What I Learned Part 3

Oh my...I still have one more day to go at the conference and my brain is already full.

The award for Weird Presentation of the Week (and that's saying a lot at a forensic conference!) goes to the poster on zoophilic interests in cases of Asperger's syndrome. I'll say no more about that. Just make sure you know who's petting your dog.

Another poster was an interesting case presentation about sleep apnea and anger and hostility. Apparently treatment with continuous positive airway pressure therapy has lead to significant improvement in irritability for sleep apnea sufferers. You might want to read a little bit about previous research on this here.

I enjoyed a panel discussion about ethical issues in forensic evaluations, particularly as it related to interviews of collateral informants. Although non-confidentiality warnings are routinely given, there is still the possibility that an informant may volunteer self-incriminating information or information that falls under a mandatory reporting duty.

Unfortunately, our luncheon speaker was held up in Tennessee and couldn't make his talk. I was looking forward to listening to Jon Ronson, author of The Psychopath Test. Instead we heard a talk by Dr. Phil Resnick about the relationship between paranoid delusions and violence. In addition to hearing a number of good anecdotes, we learned that delusions are more highly correlated with violence than command hallucinations.

The best session of the day was a panel presentation about false confessions. This has always been an interest of mine, but I've rarely had the opportunity to hear the people who have done the original research. I learned a lot about the Reid technique, including which techniques are commonly used and how the techniques are varied depending upon the presence of mental illness. I learned that of people exonerated by DNA, 16% had given detailed confessions. Overall, 80% of defendants waive their Miranda rights. In Canada, interrogations don't have to end when a defendant asks for a lawyer or when he claims his right to avoid self-incrimination. One panelist presented the results of a survey of 332 Baltimore County police officers regarding their understanding of juvenile development and their use of interrogation techniques. The survey showed that even though they understood the developmental differences between juveniles and adults, their actual interrogation practices were no different.

I listened to a presentation about the new diagnostic criteria for antisocial personality disorder coming out in DSM-5. In a word: ugh. Don't ask me how people are going to interpret the "self-identity" and "self-direction" criteria. The requirement for childhood conduct disorder will be dropped. I'm predicting even greater diagnostic discrepancies than what we have now.

Finally, a group from West Virginia presented some background information about an ongoing survey project regarding the use of social media in forensic evaluations. There wasn't a lot of data available yet because many of the forensic fellows had not received the survey (it was sent to all program directors and their students). Social media use by forensic healthys was not directly correlated to age. Both early and late career forensic healthys used it. There was a good overview of how social media content could be used in both civil and criminal cases. During the question session I added a comment about social media use in medical education as well.

Tomorrow is the last day, then I make my way back through the storm (or hopefully, ahead of the storm). Wish me luck.

Medical Education Via Twitter: Tweet Tweet

There's an article in yesterday's Hopkins Gazette about Dr. Meg Chisolm and how she's using social media to educate the medical students and psychiatry residents at Hopkins.  Greg Rienzi writes:


Chisolm, an assistant professor in Psychiatry and Behavioral Sciences at Johns Hopkins Bayview Medical Center, said that she is one of a growing number of medical professionals who, despite the present-day climate of strict patient privacy regulations and oversight, see the benefits of using social media to supplement their work and interact with colleagues, patients and the general public.
Chisolm connects with others through her Twitter accounts “whole_patients,” intended to demystify psychiatry and psychotherapy for patients and doctors, and “psychpearls,” which is targeted to learners interested in “clinical pearls” about psychiatry.

To help expose future medical professionals to the benefits and potential pitfalls of social media use, Chisolm and Tabor Flickinger, a clinical education fellow, have set forth on the design of a social media curriculum for students at the School of Medicine. Ultimately, the two plan to design, pilot, study and implement a curriculum that uses social media to promote medical humanism and professionalism.

Ah, we wrote about Dr. Chisolm once before after she gave Grand Rounds at Hopkins on "Prescribing Psychotherapy."    And, by all means, follow her on Twitter!  (Yes, I'll be tweeting this). 

The History of The Duck, etc....

Those of you who are regular Shrink Rap readers know we are rather attached to the image of the yellow rubber duck.  It started with an article on Emotional Support Animals that was in the New York Times right after we started our blog, and we latched on to the imagine of airline passengers who brought ducks (one dressed in clothing) on to flights, and then Clink began her years-long hobby of animating ducks!  And of course there was the lovely reader, DrivingMissMolly, who donated a flock of ducks to Heifer International in our behalf.  The duck appears on our blog, it was the subject of heated debate and designated committee meetings when our book was in press (see They Nixed the Duck!) and it's on our logo in the print version of our column on Clinical Psychiatry New.  We distribute candy ducks at all Shrink Rap public events. 


Needless to say, I was quite pleased to see an article in this morning's New York Times Magazine on the history of rubber ducks.  In "The Rubber Duck Knows No Frontiers,'  Hilary Greenbaum and Dana Rubinstein write:

This yellow, doe-eyed icon — a preferred bathtub ornament of toddlers and royals alike — would have never existed were it not for Charles Goodyear. The Massachusetts inventor discovered the chemical process that renders rubber more malleable (and thus appropriate for toys) by, as legend has it, inadvertently dropping a mixture of rubber and sulfur into a potbelly stove. Goodyear, who died in 1860, never benefited from this discovery, but his vulcanization process revolutionized the rubber trade.

Greenbaum and Rubinstein go on to note:

Still, it was only when Ernie, of Bert and Ernie fame, took a bubble bath with a rubber duckie in 1969 that the toy became inescapable. According to Tim Carter, a senior producer at “Sesame Street,” the story goes like this: Someone gave a rubber duckie to a “Sesame Street” writer named Jeff Moss, who put it in his bathroom window. One night while taking a bath, Moss looked over and had an epiphany. And “Rubber Duckie” subsequently reached No. 16 on the Billboard chart. “It wasn’t until ‘Sesame Street,’ ” says Charlotte Lee, a Seattle-based engineering professor who holds the Guinness World Record for the largest collection of rubber duckies, “that a rubber duck became a special thing.”  

For those who would like a psychodynamic interpretation of Ernie's relationship with his duckie, Shrink Rap provides one Here. 
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In other Shrink Rap events:

• Clink has an article up on Shrink Rap News on how social media does a lousy job of representing Forensic Psychiatry.  Please do read What Follows Is Fiction: What Orson Welles Can Teach Us About Social Media.   
• We enjoyed our book signing at Baltimore's Ivy Book Shop on Friday evening and met some great people.  We posted a photo of ourselves with author Gilbert Sandler-- he says he needs all the help he get.  He's a charming man!  Do visit our Facebook page at http://www.facebook.com/shrinkrapbook to see event photos, and do click the link to "follow" us on Facebook for the latest Shrink Rap updates.
• We are podcasting later today, we should have new episodes of My Three Shrinks up in the coming weeks.
• Jesse tells me he's planning to submit a guest post about factors that keep people from reporting heinous crimes, so do check back later today.  The events at Penn State seem to have everyone stirred up.

What I Learned Part II

Psychiatry residents on the APA listserv were surveyed about their experiences with social media. 9.7% of residents had gotten friend requests from patients. The remaining residents were asked what they would do if they got such requests. 85% of residents said they would automatically ignore them. 15% said they would discuss the request with the patient, then decline it. Less than 3% of residents received any training about proper social media use in residency. Half admitted googling their patients.

One poster presented the results of a one year study of four major media outlets: the New York Times, the LA Times, USA Today and Fox News. The outlets were culled for articles related to mental illness and violence. The stories were scored according to how many contained one of the follow true facts about mental illness and violence:
1. The majority of mentally ill are never violent.
2. People with mental illnesses are more likely to be victims of violence than perpetrators
3. People with mental illnesses are more likely to be violent against themselves than against others
4. When violent, they are more likely to victimize family than strangers.
Fewer than five percent of the articles contained any of these facts.

The state of New York has successfully used electronic monitoring and regular clinician feedback to reduce the use of polypharmacy in the state prison system.

All state prison systems were surveyed regarding their policies regarding pornography. Of 43 responding states, all banned material that represented a risk to institutional safety and security. There was high variability regarding allowed visual or verbal depictions of sexual acts. There is no published data to support any policy link between prison safety and the presence of pornography.

Crisis intervention training for police is thought to be helpful to reduce incidents of violent outcomes when responding to acutely mentally ill people, but the content of the training varies between program and lacks consistency. There also needs to be more outcome studies to learn if these programs do actually divert mentally ill people out of the criminal justice system.

The PCL-R is coming under pressure as a risk prediction tool. There was a great pro-con debate about this presented by a panel of Broadmoor Hospital healthys. Although interrater reliability is 0.8, there is still significant variance in scores and this could be enough to cause inconsistency when using cutoff scores to determine readiness for release from their severe personality disorder program. It stood out as a risk prediction tool in the 1990's because it was the only one of its kind, but newer tools are being developed with better ROC-AUC scores.

Lastly, multiple personality disorder is coming back. In spite of recent books such as Sybil Exposed, Creating Hysteria and I'm Eve, which document the role the therapist played in the creation or course of the disorder, one presentation today still featured a criminal defendant thought to suffer from multiple personality disorder. This presentation would have been much more effective had there been another expert presenting the potential pitfalls of examining criminal defendants for this disorder. The healthy in this presentation fell into many of those pits: he presented a videotape of the interview in which he asked probing and leading questions (admitting at one point he had to "dig" for symptoms for 20 minutes before the defendant reported any!), and occasionally referring to the defendant as a "patient" rather than as a defendant---clear evidence of bias. The redeeming feature of the presentation was an overview of case law regarding competency and insanity and MPD.

In 2006 there were 4000 civilly committed sex offenders in the US. In this panel they took maps of several large cities in New York, overlaid a map of schools and school bus stations, then overlaid a map of available housing. Finally, the last overlay was a map of legal exclusion zones---boundaries of areas that were legally "off-limits" to convicted sex offenders. This illustrated, at least in Buffalo, New York, that there was literally no place for a sex offender to legally live within city limits. Then they overlaid a map of reported home addresses of sex offenders: 90% were living in restricted areas. There is increasing evidence to suggest that sex offender registration and living restrictions may increase recidivism.

So that's the second conference day. I also enjoyed the computer committee's presentation, which was a two hour geek-fest off all things tech and forensic. It's something you just have to witness to appreciate, sorry. Lots of cloud-based software for document management and report-writing. Not relevant to most Shrink Rap readers but fun for me.

Podcast #62: Sooner Rather than Later

We talk about the following topics:

• Roy asks listeners to suggest a topic for our next book (Dinah and Clink suppressed all urges to scream).

• Professionalism and social media for physicians.  Roy refers to a post he wrote and Mark Ryan's discussion of the challenges of determining what is professional in social media. We ramble a lot and Dinah talks to much.  Here is the AMA policy on Social Media.  Should healthys put their poetry and their political beliefs up on the internet? We don't talk about Google+ now, but we do talk about not talking about Google+ now.

• Clink and Dinah argue about whether we (the Shrink Rappers) know a lot about social media.

• We discussed how Dinah isn't sure she believes that psychiatric patients die an average of 25 years before people without mental disorders.  Roy referred us to this article on life expectancy in chronic mental illness.  Is earlier mortality due to antipsychotic use?  Is it due to lack of coordination of medical care?  ClinkShrink tells us that people with personality disorders die more of all causes and we talk about who the studies address.

• We finally discussed Google plus-- is it going to add to medical social media or is a party that no one is going to?  Roy likes it better than Facebook & Twitter and he invites you to join his Shrink Rap readers' circle.  ClinkShrink predicts that social media will die and Roy disagrees.  He talks about the PatientsLikeMe website and an article on How Google+ Could Transform Healthcare.  

• We digress to topics of electronic medical records and what to do if patients don't want to know their diagnoses or do want to see their medical records.  I do believe we could talk about this subject for all eternity.  We came close.

No clue why ClinkShrink titled this "Sooner Rather than Later."


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.

Physician and Social Media Survey

On the American Medical News site, here's an interesting article about a recent study about social media use by physicians. According to a survey by QuantiaMD, nearly 90% of physicians use social media, much more than the general public. Most social media use---about 67%---is for personal reasons. A third of physicians reported getting at least one Facebook friend request from a patient, but most of these requests are turned down. For me the most interesting thing was that only 8% of physicians reported using a blog for professional reasons. That seemed low to me.

Not too much more to add, just thought I'd put up a link to the article.

Physician Online Behavior: Professionalism and Social Media

Mark Ryan, a Virginia family physician, wrote a blog post for Mayo Clinic Center for Social Media three weeks ago, reviewing the many definitions of "professional behavior" for physicians and how that might apply to our social media interactions.

It is apparent to me that what is considered appropriate or not for physicians using social media (eg, should you friend a patient on Facebook?) is still being tested and figured out. However, Mark's post reminds us that there are certain principles that remain immutable, despite the technology.

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.

Understanding the Research on Psychotherapy Trends-- a Discussion with Dr. Ramin Mojtabai

For whatever reason, it bothers me when media says that healthys don't do psychotherapy, and lately, it happens a lot.  What am I, chopped liver?
They quote a study by Mojtabai and Olfson in the Archives of General Psychiatry, and say, "Only 10.8% of healthys see all of their patients for psychotherapy."  Is that really true?  Is it really relevant?  I tried to read the article and I wanted to understand how the study was done so I could think about it myself, but I didn't understand how the research was done-- Roy thought it was based on CPT codes, then he said it wasn't.  So why not go to the source?  I asked Dr. Mojtabai if he would have lunch with me and tell me how the study was conducted.

If that got you curious, please read about it on over on Shrink Rap News!  You're welcome to comment there if you're physician, or to surf back here and tell us what you think.  Ramin says he's interested in what people think, and he's been very kind about humoring me, both over lunch and in the many subsequent emails over the details.

Happy Birthday in the Weird World of Social Media

I remember when birthdays were a quiet thing. A few phone calls from first degree relatives. A couple of cards from extended family members. A special meal with family, and a couple of gifts.

Now there's Facebook.

Birthdays are have become a multi-media event. The phone rings, repeatedly, a friend drops by with a giraffe toilet paper holder, there are text messages from ....my cousin, my kid, my kid's girlfriend, a friend of my other kid, and yes, a text message from the Vision Care place where I get my contact lenses. My father-in-law sends an e-card with music. Forty of my closest friends, including people I haven't talked to since elementary school, and my prom date, wish me the best. The request to serve on yet another committee comes in an email and notes "Happy Birthday." And yes, the Vision Care place also sent a happy birthday email, complete with animated balloons. For the first time ever, my beloved sibling seems to think that writing on my Wall suffices and I don't warrant a phone call, and this year, I did not get a greeting card from the Toyota dealer.

As long as the roses and chocolate continue IRL (in real life), then count me in! When the cake turns virtual, I'm signing off.

The Shrink Rappers Rap With Dr. Mike Sevilla on Family Medicine Rocks!

In case you missed it, we were on Dr. A's BlogTalkRadio show last night-- Family Medicine Rocks hosted by Dr. Mike Sevilla. Sarebear and Crazy Girl called in-- it was fun! And we got to ramble about our book and what went on behind the scenes, with a shout out or two to our oh-so-tolerant editor, Jackie.

If you missed it, don't worry, it's preserved for all time on the internet and here's the link to the Family Medicine Rocks website/blog with all the info. Mike writes:

We had a great conversation about the origins of the book, the process of editing/finalizing the book, and how they didn't kill each other during this process - Hehe.

The setup for the book is interesting that they wrote fictional characters to explain how psychiatric patients are taken care of. For example, since Roy takes care of hospital based patients, his section talked about that. Clink is a forensic healthy and she tacked questions like "What's it like in a prison setting?" And, Dinah is in private practice and she talked about issues like "What it's like inside the walls of a healthy office during an appointment."

Oh, but I cheated just a little and changed Roy and Clink back to Roy and Clink, just for our Shrink Rap blog (they've long ago outed themselves...).