Meditation: Does it Do Anything?

Meditation sounds like a great idea from the perspective of a healthy: anything that calms and focuses the mind is a good thing (and without pharmaceuticals: even better!).

Personally, I tried Transcendental Meditation as a kid...more to do with my mother than with me...and found it to be boring. I have trouble keeping my thoughts still. They wander to what I want for dinner and should I write about this on Shrink Rap and will Clink and Victor ever eat crabcakes with me again and did I remember to give my last patient informed consent and a zillion other things. Holding my thoughts still is work.

The New York Times Well blog has an article on Meditation and Brain Changes. In "How Meditation May Change the Brain," Sindya N. Bhanoo writes:

The researchers report that those who meditated for about 30 minutes a day for eight weeks had measurable changes in gray-matter density in parts of the brain associated with memory, sense of self, empathy and stress. The findings will appear in the Jan. 30 issue of Psychiatry Research: Neuroimaging.

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

-------Lower stress, lower blood pressure, higher empathy.... I may have to give meditation another try. The cartoon above, by the way, shows Roy leading a meditation session. Now there's a thought.

James Watson Live!

"To succeed in science, you have to avoid dumb people... Even as a child, I never liked to play tag with anyone who was bad as I was. If you win, it gives you no pleasure. And in the game of science-or life-the highest goal isn't simply to win, it's to win at something really difficult. Put another way, it's to go somewhere beyond your ability and come out on top."
-- James Watson, "Succeeding in Science: Some Rules of Thumb", Science, 261, 24 (September 1993): 1812. September 1993.


Snowy here in Maryland.

Yesterday, there was just a little snow, a three-inch surprise in the morning, and schools were closed, things were surprisingly still. My agenda included a trip to Hopkins to hear Nobel prize winner James Watson speak. Was it canceled? Did I really want to risk being caught in the snow coming home? No, it wasn't canceled. And when would I ever get the chance to hear James Watson speak? So yes, I did risk the weather, and it was fine.

I've never seen Hurd Hall so packed. No chandeliers, but people were hanging off the balcony, snow date and all. There weren't a lot of healthys there, even though the lecture was sponsored by the Department of Psychiatry, but this meant I got a front row seat in the reserved section.

Dr. Watson was an entertaining speaker, to say the least. He structured his talk around his "rules" for life, and said there were rules involved in the race to find the structure of DNA. Oh, I wish I written them down. He started something like this, "I was a boy on the South Side of Chicago and the first rule was Don't fight bigger boys or dogs." His second rule of life had something to do with putting a spin on balls. The rules around the story of the discovery of the double helix included things like don't be the smartest person in the room, don't research the same thing that everyone else is researching, leave a job before you get bored with it, speak to your competitors.... it was all told with a sense of humor and I should probably have taken notes for a few good quotes and a better taste of the rules themselves, but who knew? Oh, and I didn't have a pen. I have to do something about that.

Dr. Watson's account of the discovery of the structure of DNA is written in The Double Helix but since the publication of the book, letters have been found that shed more light on the relationships between the players, and Watson quoted some of these letters. They weren't quite what you'd expect from geniuses who were changing the course of science, and I suppose I forget that all stories have interpersonal dynamics and the associated banter as part of their plot.

You knew who Watson liked and who he didn't -- the stories weren't subtle, and oh, he said some things that were a bit off from the politically correct...it made for entertainment. Did he really say that? I won't repeat them, because we try to be a politically correct blog here, but you can get the flavor from the quote above.

Podcast Number 55: What Happens to Shooters with Mental Illnesses?

There has been a lot in the media recently about mental illness and it's relationship to violence.
In this episode we have ClinkShrink walk us through what happens to a mentally ill defendant in a violent crime. First, there is the question of Competence: is the defendant able to meaningfully participate in his/her trial, this is the present mental capacity. If the defendant never becomes competent, he generally remains in a forensic facility indefinitely. At some point (10 years in our state for a capital crime), the law requires a final disposition, and the defendant who is not likely to ever attain competence will be civilly committed and will remain in a forensic facility.

The second question is one of sanity at the time of the crime. ClinkShrink talks about the complexities of insanity evaluations and the rarity of having a Not Criminally Responsible plea. We discuss the idea that incidental mental illness is not enough to be found not guilty by reason of insanity, that the mental illness must have influenced the criminal behavior or obscured the defendant's ability to appreciate the criminality of his behavior. Finally, Clink talks about what happens after an insanity acquittee is released and what type of aftercare planning gets put into place.

The photo is Billy Bob Thornton in Slingblade--he's our example of an insanity acquittee.

Once again, thank you for listening and please do write a review on iTunes.

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

This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Guns and the Mentally Ill

On Facebook, I'm a fan of NY Times Reporter Nicholas D. Kristof

Mr. Kristof's status reads today:

Nicholas D. Kristof

Just in case Pres. Obama visits my FB page, what should we suggest for his State of the Union speech? My hope is that he calls for banning oversize ammo magazines, like the 33-round one used in Tucson. Even Cheney favors a ban on them. And gun serial numbers that are harder to scratch out. And tighter restrictions on the mentally ill obtaining weapons. Your thoughts? Other suggestions for the President?

I'm not an NRA member (this is my disclaimer here) and I've never had much use for guns. But I had thoughts about the issue of "tighter restrictions on the mentally ill obtaining weapons."
I wondered what that meant and how one defines "the mentally ill." Oh, and my second disclaimer here is that I don't know how current regulations work in determining who is mentally ill with regards to purchasing a weapon. I've never reported to any central source any information about who I'm treating so they can't buy guns and no one has ever asked me to sign off on a gun permit. I'm not sure how it's determined that someone has a mental illness and shouldn't own a gun.

It doesn't take very much to get yourself into the range of being 'mentally ill.' Knock-on-door community studies, known as the ECA studies-- meaning Epidimeologic Catchment Area-- show that over half of all people have an episode of mental illness at some point. This includes phobias and anxiety disorders. NAMI tells us that one in five people have a serious mental illness.

Some of the people who commit crimes with legal guns haven't sought treatment. If you haven't gotten a diagnosis, how can you be designated mentally ill for gun ownership? Does gun ownership get designated by diagnosis? Certainly, owning a gun is not a great idea for a person with brittle bipolar disorder who gets violent and impulsive. But we all know that the diagnosis of 'bipolar' disorder has become a bit loose and over-inclusive. An angsty teenager sees a healthy and is diagnosed with bipolar disorder. If he does well later, should he be forbidden from buying a gun at the age of 40? I believe one standard is a psychiatric hospitalization for over 30 days, but I'm not certain how--or if-- that's reported.

I suppose we worry about the Big Brother aspect here. Maybe instead of "mental illness" the standard should be that if college student is expelled, or an employee is fired, for certain behaviors then they are reported to a 'no-guns' data bank. Then you'd capture violent and threatening people who have not sought treatment but may well be dangerous. Oh, I'm just mouthing off here about something I admit that I know little about. But I hate finding one more thing to stigmatize mental illness over in a way that is not likely to effectively decrease gun violence.

Have a happy Facebook day, Mr. Kristof.

Any thoughts?

Is This Fish Happy or Toxic?

Thank you to Anon who sent us a clip to this interesting article in the Montreal Gazette about all the fish in the St. Lawrence River who are being exposed to anti-depressants though human waste.

William Marsden writes in "Antidepressants Found in Fish":

"It's very hard," Sauve said. "The question itself is quite interesting. You can't ask a fish whether it is happier or not. One of things they can do is use cameras to look at the male behaviour. Will it have the same behaviour in mating or feeding? Then you have to go back and look at its normal behaviour. It's quite tedious work and difficult."

Quebecers purchase about 555 million antidepressants a year. That works out to about one in four Quebecers taking one pill a day. That does not include the amount prescribed by psychiatric hospitals.

Hmm... I'm not sure what to say. Should we be more alarmed about what the meds are doing to the fish (and just how happy should a fish be?) or the idea that Quebecers average a one in four rate of taking anti-depressants?

This Medicine Might Kill You, But....

We all believe in Informed Consent and ClinkShrink likes to write about it. See Is It Malpractice to Lie...or better yet, read our book when it comes out where Clink talks all about the history of Informed Consent and many other such things. And one of the things people get angry at doctors for (? and shrinks in particular?) is when they have side effects or adverse reactions, and the doctor hadn't told them this might happen. People seem to get really mad about this, especially on blogs or on anti-psychiatry sites (sorry, no links here, find your own anti-psychiatry sites).

So I've wondered, does it matter if a patient is forewarned that they may get a side effect? There are many icky responses people have to meds, some are not very common, and sometimes it's hard to tell if it's the medicine causing the problem. And side effects can be uncomfortable, are they less uncomfortable if you were forewarned? You need a procedure and they make you sign a form saying that you know you could get an infection, hemorrhage, or die. Everyone has to sign or no procedure. If something bad happens, you can still sue, but if you're dead, you're dead. It's become so rote that it almost lacks meaning.

I do tell people about the more common side effects of medications. The pharmacist gives them a longer list. Google has it all for the curious, and I certainly don't discourage Googling, I sometimes suggest it. But I've wondered, does informed consent change things? Here's what my non-scientific observations have revealed.

There a medication that is associated with a rash that can be fatal. I tell people this, and the precautions they need to take to avoid croaking---slow titration, stop med/call if there is any rash at all. A shrink friend prescribed the medication to a patient who had a rare ?never heard of reaction and ended up in an ICU with liver toxicity and nearly died. The patient didn't die, made a full recovery, but the shrink was pretty traumatized and said she wouldn't use the medication again. After my friend's patient had this problem, I told every patient I prescribed this medication to this story. No one flinches. No one has said, "I don't want to take that medication that nearly killed someone." On the other hand, if I say, "This medication is associated with weight gain in some people," the resistance becomes huge. Even though weight gain is gradual and can be monitored, and I tell people they must get weighed twice a week and we can stop the medication if their weight increases by 4 pounds (that's my non-scientific cutoff for beyond the realm of fluid fluctuations). And I know skinny people who take lithium and zyprexa and stay skinny; not everyone gains weight. And I know people who feel so much better that they are willing to tolerate some weight gain.

Just my thoughts this chilly Saturday morning. By all means, tell us your stories.

On Health Care Reform: Stolen from the APA's Announcements

Verbatim:

Moments ago, as expected, the U.S. House of Representatives approved H.R. 2, legislation to repeal last year's health reform law. The final tally was 245-189, with 3 Democrats joining Republicans to vote for repeal. No House Republicans voted against repeal. The impact of the vote appears to be largely symbolic, since Senate Majority Leader Harry Reid (D-NV) has already said he will not bring the bill to the Senate floor for a vote, and it appears unlikely that Senate Republicans will be able to attract enough Senate Democrats to force a vote. Even if the Senate does approve H.R. 2, President Obama has already indicated that he will veto the bill, and there are insufficient votes in Congress to override a veto should it occur.

Tomorrow, the House is scheduled to debate legislation that instructs key committees to develop proposals to replace the reform law. While the President has indicated he is not opposed to modifying existing law, it is difficult to predict how likely such action is to succeed. In the meantime, the House GOP majority is also expected to seek to defund or otherwise delay implementation of the law. Numerous court challenges to the law remain in process and most likely will be up to the Supreme Court to resolve.

Genetic Friendships

Here's an interesting article I came across about the role of genetics in friendships. Two researchers studied genetics found in social networks. They asked people in two longitudinal studies to name their friends, then they compared certain genetic markers. They found that the DRD2 gene, which is associated with alcoholism, tends to cluster among friends. In other words, DRD2 positive people tend to be friends with other DRD2 people. Conversely, the CYP2A6 gene carriers tended to make friends with CYP2A6 negative people. This gene is associated with people who have open personality styles. In other words, a tendency to seek out variety and new ideas.

I'm not sure what to make of all this except to say I think it's interesting that there may be a biologically driven reason why Dinah and I are friends. In many ways we're the exact opposite. Dinah is a whirling dervish of multi-tasking in a way that I find exhausting, yet she seems to thrive on it. I'm an obsessionally detail-oriented and data-driven person who never loses her car keys (or drowns a cell phone). I enjoy living this way but have no doubt that Dinah would go mad from boredom within hours if we ever woke up and found our lives had been switched. I can guess which one of us has the CYP2A6 gene. The scientists would say that we are friends because we have complimentary genetics---traits that balance off and help one another. And I guess that's true. Our book might not ever have been finished if Dinah hadn't kept us moving and on task. And it wouldn't have been as organized and readable if I hadn't followed up with the editing. So it all works out in the end.

Now we just need to find a gene that protects against cell phone loss.

Do We Need Insight?

In the comment section of my post How Do You Switch Docs? readers Moviedoc and Kate have been having their own discussion ( perhaps to be called The Blog Within The Blog?) about the virtues, or lack thereof, of psychoanalytically-oriented psychotherapy. I've been staying out of it. I'm not a psychoanalyst and I've never been in psychoanalysis. My sense is that since psychoanalysis is so specialized and done by so few, and takes so much time and money, that in today's world, the contribution is more one of technique and assumptions that flavor most psychotherapies. Things like that the idea that there exists an unconscious mind, or that feelings that were part of past important relationships might surface in current relationships, including the one the patient has with the doctor. What role all this has in the treatment of mental illness seems to depend on the patient and the doctor. Some people find it very helpful to look at their lives and their illness and their problems as part of a continuum, and even those that don't, often find great solace in the therapeutic relationship. There is something so lonely about being mentally sick, and something so comforting about having someone to talk to about the pain without the judgments or fears that go into ordinary conversations.

That said, healthy Richard Friedman was kind enough to talk about the role of insight in treatment today in the New York Times. I feel like he really meant to chime in with Moviedoc and Kate in our comment section, but I guess he lost his way and ended up in New York instead.
In Does Insight in Therapy Equal Happiness? Dr. Friedman writes:

Psychoanalysts and other therapists have argued for years about this question, which gets to the heart of how therapy works (when it does) to relieve psychological distress.

Theoretical debates have not settled the question, but one interesting clue about the possible relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

In fact, when two different types of psychotherapies have been directly compared — and there are more than 100 such studies — it has often been hard to find any differences between them.

Researchers aptly call this phenomenon the Dodo effect, referring to the Dodo bird in Lewis Carroll’s “Alice in Wonderland” who, having presided over a most whimsical race, pronounces everyone a winner.

The meaning for patients is clear. If you’re depressed, for example, you are likely to feel better whether your therapist uses a cognitive-behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.

Identity Crisis!

So I was born a Gemini. It's been part of my identity, always. I'm not much for astrology, and I don't check my horoscope, but it's something everyone knows about themselves, and sometimes it's fun. And interestingly enough, Gemini fits me to a tee.

Here, see if you agree. From Ganeshaspeaks.com:

Ruled as they are by the Planet Budha (Mercury), Mithuna ( Gemini ) exhibit a delicious brand of mercurial energy. They are quick thinking, quick-witted and fast on their feet. It's their curiousity and cleverness that make them such a hit at cocktail parties. But they are not just good talkers - they also love to listen and learn. However, any social setting is good enough for a Mithuna ( Gemini ) since these folks are charming, congenial, and love to share themselves with their friends. Mithuna ( Gemini ) mind drives them to talk, to converse and it is not always just idle chatter. They need more and more information to feed their intellectual inclinations. They probe endlessly for more information as the more it collects the better. They are supremely interested in developing their relationships. Sharing that knowledge later on with those they love is also a lot of fun. Mithuna ( Gemini ) are bright, quick-witted and is at the centre-stage in any party. Although rational and practical, they also have a surplus of imagination. However the fact that they are unsure which twin will show up half the time they are often considered fickle and restless. They can be moody and act on simple whims. While their effusiveness may be misconstrued as scheming by some, Mithuna ( Gemini ) generally have their hearts in the right place. It is this ample energy, which can also paint them as scatterbrained and unfocused but, behind all that restlessness, they are usually busy filing all that information away. Funny, brimming with life, full of ideas, adorable, inconsistent, capricious, superficial, they are a bundle of maddening contradictions. They may deal in everything and are 'know-alls', but at the same time they also have the ability to master skills. Mithuna ( Gemini ) are versatile and have an amazing grasp of the subject they choose, although it may not interest them for long. They prize intellect and consider it to be the key to all things. At work, they are the clearest of thinkers, suggesting logical and well-thought-out ideas which make them an asset to any team. Their greatest strength lies in their ability to communicate effectively and to think clearly. Adventures of the mind are what the Twins are all about. Bestowed with a cheerful face easily detectable from signs of anxiety, tension or unhappiness the Gemini face is a dead give-away when they try to hide sorrow behind their brand of wit and humour. If even for a short while, romancing a Gemini is likely to be interesting, adventurous and fun, but the fickle, almost uncaring attitude will manage to break many hearts before they finally settle down. Although affectionate Mithuna ( Gemini ) can be extreme flirts, But be sure that the partner shares the Mithuna ( Gemini ) sense of humour. Mithuna ( Gemini ) never stray if the family life is satisfying. However it is best not to rush headlong into marriage; give adequate thought before popping the question.

So apparently, Parke Kunkle, some guy in Minnesota (homeland of ClinkShrink, no less) decides that it's all wrong. Everything is off. Now I'm a Taurus. But I'm not a Taurus, I'm a Gemini. They want to stick me and ClinkShrink under the same stars? No way.

And here are the new dates:
Here are the new zodiac dates:

Capricorn: Jan. 20-Feb. 16
Aquarius: Feb. 16-March 11
Pisces: March 11-April 18
Aries: April 18-May 13
Taurus: May 13-June 21
Gemini: June 21-July 20
Cancer: July 20-Aug. 10
Leo: Aug. 10-Sept. 16
Virgo: Sept. 16-Oct. 30
Libra: Oct. 30-Nov. 23
Scorpio: Nov. 23-29
Ophiuchus: Nov. 29-Dec. 17
Sagittarius: Dec. 17-Jan. 20

Have you been blown away, too?

What will this mean in psychiatric practice? Will everyone's personality change? Will people come to talk about the shift between who they are and who they thought they were? Will they fight back? I know that I'm staying a Gemini.

Shooter Psychology, Part II

Here's an aspect of shooter psychology you don't often hear about. It's from an article written by the mother of Dylan Klebold, one of the Columbine killers. It's hard to imagine how one's child could do something so horrific, harder still to imagine that a shooter could keep his plans so well hidden even from those who knew him best. He was a bright child with few previous problems. Certainly fewer problems than the Tucson shooter and less evidence of mental illness. How did things go wrong?

In her own words:

"Those of us who cared for Dylan felt responsible for his death. We thought, "If I had been a better (mother, father, brother, friend, aunt, uncle, cousin), I would have known this was coming." We perceived his actions to be our failure. I tried to identify a pivotal event in his upbringing that could account for his anger. Had I been too strict? Not strict enough? Had I pushed too hard, or not hard enough? In the days before he died, I had hugged him and told him how much I loved him. I held his scratchy face between my palms and told him that he was a wonderful person and that I was proud of him. Had he felt pressured by this? Did he feel that he could not live up to my expectations?"

It's hard enough being a parent, wondering if you're doing things 'right' or 'good enough', even you're kid isn't a spree killer. The parents of the Tucson shooter are probably asking the same questions.

Peter Kramer on Slate.

While we're waiting on ClinkShrink, I'll steal a link to a Slate article on paranoia by Peter Kramer. He won't mind.

Fanning the flames of paranoia

A healthy wonders how a culture of Birthers and Truthers feeds the delusions of people like Jared Loughner

Dr. Kramer writes:

The experience in my training years made me comfortable with paranoia. As a result, I have always had one or two paranoid patients on the roster in my private practice here in Providence, R.I. I should stress that no one I see resembles Jared Lee Loughner. I travel a good deal, and I can't leave the covering doctor with potentially violent patients. When my patients have schizophrenia or related conditions, they tend to be the most accomplished, most reliable, and nicest people to suffer these terrible afflictions. Their needs are serious enough.

Not much specific is known about how to treat paranoid patients. Generally, they don't come in hoping to lessen their delusions, which can be wholly convincing to them. They want relief from depression or insomnia -- or from an employer who has insisted they get help. Their mood symptoms may respond to medication, and they may even become less isolative, but generally the system of thought does not budge. After months of trials of different drugs, the patient will be less agitated and less pained but still solidly convinced that he is being watched and threatened. Always, too, there are prices to be paid in terms of medication side effects.

One thing we all seem to agree on with mental illness of this magnitude is that violence of this extreme and horrific nature is rare. It's all pretty horrible.

What I Want From ClinkShrink, by Dinah

Dear ClinkShrink,

Thank you for writing your post yesterday in response to requests for your input on the tragedy in Arizona. I liked reading about The Killers I've Known (or rather the killers you've known) and certainly I enjoyed revisiting your article on Shooter Psychology. And it does seem to be true that we all pester you every time there is a mass shooting.

I know you can't really comment on the motives of a mass murderer whom you've never examined.

Here is what I think it would be interesting for you to write about, if you want to. Or maybe if our readers bother you because they seem to have more influence than I do.

I'd like to read about the process of what will happen to the man who committed this heinous act. The descriptions in the news paint a picture of a man who may have been mentally ill or under the influence of drugs, or both. So what happens from here? Does he go to jail or to a psychiatric facility? How is it determined if he was mentally ill? What sorts of documents are examined and what sorts of people (if any) are interviewed? If he's found to be unable to stand trial, how does that work? Will he be treated with medicines? If he's very psychotic, might the medicines make him much better, and how would play out? Could he then stand trial? I'm going to assume that there's no chance (I hope) that he will be released back into free society, at least not now. What factors influence whether he is found not guilty by reason of insanity (does that designation even exist anymore?) And where does he go if he's found to be a) mentally ill and unable to understand the consequences of his actions, b) mentally ill but able to understand that what he did was wrong, c) that drugs were part of the picture or d) not mentally ill and fully able to understand what he did. How much difference does it make as to which state someone lives in who does something like this in terms of where he might end up? And in death penalty cases, does his mental state matter at the time of the crime? At the time of the trial? At the time of execution?

So perhaps I want you to give us a full forensic fellowship in a blog post. You are a good sport. It seems we're going to hear a lot about gun control and tea party's and political agendas and obstacles to treatment of the mentally ill and what obligation society has to prevent such atrocities. You have something different and important to add.

Cheers,
Dinah

The Killers I've Known

Some blog readers have been asking for a post about the Arizona shooting incident. The issue of spree killing has come up on the blog before, after the Amish killings in Pennsylvania, after Virginia Tech and the Fort Hood incidents. This will officially be my third poster about shooter psychology and it's getting hard to find something new to say.

First of all, most murderers don't have multiple victims. According to the Uniform Crime Reports, the number of multiple-victim killings has remained pretty stable over the last five or so years, at about 350 per year. Almost all multiple victim killings are committed using guns, although in 1987 there was an anomaly in which 24 people were killed by poison. More about that later.

In most cases, the killer knows the victim and that's true both for single and multiple victim offenses. The nature of the relationship varies with the setting and type of killing: spree shooters most often kill co-workers or other students, while single victim killers murder their partners or drug acquaintances. Psychotic killers will usually murder a caretaker, a mother or wife, but only if the killer is a young male. Female psychotic killers tend to kill their children. It's rare for a psychotic killer to murder multiple strangers. Locally I can recall only one case like this over the last twenty years. In this case the killer suffered from a grandiose delusion, and the victims were killed in a car crash. Psychotic people can stalk or threaten political or other high profile figures, but this usually doesn't result in violence. Typically what motivates psychotic political stalkers is a delusion of some type, for example the belief that a political (or other stranger victim) is threatening them in some way. For example, one political stalker I examined believed that a U.S. Senator was a devil worshiper, and that he was destined to kill all devil worshippers. Another psychotic letter writer had a delusion about the president, although he was so thought disordered it was a little hard to sort out the "logic" behind the delusional motivation.

Multiple victim killers could be spree killers or serial killers. That 1987 anomaly with the poison deaths was partly due to Donald Harvey, a serial killer in Ohio who poisoned patients at the hospital where he worked.

Non-psychotic spree killers have the same motivations as "regular" single victim murderers: frustration over the loss of a job, the loss of a relationship, loss of a living situation, lack of money or friends, alienation from family and substance abuse. Killing is an act of desperation whether you're killing one person or many. Political motivations may come into play, but without the "nothing left to lose" factor political motivation isn't enough.

So why did the Tucson shooter act? Ya got me, I haven't examined him so we can only speculate based on what's in the news. All I can tell you about is the usual characteristics of the killers I've known.

How Do You Switch Docs?

We got a very thought-provoking question:

I was wondering if you could address the issue of switching from a long standing healthy (who provides regular psychotherapy - the ideal which garnered so much controversy in one of your other posts!) following a scheduled medical leave because the covering doctor seemed to be a better fit. What sorts of issues could be involved in that? I know both parties are professional, but I would still be worried about hurting one's feelings. Or what if the covering doctor did not want to continue to see the person; would that then ruin a dynamic of going back to the original doctor? How can this even be addressed?

Wow. Where do I begin.

1) In a long-standing psychotherapy, one of the issues that might be addressed is the therapeutic relationship and how that plays out as a mirror of other relationships, a process known as transference. The question of what else is going on here should be addressed. Is switching doctors a way of avoiding a problem that should be examined? Is leaving adaptive or a way of not addressing an issue.

2) Sometimes in the course of the therapeutic relationship, we forget that the goal is the treatment of psychiatric disorders and the alleviation of symptoms. Before changing doctors it would be important to take stock: why did you go to treatment? What were the symptoms and difficulties, and how are they doing now. If you're doing better, then I don't think it makes sense to leave a treatment that has been helpful because someone else is an easier person to talk to or a better fit. The goal of treatment is to get better, not to find a good friend. This isn't to say that people don't feel helped by a comfortable therapeutic relationship: they do. It is to say Take Stock first.

3) If this is an insight-oriented psychotherapy with frequent sessions, honesty demands that you at least mention the fantasy of leaving to the old doctor. If it is not that type of treatment, you may want to call the covering doctor and have a brief discussion: Will she take you on? She may feel like she's stealing patients and that may not be cool with her. She may have no openings. She will likely say to discuss it with your old doc first. Before you actually leave the first doctor, it makes sense to have a phone conversation with the new doctor, or even a single one-time appointment to discuss why you want to change, whether she will see you, and if that makes sense. Are there insurance or fee issues? Can she see you at a time you are available? Since you're someone who's needed to see a covering doc, what are her policies on emergencies?

4) If you're not getting better with your first doctor and you've followed treatment recommendations and given it a long enough period of time, then switching doctors is reasonable. If you're worried about hurting someone's feelings, then hopefully it means there has been something positive in the relationship. It may be worth taking stock with your first doctor. These are things that have been helpful. This is why I'm thinking I may want to try seeing someone else. If there's nothing positive, then leave and see someone else, even if it's not the covering doc. If there are positive things, then point them out. If the doctor's feelings are hurt, they will live (I promise). It may not, however, make sense to return to someone you've fired if things don't go so well with the second doctor, and leaving may indeed include closing a door.

Thanks for the great question and I hope that was helpful.

Things I Wish I Could Blog About

I wish I could blog about my patients. I really really wish I could blog about my patients. I hear some wild stories. But I can't blog about my patients: it would be a violation of their confidentiality.

I wish I could blog about how my work makes me feel in a completely honest way. But I can't blog about how I feel in a completely transparent way: this is a blog and not my private journal.

I wish I could blog about the things that annoy me. Sometimes I do.

I wish I could blog about a legal case I reviewed recently, but I can't blog about that because it would be really stupid.

I wish I could blog about the stuff I know from being an officer of our state psychiatric society but I can't blog about those things because I can't.

I wish I could blog about the things I hear people say that other shrinks do that don't seem quite right to me. I can't because I'm not always sure that I'm in the right and it's good to at least try to stay humble.

Sometimes stuff happens, and I think I'll write about it, save it to drafts, and publish it months and months later when the moment has passed. I never do this.

I wish Clink would blog about mental illness and violence, and what issues might be considered regarding the tragedy in Arizona.

I wish Roy would write more about the zillions of things his mile-a-minute brain turns over in any given hour. He thinks a lot about hospital psychiatry and public policy and technology and how electronic medical records may help medicine.

It's bad enough that I wish for me what I could write, so I'll leave the others alone, but while I'm wishing.....

I wish I was either never hungry, or better yet, that I had a metabolism that could buzz through 4,000 calories a day of mostly ice cream and pizza. And while I'm at it, I wish I truly loved to exercise, that I was naturally athletic and could carry a tune and sing with a beautiful voice. If all these things were true, I might blog about some of them.

I wish I could blog about the things in my own head that make me a little nuts. One of the things about being a shrink is that one vaguely puts on the pretense of being sort of sane, at least in a public setting.

I wish I could blog about my trials as a parent, but I'm not sure what that would lend and there are moments it wouldn't make me very popular. It's really hard to be totally transparent about all the issues that being a mom brings up and sometimes the feelings I have-- for better and for worse-- get echoed by my patients.

Thank you for reading Shrink Rap.

The Year In Homicide

There has been a lot of stories in the news lately about homicides committed in hospitals. Just out of curiosity, I went to the Bureau of Labor Statistics web site and pulled some data from their Census of Fatal Occupational Injuries. It confirmed what I suspected, that homicides of workers in hospitals have increased at twice the rate as correctional facilities, where worker homicides have remained stable. Here's the graph I was able to make from the BLS data:


OK, I'm in a hurry and the graph is small and fuzzy. I'll try again later, but the upshot is that the red bars (hospital murders) are up to 6 and 7 homicides per year while the blue bars (correctional facility murders) have remained stable at about 3 per year. This is only for the employees who have been murdered, not all murder victims. When I get a chance I'll go to the Bureau of Justice Statistics and see if I can find data for all murder vicitms in hospitals versus correctional facilities, not just employee victims.

When we consider the cost and repercussions of increased hospital security, think about this trend. We people wonder if it's safe to be a forensic healthy in corrections, I will bring out these numbers. It does seem to be safer to work in prison than in a hospital.

A Brief Psychological Analysis of the Angry Birds

Joe Frisch is a staff scientist at the SLAC National Accelerator Laboratory at Stanford University. Dr. Frisch writes:

I wonder when we will start seeing really addictive games banned? I don't know what makes games addictive though. Civ is easy - you start to feel empathy for the people you are "guiding" and as you play more, you gain more things that can help then.

Angry birds is a mystery to me - there is no ongoing story line, you don't really gain any abilities as the game goes on, so WHY DO I WANT TO SMASH THE PIGGIES????

Isn't there some sort of conditioning to fix this - electric shocks or something?
----
I'm now on Level 4-19 of 2. Mighty Hoax. It took me days to finish Poached Eggs. Am I losing my mind? I am way too old for this. I'm slinging virtual animated birds while I leave ClinkShrink to cure the criminals of this world and Roy to index our book. What has gotten in to me?

So I want to write a post about the psychology of Angry Birds, but I need to start with a disclaimer. I haven't tried many video games. My experience is limited, and the few games I've tried, I've liked. I was once a very accomplished Tetris Player. But with limited exposure, it's hard for me to say why Angry Birds is more compelling than any other game. Civ? No clue.
But I'll take a stab at it. Please feel free to add your thoughts.

1. There's the challenge of trying to smash all the Piggies. Practice helps: the more you play, the better you get. It takes a little while, especially at first, but there is this enormous sense of accomplishment when those piggies smash-- especially if you don't use all your birds and get an extra 10,000 points/leftover bird.

2. The games are short: you move through one and then can go on to the next. So there is variety to the difficulty and landscape. Each scenario has different birds: the black bomber guys who explode are my favorite. The red do-nothings are my least favorite. The gray guys who divide into three would be better if they were more powerful. There's an option to buy some eagle guy, but I haven't done that. It's challenging, but not impossible. Okay, I did watch some YouTube tutorial videos like the one I embedded here, but only for the first level.

3. Each game can be won with 1 to 3 stars. This allows the game to accommodate the player's personality. You can proceed with just one star. To me, that feels like getting a C and I was never happy with C's. At the same time, if I needed to get 3 stars on every single game, I'd never eat or sleep, so I'm content to get 2 or 3 stars on each game, depending on how impossible it seems. Joe and Igor tell me they both move on with 1 star wins. I wonder what Roy would do with this.

4. It clears my mind and occupies my time in a relatively angst-free way. It's what I imagine that other people get out of TV, but most TV shows feel like work for me. They don't hold my attention and I have to make myself pay attention.

5. It feels important. That's really crazy, isn't it? I had the same sense with Tetris.

6. Somehow, I don't feel the least bit guilty spending hours of my day doing this. Hopefully that will change if I'm still at it in a few weeks. I typically am very efficient with, and protective of, my time, and it seems like it should be fine to devote some time to pure, mindless entertainment. I suppose the question is how many years and at the expense of what? So my kids have had to order pizza every night for the past week---is that a problem? They like pizza...

7. Empathy? I'm supposed to feel empathy during video games? I'm a healthy....I empathize all day long. I don't care about the birds or the little green piggies. They aren't real. And I had no empathy for the falling geometric shapes in Tetris. Maybe you're spending too much time in that accelerator, Joe.

8. Shock treatments for video game addiction? Hmmm... we could do a study here. I don't think we'd get past any research review boards if we proposed ECT as a treatment for video game addictions (ah, it didn't make it past APA as a diagnosable psychiatric disorder, for one thing), but I imagine we could do a before and after survey of people having ECT for depression to see if their coincidental interest in Angry Birds changed with treatment. Get me the funding and I'm there.

9. Let's talk about the anger. Are the birds really angry? The human player flings them at the structures in an attempt to vaporize the green piggies. So who's angry: the birds, the human player, or is anger even part of this equation? Joe tells me the piggies are evil. They steal eggs. I haven't seen them steal eggs. They just sort of sit their in their structures, waiting to see if the birds will vaporize them. I would contend that there really isn't much emotion of any kind involved here on the part of the animated little players. Would the game be as good if the human was flinging colored balls rather than birds? If the object of destruction were a plate or a star or a non-green-piggy object? I think so.

I'll wait for your feedback.

The DSM-5 Controversy

I've followed in bits & pieces. Sometimes for Shrink Rap, sometimes because the issues fill my email in-box, sometimes because there's no escape. Oh, and lots of the players have familiar names.

In the December 27th issue of Wired, Gary Greenberg writes a comprehensive article on the debates around the revision of the American Psychiatric Association's upcoming revision of the Diagnostic and Statistical Manual. So, "Inside the Battle to Define Mental Illness." Do read it. Here's a quote:

I recently asked a former president of the APA how he used the DSM in his daily work. He told me his secretary had just asked him for a diagnosis on a patient he’d been seeing for a couple of months so that she could bill the insurance company. “I hadn’t really formulated it,” he told me. He consulted the DSM-IV and concluded that the patient had obsessive-compulsive disorder.

“Did it change the way you treated her?” I asked, noting that he’d worked with her for quite a while without naming what she had.

“No.”

“So what would you say was the value of the diagnosis?”

“I got paid.”

As scientific understanding of the brain advances, the APA has found itself caught between paradigms, forced to revise a manual that everyone agrees needs to be fixed but with no obvious way forward. Regier says he’s hopeful that “full understanding of the underlying pathophysiology of mental disorders” will someday establish an “absolute threshold between normality and psychopathology.” Realistically, though, a new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. As Frances points out, a complete elucidation of the complexities of the brain has so far proven to be an “ever-receding target.”

What the battle over DSM-5 should make clear to all of us—professional and layman alike—is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench. Regier and Scully are more than willing to acknowledge this. As Scully puts it, “The DSM will always be provisional; that’s the best we can do.” Regier, for his part, says, “The DSM is not biblical. It’s not on stone tablets.” The real problem is that insurers, juries, and (yes) patients aren’t ready to accept this fact. Nor are healthys ready to lose the authority they derive from seeming to possess scientific certainty about the diseases they treat. After all, the DSM didn’t save the profession, and become a best seller in the bargain, by claiming to be only provisional.

Why Shrinks Don't Blog

Moviedoc writes:
The fact is, though you claim your blog is for healthys, my impression is that few of us participate in any blog. What stops them? Snobbery? Hubris? Ignorance? Apathy? Fear?

I'm going to go out on a limb here and make a guess as to the top reasons why shrinks don't blog. But before I start my countdown, let me say that when I started Shrink Rap, 4 years and 7 months ago, I thought I wanted a blog for healthys--- and suddenly lots of people came along for the ride-- other mental health professionals, other non-mental health professionals, and plenty of patients, as well as some random interested parties. We've Loved having Everyone. The funny thing is, we've learned a ton from our patient readers, and I wouldn't change a thing. A blog by healthys for anyone who wants to listen to us.

So why don't all Shrinks have Blogs???

10. Many shrinks are busy struggling to earn a living and keep up with their family obligations. As the ABPN implements expensive and time-consuming re-certification requirements, this promises to make shrinks more busy. And as more and more agencies expect their healthys to see 20-50 patients a day, shrinks may be even busier. Educational debts in the realm of $200K or higher are not helping.

9. Some shrinks like to spend their free time thinking about something other than work. The three of us don't seem to be in that category of peoples.

8. healthys have traditionally been taught that part of their work entails some secrecy about their personal lives and that the details of their lives should not be shared with patients. This creates some hesitation about blogs and Facebook and social networking.

7. healthy may fear being stalked by dangerous patients.

6. During Medical Board investigations, information about the healthy that is easily located on the internet may be used as evidence that a healthy is impaired or inappropriate. Has this happened? I've no idea.

5. Medical blogging is still seen by some as being on the fringe and not as valid a form of communication as peer-reviewed journals.

4. Remember Flea [link to Nov 2010 interview on Science Roll]? The perception is that people who blog set themselves up for bad things. Flea was a pediatrician who blogged about his malpractice case--he ended up settling the case and having his story appear on the front page of the Boston Globe.

3. healthys worry that patients won't like that they blog.

2. Blogging doesn't pay. While Roy has monetized our blog with Google Ads, we're talking about something along the lines of $100-$200/year.

1. Psychiatry is a profession that centers around intimacy, privacy, and confidentiality and a blog is a very public thing where boundaries might be breached (this from my non-shrink husband).

If you're a shrink and you don't want your own blog, you're always welcome here at Shrink Rap as one of our many anons. We're happy to have you.

Happy New Year!

Happy New Year to all our readers. Can you believe it's 2011? I remember being a kid and thinking how long it would be until 2000 and thinking I'd never actually be that old.

I almost saw out the Old Year with Roy. We went out to a local pub for the best of Baltimore's crab cakes, and Clink didn't join us, but she did text in that there was a Duck in her Jacuzzi at what ever wonderful vacation spot she's in. A duck in the Jacuzzi and we didn't even get a picture? This from the woman who texts me photos of every mushroom she runs across? We parted around 10, and for the first time in years, I was awake at midnight, drinking champagne and eating chocolate by the fire with family and friends (non-Shrink Rappers)...who came over to see the year out with us.

Shrink Rap will turn five in April. This is our zillionth post (well, not quite, but we're somewhere over 1,300 posts). Our book will be coming out around the same time, if you'd like a preview, it's up on Amazon, but not yet available. We're scheduled to talk at APA in Honolulu this year, but our talk, The Public Face of Psychiatry, has been scheduled at 7 AM on the last day of the conference. Will anyone come? 7 AM???

Finally, this past week, we were mentioned on The Psychiatric Nurse Practitioner Blog as one of the Top 50 Psychiatry Blogs (I didn't know there were 50 Psychiatry Blogs!)-- do check it out-- and we had a guest post up on Kevin MD, a revised version of our post on How to Find a Shrink.