Fighting the Stigma

I am leaving on vacation for a much needed rest tomorrow and will probably not be writing anything during that week so you will likely not hear from me. It has been a year since I have had a proper vacation and even the most dedicated professionals need a break now and then. I have reached the point where the staff have felt the need to reactivate the once dormant "F-bomb jar" because my language has been getting a little rough. I will discuss the jar in a later post. A few parting things before I go.

People do not choose to be depressed. They develop this condition over a time of prolonged stress. To pressure them to "just get over it" is one of the worst things one could ever tell a depressed person.

Prozac does not cure a person's problems. It just gives him the strength to go out and solve them himself.

Thorazine was far from the perfect medicine, but it was a start. It gave a lot of people hope where there was no hope before.

Most of the time the difference between the patient with bipolar disorder who is wildly successful and the one who is homeless and talking to a dumpster is compliance with treatment.

Every time a patient goes off his medication because he does not like the stigma of having a mental illness, he ultimately ends up decompensating, acting out of control in public, and being committed to the hospital. This only reinforces the negative stigma of mental illness.

Every time a patient remains compliant with treatment and goes back to her life, is successful and lives a happy and productive life helps to fight the negative stigma on mental illness. People like Jane Pauley, Fran Tarkenton, Mike Wallace and Kay Jameson, PhD have all come forward and discussed their struggles with mental illness and despite those struggles, continue to be productive citizens. If only more of my patients would follow their lead, the stigma would continue to lessen and the burden of mental illness become less overpowering.

Case in point. I will always be haunted by the memory of a man who when on his medication was very functional, personable and had lot going for him. The problem was he would never accept his diagnosis of bipolar disorder and would always stop his medication even though he was working, had friends, a stable life, etc. Ultimately he would lose it all and have to start all over again. This was usually after a tumultous hospitalization. One day we received word that his girlfriend had stopped by his apartment to see him, and found him hanging from a light fixture. This did not have to happen. I identified with him a lot. He was very close to me in age and I have a lot of life left to live, and so did he.

Despite the losses, if I had to do it all again, I would still choose to go into psychiatry. Even if I will never make enough money to afford a Ferrari like the heme-onc docs do. At least I can dream of that Audi R8 some day.

Things I Have Learned

I have been out of residency close to ten years and have seen a lot of patients in those years. Psychiatry is more complex than other fields of medicine and learning the subtleties of it can take some time. Certain knowledge only comes with experience and time. I wanted to share some of the knowledge that I have acquired over the years that one will never read in a textbook, but is still interesting, nonetheless.



I have met God/Jesus on several occasions as well as the Antichrist. In general, the Antichrist is a much nicer person. God/Jesus is usually not a very nice person, although there are a few exceptions to that rule. Jesus seems to like to smoke a lot of pot.

A lot of dentists are in cahoots with aliens and the FBI and implant radio transmitters in people's teeth.

Any patient that threatens to sue me for keeping him/her in the hospital against his/her will is far too manic to be discharged. These patients will always call numerous attorneys in an attempt to sue me. They have so far never succeeded in hiring one.

A patient that presents as "an excellent therapy candidate" at the on sent usually is a lousy therapy candidate.

Antisocial patients (meaning criminal, not shy) almost always present as the most charming and likable individual one would ever want to meet. For anyone who would question this, I would recommend they watch "The Last King of Scotland" to see how effective the antisocial mind is at winning over allies.

Sometimes the incredulous things that a schizophrenic says that sound like delusions are, in fact, true.

Sometimes the very believable things that non-psychotic appearing patients report are, in fact, quite delusional.

Every single patient who is admitted to the psychiatric unit is going to complain about problems with bowel movements at some time during their hospitalization. Even the young ones.


In fact psych patients, even if seen by a primary care doctor, will fail to tell him/her about their gross rash, genital sore, hemorrhoids, etc. They will save those problems for me. When I ask them why they did not ask the primary care doc, they all have the same response: "I forgot."

When a criminal is sane enough to figure out the idea to plea not guilty by reason of insanity (NGRI), he usually is not NGRI.

The criminal who is truly NGRI is too sick to realize that he is NGRI and usually ends up in the criminal system as a result.

An amazing number of patients have tried a drug only one time in their life. Even more amazing is that that night just happens to be the night before they are admitted to the psych unit as it always seems to show up on a drug screen. Sometimes they have tried that same drug only one time in their life on multiple occasions, each of those singular occasions being the night before they are admitted to the psych unit.

A lot of patients will expect you to believe that two beers will give you an alcohol level of 0.460.

Most patients that are sighted running naked in public are not the people one would really want to see running naked in public. Most incidents of people caught running naked in public occur in the Spring.

There is a phone number that civilians can call to contact the Pentagon that is apparently accessible to the public. The Department of Defense will not necessarily show up and investigate if one of the patients calls that number, fortunately.

If someone makes any sort of statement that could be interpreted as a threat to the President, the Secret Service will show up.

The guys from the Secret Service and the DEA do look like the guys from Men in Black. They are not accompanied by a cute alien pug, however. To the best of my knowledge, I have not have not had my memory erased by one of those flasher devices, but I guess if I did, I would not.

Real men do cry.

Lots of women return to abusive relationships repeatedly and there is nothing I can do to stop them.

We can provide the best care humanly possible to our patients and there are still going to be patients that commit suicide. Some people are just in too much pain to continue and there is no intervention that anyone can provide that is going to alleviate that pain.

Some patients that curse my name when they are admitted thank me for their help by the time they are discharged.

Try as I might, some patients are never going to like me for various reasons that may, or may not, have anything to do with me personally. It is a fact in this field that one must accept and not take personally because if one does, it will eat one alive.

One hundred years ago, many, if not most of these people would have spent their lives locked away in "lunatic asylums" never having any freedom or dignity. This was perhaps better than being chained up in a relatives attic like a rabid animal. Now my patients have hope and many of them live perfectly normal lives once stabilized. If it were not for the stigma that society unfairly places on the mentally ill, many more would comply with treatment and do better as well.

We need to open our mind as a society and rethink our beliefs.

Cutters for the Layperson

* I am writing this because I know there is a lot of misunderstanding about wrist cutting and people who cut on themselves in other locations in general and thought some people may want to know more about this phenomenon. I recall my cousin's struggles with a college roommate who cut herself on a regular basis and her difficulties in knowing whether or not to

press the panic button as it were or not when this occurred. We deal with "cutters" on a daily basis in psychiatry and are not as uncomfortable in dealing with this behavior. If anything, there is a level of frustration at it because cutting is so often used to manipulate and control other people and becomes very old after a while.

First, to clarify some misbeliefs about cutting one's wrists. It is almost impossible to die from cutting one's wrists. I have had many patients tell me that they know they need to cut lengthwise, or soak their wrists in water to keep the cuts from clotting or take rat poison (a potent blood thinner) to prevent the blood from clotting, etc. None of this is true. A healthy adult can donate a pint of blood without risking his/her life and would have to lose far more to die, and one is simply not going to lose that much blood from an incision on the wrist. If one were to cut clear down to the artery, which would in fact be straight across, maybe one could bleed out enough. The problem is cutting that deep is extraordinarily painful and most people are simply not able to do that. For someone to die of cutting his wrists, the plan must be very carefully planned and the cut must be pretty deep. The person also needs to make sure that he/she is somewhere very remote because it is going to take hours to bleed out that much. I have never seen a patient die from cutting themselves anywhere and only had one close call. Morbid to keep a head count, but that is the reality.

Cutters know that cutting is not lethal. They often say they are making suicide attempts when they cut, but in all reality, they are upset and saying something out of anger that they do not really mean. It is true that some people do intend to kill themselves by cutting their wrists, but these people are usually not chronic cutters and di not really know how unlikely it is to die from cutting themselves.

So why do they cut? Many will describe it as a release. This could be a release of anger, frustration, panic, just about any powerful emotion that the sufferer cannot tolerate. A large percentage of cutters have the diagnosis of borderline personality disorder, but this is not the case in all cutters. Certainly when this behavior becomes a pattern, this diagnosis needs to be entertained. Borderline personality disorder is a complex disorder in itself and volumes have been written but suffice to say for this piece, these people have very immature and chaotic coping mechanisms and cutting is a frequent way they turn to to deal with their frustrations. Often cutters have been victims of abuse as children and they have learned to abuse themselves when they perceive themselves as having done something wrong. This often manifests as cutting.

For others, it is a way of manipulating others. I see this more with men who cut themselves when their girlfriends break up with them to get them back. This is sadly, surprisingly effective and the men usually get their wish. These relationships are often chaotic and there is most of the time a fair amount of domestic violence involved. Drugs and alcohol usually come into play as well. They almost always make a statement about "showing her how much I love her because I cannot live without her". I usually try to point out that if this person truly loved his girlfriend, he would want her to be happy. If she is not happy with him, coercing her to go back to him is not showing love, it is showing a need to control. My confrontation usually goes unheard or receives an angry response, but I feel compelled to tell the truth in these cases. Women are certainly not immune from this behavior and can be just as manipulative but usually there is not the domestic violence element involved.

The reason that people pick up the habit of cutting is multi factorial but the element that is in these cases most often is a history of abuse, especially sexual abuse. This is probably why it is much more common in women. Other forms of abuse may be involved but for some reason, sexual abuse seems to show up most often. Behaviors in adulthood are learned in childhood as is one's view of oneself. Children who are abused regularly as children learn to abuse themselves. It is what they know, and what their "inner child" tells them should be the result of being "bad". People who cut often do so over a sense of guilt from events that may or may not have been their fault, an they are very prone to blame themselves for things that are not their fault. They probably always were as children.

There are endless aspects of cutting that could be discussed, more than could be realistically talked about in one essay so I am excluding a large amount of information simply for lack of space. Understand self mutilating is something that cannot be taught in a book and takes years of experience to fully understand and interpret but I tried to touch on some of the basics.

The biggest problem one runs into with cutters is how to treat them. There is simply no magic pill that will stop this behavior and very few therapies that are very difficult to access and get insurance companies to pay for that can effectively treat this problem. Cutting is not necessarily a sign of depression, and the cutter may not be depressed at all. Whether or not to hospitalize a cutter is also an issue. People who cut themselves superficially know they are not going to harm themselves and are just venting. Putting them in the hospital every time they cut may be counterproductive. Trying to find the balance between what was a serious suicide attempt or a serious action vs a baseline cutting behavior can be tricky. As hard as it seems, sometimes the best way to deal with the behavior is to ignore it. Maybe not when the person in question locks herself in the bathroom, texts suicide notes to her friends and shouts out "this time you'll be sorry!" But for the women who every time she gets in a spat with her abusive boyfriend makes some superficial cuts on her thighs, sometimes paying too much attention just increases the behavior. The best that a layperson can do is get the person in question to a good therapist, psychiatrist or if the person is really making a lot of suicidal threats, to hospital ER or crisis center, if available, and allow a professional figure out a treatment plan. Do not expect a miracle cure or long term hospitalization in most cases. This simply does not happen, but with the right, long term, treatment this behavior can be reigned in to a manageable level.

One caveat with this is that cutting in adults if often a long standing and habitual pattern and very difficult to stop. This is not true for children and adolescents. Cutting behavior at this age is a sign of a person who may truly be suicidal and needs to be taken seriously. Never tell an adolescent they are cutting "for attention". Sometimes once they realize that cutting does not work, they move up to more lethal measures, and a bottle of OTC Tylenol is quite lethal, and easy enought to obtain. Get them help quickly. In some cases, cutting could be a case of an evolving personality disorder that will become a lasting pattern in adulthood, but if an intervention is made early enough, teenagers can grow out of cutting patterns, so do not ignore this. It could save them a life of misery and thousands of scars. Or it could save a life.

*Photo courtesy Scott Feldstein on Flickr

Mismanaged care

We have all heard the term "managed care" as the new paradign for running medical insurance. Designed to decrease what was most certainly abuse of the system, these programs are becoming very overbearing, tightly controlling the way doctors practice medicine and dictating areas that they have no business interfering with. The word "care" truly has no business in the name at all. The true name of this practice should be "managed medicine" if not "dictated medicine". I have no issues with trying to contain the spiralling costs of medical care or to prevent abuses that have occurred in the past, but insurance companies have immunity from litigaton. They cannot be sued if something negative happens to the patient when they refuse to pay for a treatment that is felt to be medically necessary, and they know this. Doctors and hospitals are forced to decide between doing what is right for the patient and face significant financial losses or not provide care and face malpractice suits for a negative outcome. This is not my gripe today, but the utter silliness that some of these companies. The length they will go to to dictate how care is rendered can be quite ridiculous and bears mentioning.

I have mentioned before that the economy in my city is not good and the majority of our patients are either uninsured or have Medicaid. The psychiatric benefits for Medicaid in this county were farmed out a few years ago to a private, and sadly, for profit company that has spent a great deal of effort trying to tell us how to do our jobs. Much of this is because if every little piece of busywork that they want completed is not done, they can deny payment for the service . This is the ultimate goal of any insurance company. Sometimes, however, I honestly believe that there are some poorly qualified individuals with a correspondence degree and a GED who think that they are improving care by coming up with suggestions to help our patients in the so called "recovery model".

The recovery model of treatment is a perfectly reasonable approach to treatment but needs to meet the patient where he/she is at. The idea is to help people to look beyond their diagnosis and strive towards recovering to a higher level of function. Hopefully the patient will be able to return to a work setting, or at least remain in the community, living independently and living a healthy lifestyle. This was opposed to the older model with tended to lock patients in psychiatric facilities for years or even life, a system which has been abandoned decades ago.

Our particular managed care company, I will call NBH (Nag,Bitch,Harass), not their real name, has decided they want an individualized safety plan to prevent suicide in every patient we discharge. They suggest we have them plan such activities as: walking, meditation, attending a church, joining a gym, getting a volunteer job, etc. Of course, not all of our patients are suicidal when they are admitted to begin with. Some become quite defensive when you ask them if they are suicidal and refuse to participate in such discussions. Some are homicidal, some psychotic, some are just trying to get their girlfriend to come back to them so they cut their wrists and claim to be suicidal. But they think that they have a great idea and if we are to get paid, we have to do this.

Some of us were sitting around trying to come up with some ideas that would fit their criteria but might be more appropriate for our patient population. When a patient claims to be suicidal because she got a second floor apartment and now has to climb a flight of stairs to get home is not going to get a volunteer job. In fact, she is too lazy to put her street clothes on when she is on the unit and we are just happy if she will shower and put her underwear on. Meditation? The closest thing to a meditative state our patients will ever see is drug induced are we are trying to discourage that. Join a gym? These guys will not pay a $1 copay for medication. Where are they going to get $50 a month to join a gym? So we tried to come up with ideas that would calm NBH's jets. They are not going to work, but they will fit the criteria. Then we came up with what our patients would be more likely to be receptive to. Not to sound cynical, but you have to be realistic sometimes.

What NBH Expects	What They Will Do
Call a friend	Call a friend and tell her you took an OD
Join a club	Join a drug gang
Reconnect with family	Have sex with a family member
Read a self help book	Read a porno mag
Meet you neighbors	Get in a knife fight w/ the neighbors over a man
Go to AA	Go to AA for 13th stepping(picking up chicks)
Take a walk	Take a walk to the stop'n'rob to buy smokes
Start a garden	Grow marijuana in the closet
Start an exercise program	Get drunk and run naked through the streets of downtown
Get into art and paint a painting	Get a new tattoo
Get a volunteer job	Volunteer to be the lookout in a drug deal
Go to church	Join a Satanic Cult

And finally...

Go to a public event	Go to a bar and get shit faced.

The Real World

Mental health workers deal with the sometimes odd behaviors our patients exhibit every day so we are not always bothered by it. Psych patients do have medical problems, though and sometimes we end up calling consults from often unprepared medical specialists. Sometimes their responses to our patients is quite hysterical.


Sometimes the reason for the consult is tragic and one learns something new. As a resident, we were brought a patient who was transferred from another facility after trying to pluck her eyes out and was left with nothing but the ability to see a little bit of light. There is nothing funny about this case and it is terrible to see a horribly psychotic patient who slowly starts to come out of her delusional state and realizes what she has done. In a failed attempt to change from a very effective medication with terrible side effects to a newer one with fewer side effects, she fell apart and became religiously preoccupied. This is a very common theme in psychotic patients' presentation. The voices took over and told her "If thine eyes offend you, pluck them out" and that is what she did. The irony is that the patient is an atheist.


The ophthomologist, a quite respected and experienced one, was consulted to see her and provide whatever treatment that he could. He told us that this was the eighth case in his career where he had treated a psychiatric patient who had tried (or succeeded) at plucking his/her eyes out. It is sad to know that this is not an exclusive case. I have never seen this happen again, and hope never to, but I know something to look out for now.


Usually these encounters are not so tragic. Just a basic medical issue that needs addressed and a sometimes humorous result. For those who do not know, psychiatrists are medical doctors, and our training in medical school is no different than any other physician's. The difference is we chose to specialize in psychiatry rather than say, family practice or surgery. To do this, we complete a residency after medical school in that area specifically, just as other doctors complete residencies in their own fields. We are able to treat minor issues, mild hypertension, bladder infections, reflux, but when the patient shows up with uncontrolled diabetes, we are going to need to call a consult. Some consulting physicians handle these situations well, some do not.


We had one patient who was quite insistent that he did not hear voices that tended to carry on conversations to himself all the time. We knew he was hearing voices and did not even bother to ask because it would just get him riled up. He did not tolerate a lot of stimuli and stayed in a quiet area isolated from other patients much of the time. When his diabetes spiraled out of control (this is a common problem in psychiatric patients) we called an endocrinologist to see him. He did make the mistake of asking the patient about hallucinations, and got a very terse response that, no he did not. He would have better to stick with blood sugars but for some reason, asked. Our consultant walked out of the quiet room and stated "You know, when I was walking out Tim (not his real name) turned to the air and said 'Did you hear that? He thinks we're hearing voices!'" Our amusement was more with the doctor's reaction than the patient's. My response was a simple "Yeah, he does that." He seemed bothered that we were not more concerned, but there was nothing to that could be done about the situation. We were just glad that he was not throwing chairs across the room or assaulting security officers, which he has been know to do. If he wants to talk to an invisible man, let him.


Sometimes people are just too intimidated by the patient's behavior to know how to approach it. We had a patient who tended to stand at the end of the hall and walk down it in a series of lunges that reminded me of the "Ministry of Funny Walks" sketch in Monty Python's Flying Circus, for those who know the show. For those who do not, just know that it was a rather strange exhibition. Most psychiatric units at some time or another have nursing students doing rotations and we had some around the time of his stay. Some of them seemed bothered by this behavior and came to me about it, wanting to know why he did this. I gave them a very simple response- "Have you asked him why he does that?" Of course they had not, and seemed rather shocked at the whole idea. "I could never do that, he might get angry at me" was one response I got. I reminded them that he must not mind answering the question that much or he would not be behaving that way in a public setting. I already knew his response because I did ask him, but tortured them by not telling them. They needed to learn on their own. Part of treating a patient is asking questions. If the patient says he hurts, you ask where. If a patient acts strange, you ask why.


He told me he walked like that because he liked to walk that way. And he did not get angry when I asked. Fair enough.


Sometimes the issue is dealing with patients who tend to be rather disinhibited. The manic patient who started propositioning the public defender before a committal hearing will always remain in my mind. Everyone who was to be at the hearing was there to witness this interaction, also. He turned all kinds of shades of red, but still fought like hell to argue that she did not need inpatient psychiatric treatment. He did not win, which is probably good or he might have had an unwanted paramour stalking him if he did. I do not get along with this particular PD anyways.

The best encounters I have seen are with non psychiatric residents, solely because of the fact that their inexperienced nature can result in such shocked expressions when they hear comments they do not expect to hear. We had a very sexually preoccupied patient fall and split her eyebrow open and had to consult family practice to come and suture her back together. I am not sure what crime against humanity the poor intern they sent up had committed for him to get chosen for this detail but the poor kid was as green as the rain forest during the rainy season. He had been given no warning that he might hear something odd or out of the ordinary. He was probably expecting the typical patient who comes in with their face cut open, pretty nervous and not saying a whole lot. Instead, he was treated to her nonsensical ramblings about being a model and a porn star (she was in her late 50's, a heavy smoker and looked much older than her age) with added mumbles, which is her baseline behavior. He was really startled when she asked him "Can I still have intercourse with these in?" The expression he had on his face was priceless. The advice to the intern: just ignore that and keep suturing. He survived to continue his internship and eventually complete his training, but not quite as naive as he once was, and perhaps a bit wiser.

The Unreal World

My favorite population to work with is the very chronically mentally ill, especially very psychotic patients. They are frequently misunderstood, isolated and rejected by their families and friends. Their lives can be a very lonely and sad one of lost dreams and little hope for the future. With the emergence of newer antipsychotic medication, there has been more hope for these patients, and their prognoses have been much improved but there is still quite a way to go before we can truly say we have fully controlled these conditions. They are by far the most interesting people to work with and their behaviors, although bizarre to the outside world are not that hard to understand if one understands why they do what they do. Despite this, some of what they say is still fairly comical.

A patient we have been dealing with has refused to accept her diagnosis and will stop her medication after discharge from the hospital invariably. Despite this, she functions and manages to survive until her behavior becomes simply too strange for the neighbors to tolerate and she is dragged in on an involuntary commitment. We repeat the cycle of resuming medication to clear her just enough that she makes some sense and send her home and the whole thing repeats. She is most noted for having what is called disorganized thoughts. She denies hearing voices, although it is clear she does, but her biggest problem is her inability to communicate in a coherent manner. Today she accused me of being a women who she believes has been tormenting her for years, pretends to have many jobs and aliases, the most memorable of which was "Ringbo Money Money Monkey Potato Gun." It took everything within me not to break out in laughter. It is very bad form to laugh at your patient when he/she is not trying to be funny. My contract is in the process of being renewed and I am pretty sure the hospital is not going to be willing to change my name to Dr. Ringbo Money Money Monkey Potato Gun. It will not fit on my ID tag for certain.

Disordered thinking is something that is hard to fully appreciate unless one has actually heard it in person. It is noted by rather nonsensical rambling, often where the patient will jump from one topic to the next in the same sentence and tie unrelated ideas together through words. Sometimes they will talk in rhyme, known as clang associations. They often do not make much sense until you get to know them, but once you do, you start to understand as least some of what they are talking about, usually by knowing what is concerning to them in life. Many people will never encounter this in person as so many psychotic patients tend to isolate and do not socialize often.

Most people have encountered people talking to themselves, though. Not just those that are frustrated and grumbling, those that are carrying on full conversations. Comedians make jokes about pairing them up so they have someone to look like they are conversing with. People cross the street and shelter their children from these people. They are quite misunderstood. Most of the time, these people are totally harmless and would be happy to carry on a conversation with you if you were to approach them. In truth, they are not talking to themselves. They are talking to someone else, or maybe many people, but the outsider just cannot see them. Most of the time they cannot, either. But the voices are very real sounding to them and are very much a part of their reality. Often it is not very fruitful to ask a patient if they are hearing voices because "hearing voices" implies one is hallucinating, and the patient does not view the experience as a hallucination. I have found it useful to ask if they hear the neighbors through the walls, people walking outside of their homes, or in the distance. Often they believe they are reading other people's thoughts. If someone is truly hearing voices (as opposed to those who claim this for personal gain) they believe the voices are real and it is not uncommon for them to talk back to the voices, hence the people who talk to themselves. Some know enough to go in private to have a conversation, so do not. Even those who do not openly talk with their voices are often preoccupied and looking around at other parts of the room when they are being talked with. They cannot tell where the voice is coming from, whether the interviewer, the invisible voices, or another person in the room. So they are looking around to find the source.


It is how a psychotic patient deals with the voices that can sometimes be rather amusing. It is not that we spend out days making fun of our patients but when a patient is standing in the hall talking to the fire extinguisher much of the day, one must admit that this behavior is comical. Some can get into pretty heated arguments with the voices, even threatening violence, yielding knives, etc. Sometimes they just look over and talk to the air. Commonly they whisper to themselves, sometimes mid sentence during a discussion with another person.

Treating for this population has gotten much better than in previous generations, and some have reported near total relief of their symptoms, or at least a dulling enough to be able to return to regular function. It is gratifying to be able to offer options that can actually give these patients the hopes of some degree of normalcy. Most will never be able to get married, have a FT job, raise a family, etc, but the days of being locked away in a run down state hospital for years is long gone. Many people are able to have friends and live independently. It is nice to see that and give people some of the life they lost back.