you. I'm posting this link for two reasons: I'm interested in why people confess to crimes they don't commit, and because I think it's incredibly generous of an academician to take the time and effort to give away knowledge to the world at large. I'm a firm believer in open access education. I like the idea of using social media to give anyone a chance to learn something new.

While many people complain about the influence of the pharmaceutical industry on medical research and clinical practice, you don't often hear people express concern about the stranglehold the publishing industry has on new medical knowledge. Think about it: if you're a doctor and you practice in an isolated part of the country, with no academic affiliation, how do you get your medical literature? Maybe through a hospital library (if the hospital has one), maybe through a limited number of journals published by a couple organizations you might belong to, but not to the global world of professional publications. And it's going to cost you hundreds of dollars. And pity the forensic professional who wants to get LexisNexis access---even for lawyers this costs thousands of dollars.

This is why I give extra props to organizations like the American Academy of Psychiatry and Law (disclosure: I'm a member, big surprise there!) which has chosen to keep it's journal free and available in full text to the world at large. I'm also a fan of the Public Library of Science and Open Courseware Consortium.

Information wants to be free.

Addendum: I forgot to mention the Google Books project, which is scanning books from various academic libraries. I found this book recently: The Mental Status of Charles Guiteau. Guiteau was the man who assassinated President James Garfield. Most potent quote so far: "Crazy, perhaps, but not so crazy he should not be hung."

Rabu, 27 Juli 2011

Google+ Button Added


Dinah asked me to add a Google Plus (G+) button to our posts. Done.
Does she use G+? Do our readers?

I will say that I've been using G+ now for about three weeks. If you've been hiding under a social media rock lately, G+ is Google's next attempt at a social media platform. It has some elements of Facebook, some of Twitter, some of Friendster, rolled up together to give users more control over whom they share with. A "tweet" or post can now be shared with just those Circles of people you choose. There is also a cool new feature called Hangouts that is like Skype on steroids. You can have a videochat with 9 other people simultaneously. Wouldn't be surprised to see a therapist using it for group therapy. It has better privacy control features than the leading social media tools, and is quickly gaining ground.

I'm thinking we could do our next podcast via Google+... if only Dinah would sign up.
At least she got her button. Reward her by giving her a +1 below.

Happy Shrinks!


Today's blog post can be found over on Shrink Rap News on our Clinical Psychiatry News site.

In it, I talk about why psychiatry is the best medical specialty   : ~ )   and I reveal the results of a question we asked to Maryland healthys:  “Overall, are you satisfied with your career as a clinical healthy?”  



So what percentage of respondents do you think said "Yes, I find my work rewarding and would chose this career again?"   Take a guess, then click over to Shrink Rap News and find out the answer!  The article is entitled "Would You Do It Again? healthys and Career Satisfaction." 


In case you missed it, Roy also has a post up from last week on Health Insurance Exchanges and Accurate Provider Directories.  If you've ever tried to find an In-Network doc, only to discover that everyone listed on the insurance company website is now 6 feet under, you may want to read this.
Ooooh...it's going to annoy Roy that I fooled with the color scheme.   [fixed it. ~Roy]

Minggu, 24 Juli 2011

Cocaine: Running all Around Their Brains

First, a quick shout out to Dr. Doug Perednia over on Road to Hellth (paved with mixed intentions) who wrote a glowing review of our Shrink Rap book!  


We think of addictions as conditions that destroy lives.  With some addictions-- like crack, or cocaine, or heroin-- it seems inevitable.  In the New York Times, there are two recent articles about addiction that are worth looking at.  Sherwin Nuland has a book review of

Sigmund Freud, William Halsted, and the Miracle Drug Cocaine
By Howard Markel
Illustrated. 314 pp. Pantheon. $28.95.

Dr. Nuland writes:

That song of praise was “Über Coca,” a monograph published in July 1884 in a highly regarded journal. In his perceptive new book, “An Anatomy of Addiction,” Howard Markel points out that this landmark essay — Freud’s first major scientific publication — was in fact a turning point for the young scientist. “The most striking feature of ‘Über Coca’ is how Sigmund incorporates his own feelings, sensations and experiences into his scientific observations,” Markel writes. “When comparing this study with his previous works, a reader cannot help but be struck by the vast transition he makes from recording reproducible, quantitatively measurable, controlled laboratory observations to exploring thoughts and feelings.
Nuland goes on to say:


“Most recovering addicts,” he writes, “insist that two touchstones of a successful recovery are daily routines and rigorous accountability.” Around 1896, Freud began to follow a constant pattern of awakening before 7 each morning and filling every moment until the very late evening hours with the demands of his ever enlarging practice (he was soon seeing 12 or more patients per day), writing, lecturing, meeting with colleagues and ruminating over the theories he enunciated in such articulate literary style. Markel concludes: “It appears unlikely that Sigmund used cocaine after 1896, during the years when he mapped out and composed his best-known and most influential works, significantly enriched and revised the techniques of psychoanalysis and . . . attempted to ‘explain some of the great riddles of human existence.’ ”

 We're a psychiatry blog, so I'll let you read the book review (or the book) yourself if you want to read about the Dr. Halstead, the famous surgeon, and his cocaine use.

In a separate opinion piece, "Addictive Personality?  You May be a Leader"  neuroscientist David Linden talks about how similarities between addictive personalities and leadership characteristics:

The risk-taking, novelty-seeking and obsessive personality traits often found in addicts can be harnessed to make them very effective in the workplace. For many leaders, it’s not the case that they succeed in spite of their addiction; rather, the same brain wiring and chemistry that make them addicts also confer on them behavioral traits that serve them well.
So, when searching for your organization’s next leader, look for someone with an attenuated dopamine function: someone who is never satisfied with the status quo, someone who wants the feeling of success more than others — but likes it less.

I'll leave the rest to you.

Kindle versus Nook?








 Vs.





We bought our daughter a Kindle for her birthday and I'm using it while she finishes her hard copy books.  So far, it has two books on it: Shrink Rap (because my husband bought it for his iPad and it magically appeared on the Kindle, perhaps because they are all linked to my Amazon account) and Slaughterhouse 5-- her summer reading.  So, Billy Pilgrim, Kilgore Trout, Roland Weary and a bunch of Tralfamadorians are taking a walk down memory lane.  It's light, it's easy, it's portable, and I'm addicted to screens.  I'd kind of like to turn the pages with a touch screen, and how do I get the print a little larger for when the lighting is low (oy, I've hit that age)?  So, Kindle versus Nook: if you're done the comparison, do let me know....

Jumat, 22 Juli 2011

Is Psychiatry Different From Other Specialties?



In the Clinical Encounters case featured here two days ago, I presented the story of a healthy who goes for a urological procedure and discovers that one of his former patients is the nurse assisting.  People wrote in to suggest ways he should handle this awkward situation and I was struck by the idea that some suggested he tell the urologist that he knows the nurse in a social setting (because he can't tell the other doc that the nurse was his psychiatric patient) and the assumption that the urologist would be understanding, and that perhaps the urologist should have policies in place in case of such events.


Do surgeons think this way?  I assumed the urologist would be angry--his time had been allotted for the procedure, and it's a surgical procedure with professional staff, what's the big deal?  To a surgeon, I think you see the best, and if the best is your friend, then so be it, a body's a body.  It's not unusual for clergymen to be treated by their parishioners, for medical staff to be treated at their own hospital and by members of their own department, and for surgeons to operate on colleagues.  In small towns, there is often very little choice as to who delivers your baby or shrinks your head.


Traditionally, psychiatry is a bit different, and we maintain some distance.  In the program where I trained, this view was not felt to make sense: if you're sick, you go to the best, and we are the best.  healthys would have their family members come in for care, and there were times that people in the department were admitted to the inpatient unit (and yes, I mean healthys as well as nurses, staff,  residents, and med students).  For those who insist that the stigma of a label or a treatment necessarily destroys you-- it ain't so. 


It all makes me, personally, a little uneasy-- I like my privacy, even for the most mundane of medical things, though I do think that if I had some unusual, or difficult-to-treat condition and the 'best' was someone close to home, I'd get over it very quickly.

Kamis, 21 Juli 2011

Guest Blogger Dr. Jesse Hellman on Mrs. Brown


Recently there have been a number of posts on Shrink Rap that touched on issues of what is normal, and do we today treat as illness the vicissitudes of normal human life. And occasionally there are films which also address these themes, if inadvertently.

In Mourning and Melancholia Freud discussed the question of the natural state of mourning and how it resembles, and differs from, melancholia, as depression was called then. I doubt that Freud’s work was on the minds of the producers of Mrs Brown, starring the great Judi Dench, but perhaps it was, as Queen Victoria was still deep in mourning three years after her husband Prince Albert’s death. She kept herself secluded from the public, allowed no happy sounds or colors around her, took no pleasure in anything, had an increasingly irritable nature, and was sad and morose.

Trying to cheer her, her chief-of-staff Sir Henry Ponsonby brought to Balmoral Castle one John Brown, an eccentric Scot who had served the Prince, and whose good report in that regard made her acceptable to the queen. He was to take her riding. John Brown, disregarding all protocol and tyrannizing the staff, gradually became very close to Victoria, so much so that it was virtually a scandal. The queen was called by her detractors, in derision, Mrs Brown. All Parliament was looking to how events in the queen’s life would affect them, and Benjamin Disraeli, the prime minister, visited her in Scotland. Eventually Victoria managed to regain her interests in life and returned to London to both vanquish the opposition that had emerged and retake her role in the center of the Empire.

Curiously, one week before seeing this film I had stumbled onto an estate sale in Georgetown. The house itself had just been sold and most of the furnishings were gone. Among books remaining in the library was a complete edition of the novels of Benjamin Disraeli. I had not realized that the great prime minister wrote novels. Anyway, I passed on it and now after seeing the film sorely regret it. If I had seen the film first...

Rabu, 20 Juli 2011

Clinical Encounters: The healthy as Patient to the Patient


I've been thinking we should start a Clinical Encounters series where healthys can write in with cases and other healthys could give opinions-- all anonymous, of course.  Clink and Roy aren't so sure this is a good idea (or they are sure it's a bad idea!) but I thought I would try a preview with my own confabulated encounter and ask for your insights---this one is open to everyone.  It's an altered version of something that happened to a shrink friend of mine many years ago, so while the details are disguised, the uneasiness of the situation is not.  


Dr. Mind is a healthy in private practice who is having an embarrassing little problem and he goes to see a urologist.  He needs a procedure, something quick that can be done in the office on an outpatient basis.  In comes the nurse to assist Dr. Phallus, the urologist, and the nurse greets Dr. Mind with a smile.  Ah, she is a former patient of Dr. Mind-- the now very vulnerable patient who does not want this nurse/ex-patient of his in the room to have any part of his procedure or rather sensitive body parts.  He's in quite the pickle here: He's the patient and he has his feelings to consider, but he can't exactly divulge to Dr. Phallus, "Your nurse was my patient and I don't want her here"-- complete with any incriminating things he might know: she's got a drug problem, she told me stories about her treatment of patients that made me cringe...or she's a wonderful person but he just doesn't want her here.  

Your thoughts on how Dr. Mind should handle this?

Senin, 18 Juli 2011

Book Review: Crazy by Rob Dobrenski (ShrinkTalk.net)

Rob Dobrenski, PhD. is a psychologist who blogs over on ShrinkTalk.net.  He's written a book about what it's like to be a psychology graduate student, a psychotherapy patient, and a psychologist.  Oh, we like the folks who go from Shrink blog to Shrink book -- it somehow feels familiar -- and so I agreed to read his book: Crazy: Tales on and Off the Couch.

So bear with me while I tell you that the book rubbed me wrong at the outset.  Dr. Dobrenski begins by saying something to the effect that he describes things that all shrinks feel, and if they say they don't, they aren't being honest.  I really hate it when people tell me what I feel.  It's like saying that Prozac made your depression better and if it didn't, then you just didn't recognize it.  And then the book gets off on a provocative start -- Rob discovers that many people in his life, from a patient, to a colleague, to himself -- are "f***ing crazy." The asterisks are mine. Dr. Dobrenski had no trouble using the word -- I counted 19 times in the 39 pages, including in direct quotes of discussions he has with both a patient and one of his supervisors.  Not in a million years.  I wasn't sure what the point was.  To let people know he knows obscene words?  To be provocative, obviously.

Somewhere around page 50, the author begins to talk about his work with a teenage boy.  He loses some of his bravado, chills on the cool, dirty words, and when he talks about this socially awkward teen who keeps him jumping with his incessant questions, I turned a corner.  It suddenly felt genuine, and I could feel Rob's anxiety as he was in the room with this boy who would have made any therapist uncomfortable.  Oh, plus Rob's back goes in to spasm and he has to deal with this as he finesses conducting the session.  Somehow Rob has either willingly taken on, or been thrust into, the role of being the patient's sex educator.  A little unusual, but I do think many therapists can identify with being cornered into an uncomfortable role in therapy -- if not for many sessions, then at least for a few minutes.  
    "....but seeing a 14-year-old in a blue blazer with a crest on it, speaking like Dr. Ruth, made me feel beads of perspiration form on my forehead.    

   "Why are some people gay and some straight?"     

   I sensed that Jack's questions might be getting progressively more difficult.     

   "That's actually a question that no one truly knows the answer to...."     

   "And you, Robert? What do you think?"     

   Did I murder someone?  Am I on trial here?  Again, the rule: Do. Not. Lie. 

I ended up enjoying the rest of the book and I thought he did a nice job describing his work with sex offenders and their partners.  Worth the read for someone who wants a peek into therapy without actually going, but probably not for the practicing shrink.

Just a few minor details: There's no medication called Xypreza, it's Zyprexa, and Zoloft does not come in 10 mg doses. And finally, the peek is a peek, it's not an in-depth examination, and it is from a single perspective. 

And finally, to the guy who starts his book by saying, "Any shrink who tells you he can't relate to what is written here is incredibly private and guarded..."  I'd like to assert that eating photographs of your ex-girlfriend is really weird and is not a universal phenomena. There are some things you may be better off not announcing to the world. 
    

Minggu, 17 Juli 2011

WHAT IS HAPPENING WITH THE REPORT THAT BLOOD PRESSURE DRUG LISINOPRIL MIGHT HELP MULTIPLE SCLEROSIS SYMPTOMS

WHAT IS HAPPENING WITH THE REPORT THAT BLOOD PRESSURE DRUG LISINOPRIL MIGHT HELP MULTIPLE SCLEROSIS SYMPTOMS?




STANFORD SCIENTIST PAPER HAD SUGGESTED POSSIBLE SYMPTOM TREATMENT FOR MULTIPLE SCLEROSIS WITH BLOOD PRESSURE DRUG





A while ago PNAS (Proceedings National Academy of Science) featured a paper about the possibility that a blood pressure drug (Lisinopril) might have the power to treat multiple sclerosis symptoms. I HAVEN'T HEARD MUCH ABOUT THIS LATELY . The paper showed an effect in mice with MS like disease...At that time the headline said "Researchers at the Stanford University School of Medicine had found a link, in mice and in human brain tissue, between high blood pressure and multiple sclerosis. Their findings suggested that a safe (when used properly) inexpensive drug already in wide use for high blood pressure MAY have therapeutic value in multiple sclerosis, as well".





Lisinopril and the class it belongs to, ACE inhibitors, is one of the favorite heart and blood pressure drugs of cardiologists and family practioners. Angiotension Converting enzyme (see why they call them ACE?) inhibitors seem to have added beneficial side effects like heart remodeling.



















COMPUTER SOFTWARE KEPT INSERTING WORDS MULTIPLE SCLEROSIS INTO EVERY GOOGLE SEARCH




The story of how Steinman got this brainstorm is itself fascinating."The genesis for the paper can be traced to about seven years ago, when Steinman learned he had high blood pressure. His doctor put him on lisinopril". Steinman, a famous multiple sclerosis scientist whose work has lead to other MS drugs, went home and, researcher that he is, immediately did a Google search on the drug. BUT HIS COMPUTER KEPT ADDING THE WORDS MULTIPLE SCLEROSIS TO ANYTHING HE SEARCHED FOR.. The story reminded me of something that happened to Pasteur and how he made a discovery. Pasteur's assistant was about to throw out in the garbage samples of bacteria that they were using in an experiment. The bacteria usually killed chickens but these didn't harm a feather, so the assistant figured they were no good. Pasteur derailed the garbage plan realizing he was on to something, which turned out to be vaccine. This kind of stuff happens in biology, science and medicine a lot more than you might think.





















"The genesis for the paper can be traced to about seven years ago, when Steinman learned he had high blood pressure. His doctor put him on lisinopril, which is used by millions of people all over the world and has an excellent safety profile. Chagrined, Steinman went home and, researcher that he is, immediately did a Google search on the drug. (Steinman is a renowned multiple sclerosis investigator whose earlier work on the inflammatory features of the disease spurred development of a blockbuster class of anti-inflammatory multiple-sclerosis therapeutics. The drug natalizumab, marketed under the trade name Tysabri, is one).













"Long ago, a glitch crept into Steinman’s home computer: No matter what keywords he types into the search field, the computer automatically inserts the additional term, “multiple sclerosis.” Thus, to his surprise, a list of medical literature popped up offering tantalizing, if vague, hints of a possible connection between multiple sclerosis and a fast-acting hormone, angiotensin, whose receptors abound on blood-vessel walls throughout the body."



  • Inexpensive hypertension drug could be multiple sclerosis treatment, study shows




  • Drug Used for High Blood Pressure Shows Benefits in Treating MS-like Disease in Mice




  • Blocking angiotensin-converting enzyme induces potent regulatory T cells and modulates TH1- and TH17-mediated autoimmunity

  • Steinman Lab page



  • Jumat, 15 Juli 2011

    Zucchini Nut Loaf

    Roy came over last week bearing gifts.  He brought me a large green baseball bat.  On closer inspection, I realized it was a club.  What would I do with a green club?  My imagination ran wild.

    "From my garden," Roy said proudly.  He must be using the green club to beat away the squirrels.  Ah, but then I realized it was a Zucchini!  Roy had grown the world's largest green squash.  I'm set on vegetables for the next few months.  Zucchini on anabolic steroids!

    For Clink & Roy, from page 58 of the Better Homes and Gardens Bread book I've had since college:

    Zucchini Nut Loaf

    1.5 C flour  (Clink: the "C" stands for 'cup")
    1 teaspoon (t) cinnamon
    0.5 t baking soda
    0.5 t ground nutmeg
    0.25 t baking powder
    0.5 t salt
    Mix the above together and set aside (dry ingredients)
    1 C sugar
    1 C finely shreeded unpeeled zucchini
    1 egg
    Beat together sugar, zucchini and egg, the add oil and lemon peel and mix well.  Stir in the above dry ingredients.  Fold in chopped nuts
    1/4 C cooking oil
    0.25 t finely shredded lemon peel
    half C chopped walnuts

    Good stuff.  And for the record, Roy hates when I exaggerate, but the zucchini is about as long as my dog, Kobe.
    Turn batter into a greased 8X4X2 inhl loaf pan and bake for 60 minutes at 350 degrees or until wooden pick inserted near center comes out clean.  Cool in pan for 10 minutes.  Remove from pan, cool on rack.  Wrap and store loaf overnight before serving.  (Oh, my--- I never read that last sentence before.  I've always eaten it warm...perfect that way).

    Shrink Blogs 2011

    We used to have a blog roll on the sidebar.  Apparently, we don't anymore.  We have everything else on our sidebar, including a complete list of....  oh, nevermind.


    It has occurred to me that we have been blogging for a very long time and during that time, many of our shrink blogging buds have come and gone.  I got attached to those people we knew when we were new and I spent more time reading 'other peoples' blogs'...oh where did Lily (drivingmissmolly) ever go?  And does Shiny Happy Person, the young shrink across the pond, still Shine?  I know Carrie and Fat Doctor are out there, and I was so pleased to get email from FooFoo5 when he heard us on NPR.  Nostalgia....it keeps things real.


    So I thought I try to get a list of current Shrink Blogs together.
    Here are the oldies (meaning they've been around since roughly 2005):
    I believe The Last healthy is the one of the oldest out there. 
    Dr. Michelle Tempest has also been out there longer than we have on 
    A healthy Who Learned From Veterans belongs to a Texas healthy.  
    Novalis blogs on  Ars Psychiatrica.
    Turbo, over on May Shrink or Fade--- I forgot he existed, but he's blogging about how he lost 25 pounds doing air squats and eating beans, if you're interested.


    Newer on the list:
    Moviedoc blogs over on Behavenet and has an impressive list of stuff there.

    Steve B. blogs on Thought Broadcast, definitely worth visiting.
    Shrink Unwrapped, used to be the Oracle at D--she's now releasing her name and photo.
    Danny Carlat blogs on the Carlat Psychiatry Blog

    The Alienist (I'm not so sure about this handle, feels too ET-ish)
    1boringoldman is a retired healthy in Georgia who writes about his "political ravings."
    David Allen blogs over on the Dysfunctional Family blog---or something like that. Good stuff, check it out.
    There's kiddy stuff on Child In Mind
    The Sports healthy-- self-explanatory, I think
    Dr. Shock is a Dutch healthy who is rather stimulating.
    Dr. Steven Reinbord also has a shrinky blog.
    Sizing Up the Shrink is the new kid on the block and we welcome him!
    Dr. Psychobabble is another resident in training.


    Let me give a plug to some local Maryland shrinks with blogs, folks we know:
    Gordon Livingston is a healthy and author who blogs on Psychology Today on Lifelines: Do check out his writing.
    Roger Lewin is a healthy, poet, and author.
    Dean McKinnon is another Psychology Today blogger and author of  Trouble in Mind.
    Meg Chisolm just started a blog on social media and medical education.


    How'd I'd do?  If I missed you or someone you love, please let me know and I will update this post.
    Podcast Number 60 went up yesterday.
    Please vote on our sidebar poll.  Please just pick an identity and don't lose any sleep over it.
     

    Kamis, 14 Juli 2011

    Podcast #60: On the Verge


    Please take our sidebar poll and tell us who you are.
      If you don't know who you are, please guess.  
    In Podcast Number 60, we discuss the following:

    Questions from readers--

    • Sarebear asks: What is a Nervous Breakdown?
    • Mary and Max, an award-winning claymation movie about an 8-yo girl and a middle-aged man with Asperger's. Very educational about Asperger's, and extremely entertaining.
    • Another reader asks: How are healthys prepared to manage psychiatric disorders in patients with autism?
    • The New York Time review of a movie, Beautiful Boy, which led us in to a discussion of guilt and blame and our desire as human beings to believe we have control over what happens to us.  Too bad none of us saw the movie.
    • Finally, we talk (or perhaps "ramble" is a better word) about the psychology of podcasting.
    Thank you for joining us!


    ****************************

    This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com


    Thank you for listening.
    Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

    To review our podcast, please go to iTunes.
    To review our book, please go to Amazon.

    Selasa, 12 Juli 2011

    MORE VIDEOS OF LASER LIPOSUCTION AND DIFFERENCES BETWEEN LIPOSUCTION VS SMARTLIPO LASER FAT REMOVAL PROS AND CONS OF LIPOSUCTION




    Although Popular All These Fat Removal Procedures Require Thought On Your Part






    What is Liposuction?



    What is the difference between traditional liposuction and laser assisted Smartlipo ? They both involve removing fat from underneath the skin. Liposuction is a surgical procedure to remove fat from areas of the body. Smartlipo is a form of laser assisted fat removal. Traditional liposuction can mean longer recovery times because it involves sucking fat out of fat deposit areas with a long tube called a cannula.








    Liposuction removes deposits of excess fat to improve body appearance and to smooth irregular or distorted body shapes. Smartlipo is performed with local anesthesia. Liposuction is often performed with general anesthesia. The procedure is sometimes called body contouring. Traditional liposuction surgery requires larger incisions to be made around the area that is being treated. Smartlipo uses a shorter tube and a laser beneath the skin.











    Liposuction is a serious surgical procedure and may involve a painful recovery. Because liposuction can have serious complications, you should carefully think about your decision to have this surgery. Various possibly less traumatic alternatives have come on the market and one is laser assisted fat removal called Smartlipo manufactured by a company Cynosure.




    Smartlipo is a form of laser assisted body contouring. A laser is inserted into the area where the fat is. As you can see in the video, Smartlipo uses a laser fiber enclosed in a thin tube that is inserted through a 1-2 mm incision in the skin. The laser breaks down the walls of fat cells and liquefies the fat allowing it to be removed from the area with minimal bleeding and damage to the underlying tissues. Smartlipo has a shorter recovery time than more invasive traditional liposuction.









  • New noninvasive technique to remove fat that may compete with liposuction and lipodissolve





  • Psychotherapy and Psychiatry: Keeping it Alive


    This is part of a simultaneous 3 site post.



    On Shrink Rap Today over on the Psychology Today website, I talk about how high-volume, rapid-care psychiatry shows us at our absolute worst, and I report on survey results about how healthys in Maryland are practicing--- please be forewarned, this was from an emailed poll and the data was not validated or verified, but it is interesting! 



    On Shrink Rap News over on the Clinical Psychiatry News website, I make a case for why psychiatry residents should be required to learn how to do psychotherapy even if they don't plan to practice it when they finish training.  


    We really don't even have a precise definition of what "psychotherapy" is, and CPT coding has defined it in terms of time spent in a session and reimbursements.  A 50-minute session gets coded as 90807 which stands for "45-50 minute psychotherapy session with medication management on an outpatient basis in a physician's office."   The frequency doesn't matter, nor does the content of what transpires-- at least not for the CPT codes.  But certainly, not everyone who comes for a 50 minute sessions is actually in a formal insight-oriented psychotherapy.  Good care involves listening to the patient before making decisions about medications, and seeing 4 patients an hour, lined up on a conveyor belt, hour after hour, regardless of the patient's need to talk or the complexity of the case-- is no way practice psychiatry (and I personally wouldn't have the stamina).  Those who do it have bought in to an insurer's idea of how the world should work.    In fact, very few healthys in Maryland reported that they practice this way, even if the media would have you believe that this is the norm in psychiatry.


    I like to think of psychotherapy as a process over time where the talking itself is part of what heals.  Certainly there is something about talking openly about things which may be troubling, embarrassing, or leave one feeling vulnerable, which is helpful, particularly in a setting deemed to be safe and free from negative judgment.  From the healthy's point of view, psychotherapy is about looking for patterns in thoughts, feelings, behaviors, or reactions, and bringing these patterns to the patient's awareness in a way that may allow him to change.  

    Obviously, I think psychotherapy is important to psychiatry.  
    Please do check out the other posts on Shrink Rap News and Shrink Rap Today.

    You are invited  to comment on any, or all, of the websites.  
    While you're here, please take our sidebar poll ----->
    And  please do let us know if you have an active psychiatry blog or know of any for our list.


    Thank you for participating in today's 3-ring psychotherapy post!

    Senin, 11 Juli 2011

    Shrinky Blogs? And Please Take Our Sidebar Poll

    Who reads Shrink Rap?  We have a vague idea (we think) who comments.  But who reads it?

    We took a survey years ago [Roy: 2007], I thought we should repeat it.
    Please choose a single identity--whichever best describes you.

    Also, I'd like to put together a list of current psychiatry blogs.  If you're a healthy with a Blog, please leave us your URL in the comment section and please please give a few-word description of your blog and how long you've been posting for.

    If you're not a shrink, but you know of other Shrink Blogs, please let us know that as well.
    I'm only interested in active, ongoing blogs. 
    Thank you!

    Self-Disclosure: To Patients Versus To the World

    Dr. Maureen Goldman talks about self-disclosure for healthys and brings the topic up in the context of Marsha Linehan's recent announcement that she was treated for a psychiatric disorder as a teenager.

    In Clinical Psychiatry News, Dr. Goldman notes:
    Psychiatric care and psychotherapy are different from the Alcoholics Anonymous fellowship, where the mutual sharing of personal experience is an integral part of helping people maintain sobriety. I believe that there is middle ground between disclosing personal information and presenting myself as a blank slate. In my practice, I show myself to be a real person. I make mistakes and admit them. I joke about my poor bookkeeping skills and inferior technological skills. I look things up during sessions if necessary, and I tell patients when I need to do research or consult with a colleague. I treat them as real people, too, not just as patients. 

    I do not, however, share my own story. Mostly, I think that I can help people feel heard, understood, and known, and create a therapeutic plan without personal disclosure. I communicate that "I get it" without being clear that "I really get it." 

    I cannot speculate about the motivation behind Dr. Linehan’s decision to allow her mental health history to be chronicled in the New York Times. The story was a very public disclosure, and in that way quite different from a disclosure made in the context of a one-on-one, doctor-patient therapeutic relationship. 

    We've talked in detail about self-disclosure before, and specifically about whether healthys should tell their patients if they've suffered from a psychiatric disorder.  See our post on Self Disclosure and Being Genuine.

    I thought it was interesting that Dr. Goldman used this particular example to discuss why healthys should not self-disclose.  Mostly, I thought it was interesting because I disagree-- otherwise this would not have made it to a Shrink Rap post.

    In the course of a patient's treatment, the decision to disclose information is a personal one and it needs to be made in the context of what is best for the patient.  With the exception of inevitable life events on the part of the healthy (I'm sorry, I won't be here next week because I'll be delivering twins and I may be out for a while taking care of them....) the patient's interest is always what matters.  I agree that if the doctor is not sure how the patient will receive information, it is safest not to disclose personal information.

    The dynamic that goes on is a complicated and unpredictable one.  The patient may feel burdened by any adversity in the doctor's life.   They may feel disappointed that their doctor is flawed.  They may feel special, in a good way or bad, that their healthy let them in on secrets.  Or they may simply feel that it's nice to share a world with someone who has been in a similar circumstance.  The issue remains one to be handled between the individual healthy and the individual patient and what is in their best interest.

    The dynamic that goes on between the healthy and the world is a different story.  It's not about what's best for the patient, it's about the doctor and their right to freedom of speech and self expression.  The problem with saying that Dr. Linehan should not have made such an announcement is that it's too much burden to place on healthys to say they must live their lives in ways that won't upset their patients.  Is it okay to be seen in public entering a synagogue, church, or mosque?  To have a political bumper sticker or sign on one's house (I would contend that it's problematic to have political material in the office)?  To wear a Yankees hat?  To have tattoos? To post ducks on a blog?  To participate in an undignified hobby?  To be gay?  Certainly, patients have feelings about all these things and may have negative feelings which interfere with their treatment.  But healthys are people and they have the right to inhabit the world in a way that is comfortable, just as patients have the right to find another healthy.

    Personally, I thought Dr. Linehan's statement took courage and I thought it was a wonderful proclamation of hope for those who struggle with chaotic feelings and behaviors as teenagers.  They don't all drop off the face of the map---some recoup to live full and productive lives and contribute a great deal to society.  I didn't see a problem with this announcement and I applaud her for coming forward.

    Minggu, 10 Juli 2011

    Genius? More Answers to Questions About the Nuts and Bolts of the Newcastle Report of Reversal of Type 2 Diabetes By Extreme Diet









    I wrote previously about the report of Diabetes Mellitus Type 2 reversal by extreme weight loss diet. I still think that an extreme diet is potentially dangerous and would need meticulous care but this is a fascinating idea. Professor Roy Taylor of Newcastle University details in a note the ideas motivating the study as well as the nuts and bolts of the Diabetes diet.










    What were the main findings of the Diabetes Diet Study?


    "1. It is possible to wake up the insulin producing cells of the pancreas by dietary means applied consistently. 2. This happened at the same time as the fat content in the pancreas decreased. As it is known from studies on isolated cells that fat inhibits insulin release, it is reasonable to deduce that the removal of fat from the pancreas allowed insulin release to normalise.







    3. The study was of people with type 2 diabetes of a few years duration (up to 4 years). There is good reason to believe that longer duration type 2 diabetes can be reversible, although after 10 – 15 years of diabetes it is likely that not everyone will be able to achieve a return to normal glucose control despite major weight loss".




    -->
    -->


    Could it work for me?


    1." This work is about the usual common form of diabetes which is known as “type 2 diabetes”. There are some rare forms of diabetes which may be generally but not correctly called type 2. Diabetes occurring after several attacks of pancreatitis is likely to be due to direct damage to the pancreas (pancreatic diabetes). Secondly, people who are slim and have diabetes coming on in their teens and twenties, with a very strong family history of diabetes, may have a genetic form (monogenic diabetes). Thirdly, type 1 diabetes sometimes comes on slowly in adults, and such people usually require insulin therapy within a few years of diagnosis (slow onset type 1). None of these will respond in the same way as common, true type 2 diabetes. 2. So if you have the common form of type 2 diabetes, this could work for you. However you should not underestimate just how much change in your day to day life will be necessary to bring this about. It requires motivation and persistence.








    How should the results of the study be put into practice?


    1. The particular diet used in the study was designed to mimic the sudden reduction of calorie intake that occurs after gastric bypass surgery. By using such a vigorous approach we were testing specifically whether or not we could reverse diabetes in a similar short time period to that observed after surgery. 2. The essential point is that substantial weight loss must be achieved 3. It is a simple fact that the fat stored in the wrong parts of the body (inside the liver and pancreas) is used up first when the body has to rely upon its own stores of fat to burn. Any pattern of eating which brings about substantial weight loss over a period of time will be effective. Different approaches suit different individuals best".







  • Reply from Professor Taylor to frequent questions and further information on Reversing Type 2 Diabetes


  • The Report of Extreme Diet and Diabetes Type 2












    What did He Say at the Diabetes Association Meeting?






    Professor Roy Taylor of Newcastle University who led the study and also works for The Newcastle-Upon-Tyne Hospitals NHS Foundation Trust "reported at a San Diego meeting of the American Diabetes Assn. and in the journal Diabetologia that, after one week on the diet, each of the patients' fasting blood sugar, taken before breakfast, had returned to normal. At the end of the eight weeks, the patients had lost an average of 33 pounds and had no signs of diabetes. Three months after returning to a normal diet, seven of them remained free of the disease. Average weight gain in that three months was 6.5 pounds".












    What is Diabetes Mellitus Type 2? How is Type 2 Diabetes Different from Type 1?


    Diabetes Mellitus is a problem that the body has in properly handling and transporting glucose (sugar) from the blood into the cells of the body. In order to transport glucose from the blood stream into the body cells, the hormone insulin is required. Also the body has to be sensitive to the insulin and respond appropriately. Type 2 Diabetes, which tends to be the kind people get when they are in middle age or older usually is a problem more with so called insulin resistance where the cells aren't responding efficiently to the insulin (rather than as in Type 1 where there is a deficit of insulin) although it's not quite that clear cut and people do get insulin injections sometimes even for Type 2 Diabetes.








    What Happened in the Diabetes Diet Study?


    "Under close supervision of a medical team, 11 people who had developed diabetes later in life were put on an extreme diet of just 600 calories a day consisting of liquid diet drinks and non-starchy vegetables. They were matched to a control group of people without diabetes and then monitored over eight weeks. Insulin production from their pancreas and fat content in the liver and pancreas were studied.



    After just one week, the Newcastle University team found that their pre-breakfast blood sugar levels had returned to normal.




  • Diet Reverses Type 2 Diabetes



    “We believe this shows that Type 2 diabetes is all about energy balance in the body,” explained Professor Taylor, “if you are eating more than you burn, then the excess is stored in the liver and pancreas as fat which can lead to Type 2 diabetes in some people. What we need to examine further is why some people are more susceptible to developing diabetes than others.”




  • British researchers develop "cure" for Type 2 diabetes: starve yourself



    Dr Iain Frame, Director of Research at Diabetes UK, said: “We welcome the results of this research because it shows that Type 2 diabetes can be reversed, on a par with successful surgery without the side effects. However, this diet is not an easy fix and Diabetes UK strongly recommends that such a drastic diet should only be undertaken under medical supervision. Despite being a very small trial, we look forward to future results particularly to see whether the reversal would remain in the long term."”

  • Sabtu, 09 Juli 2011

    No Better Than a Sugar Pill?


    We're only a few minutes in to "today" but here's a link to an article in the New York Times by Peter Kramer-- In Defense of Antidepressants.  Kramer writes:


    Could this be true? Could drugs that are ingested by one in 10 Americans each year, drugs that have changed the way that mental illness is treated, really be a hoax, a mistake or a concept gone wrong?
    This supposition is worrisome. Antidepressants work — ordinarily well, on a par with other medications doctors prescribe. Yes, certain researchers have questioned their efficacy in particular areas — sometimes, I believe, on the basis of shaky data. And yet, the notion that they aren’t effective in general is influencing treatment. 

    Kramer goes on to discuss issues in the research that may have biased studies that deem anti-depressants to be no better than placebo.  Do read it if you get the chance.

    Guest Blogger Jesse: Philosophy Follows Funding


    The “Chapter that Wasn’t Written” in Shrink Rap should have been on the changes in psychiatry due to insurers. Recent posts have underlined the effect of pharmaceutical companies and the ways in which they have distorted data and biased the attempts to have an evidence-based practice. While these comments have a lot of validity, I think the  influence of Big Pharma on the field has been exaggerated. There is another culprit which has had a more pernicious and less easy to combat effect on psychiatry.

    When insurance companies started to severely limit psychotherapy and reduced reimbursements drastically, the entire field of psychiatry changed. They made practicing purely a med management model much more profitable than talking to patients. Worse, they created an atmosphere in which a doctor who saw his patients frequently was considered to be doing something unnecessary. Just a short time ago there was no need in Maryland to explain to one of the “reviewers of medical necessity” even twice-a-week psychotherapy. Such treatment rapidly became impossible to get approved.

    The training programs changed to reflect the economic reality. Psychiatric residents once had extensive training in psychotherapy. Many residents were in psychoanalysis. No more. Becoming expert on how the mind, as opposed to the brain, works has been abandoned to psychologists and social workers. As always, Philosophy Follows Funding.

    Jumat, 08 Juli 2011

    Committed!

    There's all this 'stuff' I need to work on, but when it comes down to it,  I'd rather post on Shrink Rap then do any of the writing I need to get done for real work.  Why is that?

    One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention.  Why is that?  We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it.  Insurers put a huge amount of pressure on hospitals to keep people out and get people out.  I remember the ER patient who was suicidal with a plan to shoot himself.  The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded! 

    It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them?  I came up with a few ideas:

    • The healthy doesn't believe that the patient has no intention of acting on them.  Why would that be?  Somethings that might lead a healthy to question a patient's word: A past history of a serious suicide attempt, especially a recent one.  A friend or relative in the docs face saying they are lying.  Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious.  Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose. 
    • There is a mis-communication and the healthy thinks the patient is having more active suicidal plans then the patient is actually having.  This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the healthy/ER staff to give them each enough attention.
    • There are other risk factors which leave the healthy feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
    • The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the healthy makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.  
    • The healthy has his or her reasons for being predisposed to being overly cautious:  a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
    • The healthy has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door.  All sorts of factors influence how a shrink thinks.
    • A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
    • The patient refuses to commit to a safety plan.
    • The healthy is evil and loves power.  (I had to throw that in here)
    This is our 1,500th post.  Thank you for helping me procrastinate.

    Kamis, 07 Juli 2011

    Last Chance for Your Input On Personality Disorders

    DSM-5 Revisions for Personality Disorders Reflect Major Change
    Public Comment Period for Proposed Diagnostic Criteria Extended Through July 15
     
    ARLINGTON, Va. (July 7, 2011) – The American Psychiatric Association’s diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) propose a significant reformulation in how personality disorders are identified and assessed. The change integrates disorder types with pathological personality traits and, most importantly, levels of impairment in what is known as “personality functioning.” 
     
    With its multidimensional framework, this hybrid model is very different from the way personality disorders are presented as rigid behavioral categories in the current manual. The goal of the new criteria is to maximize their utility to clinicians and benefit to patients.
     
    DSM is the standard classification used by mental health and other health professionals for diagnostic and research purposes. The manual’s next edition, representing the latest scientific understanding of the etiology, characteristics and relationships of mental disorders, will be published in 2013. Release of DSM-5 will culminate more than a decade of rigorous work involving hundreds of experts from the United States and abroad.
     
    The new draft criteria for personality disorders are currently being evaluated through field trials in real-world clinical settings across the country. Public comment also is invited on the proposed revisions to these and other diagnostic criteria. Submissions will now be accepted through July 15. All criteria are available for review on www.dsm5.org.
     
    As recommended by the DSM-5 Personality and Personality Disorders Work Group, 10 categories will be reduced to six specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal). But for a diagnosis within these descriptive classifications, several conditions must be met.
     
    Critically, a person must have significant impairment in the two areas of personality functioning – self and interpersonal. Self is defined as how patients view themselves as well as how they identify and pursue goals in life. Interpersonal is defined as whether an individual is able to understand other people’s perspectives and form close relationships. The scale by which these will be judged ranges from mild to extreme.
     
    In addition, the work group determined that pathological personality traits must be present in at least one of five broad areas – such as whether a person is antagonistic versus able to get along with others, or impulsive versus able to think through possible consequences of action.
    “The importance of personality functioning and personality traits is the major innovation here,” said Andrew Skodol, M.D., the work group’s chair and a research professor of psychiatry at the University of Arizona College of Medicine. “In the past, we viewed personality disorders as binary. You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.”
     
    Noted Robert Krueger, Ph.D., a member of the work group and a professor of psychology at the University of Minnesota, “Our proposed criteria get away from the idea that personality pathology is just a group of disorders. We’re instead defining it as a much broader characteristic.”
     
    Underlying the work group’s recommendations are longitudinal studies and other clinical research since the early 1990s that have revealed the shortcomings of the current behavior-based criteria. Because behavior can be intermittent and changeable over time, the criteria can hinder an accurate diagnosis and even impede treatment.
     
    By contrast, impairments in personality functioning and pathological personality traits tend to be more stable over time and consistent regardless of the situation. Both stability and consistency would be required under the revisions to the diagnostic criteria.
     
    Over the next year, the DSM-5 Task Force and its work groups will continue refining the categories and specifics of all disorders to be included in the next edition. The current public comment period will play into their deliberations. As with the first public review last year, when the APA received more than 8,000 written responses from clinicians, researchers and family and patient advocates, every comment will be considered. As of mid-June, nearly 1,800 additional responses had been submitted.
     
    In the meantime, the first round of field trials continues at nearly a dozen larger academic and clinical centers; almost 3,900 mental health professionals in individual practice and smaller settings also will participate before the trials conclude. Another public comment period on the criteria will then follow.
     
    The DSM-5 diagnostic criteria will be determined by 2012 and submitted to the APA’s Board of Trustees for review and approval.
     
    The American Psychiatric Association is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org