Sunday, August 31, 2008


A new patient walked into my psychopharmacology clinic last week. She seemed reasonably typical at first. A line in the chart noted that she was somewhat wary of psychotropic medications, but then many patients are, and I don't tend to mind that attitude myself since I also subscribe to the less-is-more theory of psychiatric meds.

She was on a fraction of the normal dose of a common antidepressant, which, she reported, was her only medication. It seemed unlikely that this small dose was having any effect, positive or negative, on her mental health; but her mood was stable and she was sleeping and eating well. Things looked good. The main points covered, I asked if she had any other concerns.

"Well, I had my brain imaged," she offered. Brain imaging? Did she have a neurological disorder I hadn't known of? I asked which physician had ordered the tests.

"Oh, I did it myself. I saw it on TV and thought it would be a good idea."

Brain imaging advertised on TV, direct-to-consumer?

She handed me a sheaf of papers, of which the first few pages read like Baby's First Book of Neuroanatomy crossed with the New Age Guide to Herbal Remedies. "Prefrontal cortex: Planning ! Attention!... L-tyrosine!... Anterior cingulate: Cooperation! Flexibility!... St John's Wort!" There was then a list of "hyperactive" and "hypoactive" regions in this patient’s brain.

She'd paid out of pocket to have her brain SPECTed at a clinic that advertises on late-night TV.

Where to begin.

Let me just state up front that there is no established role for brain imaging in psychiatry at this time. None. You can't look at a picture of blood flow (or any other parameter) in the brain and make a diagnosis. (SPECT has some utility in distinguishing Alzheimer's from vascular dementia, but that's more neurology than psychiatry.)

To start out with, despite the existence of a number of studies looking at blood flow in depression, there is not a clear consensus on which areas of the brain are most involved.

Then, let me point out that we have no standard against which to judge baseline levels of regional activity. Blood demand fluctuates on a moment-to-moment basis depending on what the brain is doing at any particular time. The variation in demand between individuals and times is not very well described. So my patient's brain regions were over- or underactive compared to what? Somebody else's brain thinking sad thoughts? Her own brain thinking happy thoughts? The average of ten other people's brains doing a crossword puzzle? Any way you slice it, it doesn't sound informative.

Even when looking at more stable and reliable imaging correlates of clinical depression, in which a clear average population difference exists between depressed individuals and normal controls, there is so much overlap between the two groups that you can't usually infer a person's mood from his brain scan alone. Check out this graph from a review by J.H. Meyer, showing MAO-A density in different brain regions.

While there are clear differences between the populations on the whole, it's also just as clear that an isolated brain scan likely won't tell you much about whether that individual is depressed or not. There are just too many people in the overlap region.

As you can tell from these links, science is still in the phase where we use clinical data as the gold standard against which to judge the validity of imaging results. Going the other way round - starting with the scan and inferring the diagnosis - is something that's far away from our current level of understanding.

Consonant with this, the 'interpretation' of this woman's SPECT scan was nothing you couldn't have figured out from talking to her for a few minutes. After citing a number of areas in which 'dysfunction' was discovered by the SPECT scan, it described some related problems she might have, such as "negativity, guilt, blame, irritability." The kinds of things you could diagnose more easily from a cheap interview than from an expensive brain scan.

The recommendations included a number of OTC supplements (without indication of dosage, of course, since these supplements are largely unregulated, little is known about optimal dosing and in any case actual content may vary wildly from what's written on the label). Some of them were items that have some evidence for their utility (e.g., omega-3 fatty acids); others seemed relatively benign (e.g. Coenzyme Q10) but with little available evidence regarding their use in depression; and others (e.g., St John's Wort - see this FDA advisory) can be positively harmful under the wrong circumstances.

My patient was on all of the recommended supplements - some six or seven different pills - despite having declared the Lexapro as her only medication. This is an incredibly frequent error made by patients, who are soothed by the 'supplement' label into thinking the items are somehow safer or less likely to produce side effects than chemically prepared medications. In fact, there are a number of supplements that have produced significant health problems in their users (e.g., ma huang, which was ultimately banned by the FDA), and since their preparation is poorly regulated, both the dose of the medication and the number and identity of the compounds present are pretty much up for grabs. These facts make supplements a rather riskier bet than prescription preparations.

There were some other very general recommendations of the type that any mainstream psychiatric practitioner would typically make: cognitive behavioral psychotherapy, good social and emotional support, exercise, self-relaxation, and a balanced diet without excess use of nicotine and caffeine. All useful advice, none of it requiring the service of gamma ray scans.

I fully expect that brain imaging will one day have a place in psychiatric practice. However, that day is not today, and I find it upsetting when my patients are conned into paying good money for a useless procedure, a dose of radiation, and some occasionally inappropriate advice.

I do find it curious that so many people place deeper trust in the uncharted waters of alternative medicine than they do in the well-documented, frequently evidence-based recommendations of the standard medical establishment. Things aren't always peachy in the world of traditional medicine; doctors have done a lot of harm as well as a lot of good. But I like to think that as a profession we ultimately learn from our mistakes, and I'd submit as evidence the enormous strides modern medicine has made in extending the productive lifespan, reducing infant mortality, etc etc etc. And in a plug for my own specialty of psychiatry, although there are many patients who are beyond our present capacity to help, I know many others who have unquestionably been saved from suicide or from personal and social destruction.

When someone shows me a randomized controlled trial that demonstrates the utility of a supplement, I'll be happy to use it and recommend it. (I already do recommend both fish oil and melatonin under the appropriate circumstances.) Until then, it's just a black box; and that's not something I'm comfortable giving to a patient.

Tuesday, August 26, 2008

mind control II: yours

I wrote last week about how surprisingly simple it can be to turn around an angry patient. Two small words hold the key to taming the beast: "You're right." Those words are like a magic tonic, a soothing balm. The patient drops his offensive posture, loses his hostile glare. His hackles soften. His ears are open, receptive. Magic.

But it's not enough merely to mouth the two magic words. You need to believe them, to find the grain of truth in the patient's angry accusations and hold it up to the light. Typically that grain of truth contains a failing of your own. That's hard to admit.

In the CBT group I attend we use role-plays as learning tools. We mimic angry patients, throwing harsh words at our colleagues as a challenge to their empathetic skills.
It's curious that even when you are merely acting a role, pretending to be upset, you can feel in yourself the good or bad reaction to the 'therapist's' words. Defensiveness from the therapist provokes further heights of anger. But the crucial initial words "you're right" produce a rush of surprise and disarmament, a shock of pleasure at being understood, a hint of gleeful righteousness, and an intense curiosity and complete willingness to listen to what's coming next.

Rookies never get the task right the first time, or even the first ten times, even after having the strategy thoroughly explained and seeing more experienced members employ it. They simply can't get themselves to say, "You're right; I've failed; you're understandably angry; but tell me more so I can try to fix it." Instead they mouth platitudes like "I hear that you're frustrated," or "Why don't you calm down so we can discuss this," or they get defensive and explain why the patient is wrong to be angry. These strategies are all, of course, bound to escalate the situation.

Never, never on the first try do they plainly acknowledge the patient's anger and the faults of the therapist. I sure didn't, and I've yet to see any other rookies manage it either. It's suspiciously simple, yet incredibly difficult to do.

As I mentioned last week, I've been using this strategy on belligerent colleagues and other assorted meanies as well as on patients. It's been absolutely foolproof so far. But interestingly, when I shared the strategy with some of the psych residents who are not in the seminar, I met stubborn disbelief.

"I don't think it's appropriate to just subdue yourself to the demands of the patient. You have to maintain your own integrity," one woman said.

She'd verbalized the gut resistance to this strategy that comes from your own ego. That's exactly why it's so hard to implement, despite being so simple. Because you have to lose in order to win. You have to cave in order to prevail. You have to drop your ego in the dust and squish it with your toe in order to have any hope of success.

Even in the false environment of the role-play, where your partner flings made-up accusations at you, it's hard to accept and apologize for these acts you didn't commit. In that setting it's really just a script you could recite with no personal involvement whatsoever. "You're right, I did [fall asleep during your session/give you the wrong drug/insert horrific therapeutic sin of your choice], I bet you're feeling really angry right now." That's it, and with minor variations it's pretty much always the same. Yet it takes a long time to be able to do, even under laboratory conditions. How much harder is it when it's truly your own actions that are being assaulted.

Seeing the patient's anger as a threat to your ego integrity is losing sight of the goal of the therapy, which is to help the patient. The goal is not to maintain your own sense of dignity and self-worth; presumably you've already got a healthy dose of those or you haven't any business trying to therapize others. And if you consistently put the goal of preserving your dignity ahead of the goal of helping the patient, you'll have a lot of frustrated patients and that won't be good for your ego as a therapist in the long run anyway.

But we're accustomed to working hard to maintain our dignity and self-worth, because people without them are racked with doubts and insecurities and generally have a difficult time in life. So we're pretty well programmed to protect our egos, which we do in different ways depending on our basic characters, stages in life, and how we frame ourselves to ourselves. But we all do it. When faced with a blow to our egos, we're socialized to parry it, swiftly and surely.

However, it's all too easy to forget that an interaction between a therapist and a patient is not the same as a typical social situation. Your goal is to help the patient support and develop his ego, not to prop up your own. But when faced with a threat, it's instinctive to forget that, and to fall back on the strategies that have always been helpful (defending or rationalizing or denying your actions, deflecting the blame, etc.).

Hence my colleague's assertion that it was important to maintain one's own integrity. But important for what, I'd ask? Important for the patient, I suspect she'd say - to set limits, to teach the patient how to behave calmly and fairly. But the key point here is that there is always a reason for the anger. Truly isolated, reasonless, purely biological anger is a rare thing that occurs with specific brain lesions, typically affecting the hypothalamus. Real humans in the real world have triggers, and if the patient is lashing out at you it's likely that you're at least part of the trigger. It's your job to be the level head and figure out what that part is and what you can do about it. Otherwise your chances of getting the patient to a state where he can be calm and fair are going to be on the slim side of nonexistent.

Sunday, August 24, 2008

mind control I: theirs

I'm in a seminar that meets once a week to educate ourselves in the technique of CBT (cognitive-behavioral therapy). This is only one of a plethora of available therapeutic modalities (dialectical behavioral therapy, psychodynamic, psychoanalytic, etc etc etc).

We're learning specific, codified techniques for making our interactions with patients productive. Some of them are very simple; but the results are absolutely amazing.

One of the things that attracted me about psychiatry was how smooth the attendings were about dealing with difficult patients. You'd have an obnoxious patient on the medicine or surgery floors who would have all the docs chewing their stethoscopes with utter frustration. Then the psychiatry consult would walk in and in three minutes he'd have the patient eating out of his hand. Unbelievable. I wondered whether this was a talent they were born with or a result of their education. (Ultimately, as with most things, it's probably a little bit of both.)

It's a bit of a chess game, as one has to think a few moves ahead. If I say this, he'll likely say this. If I don't say this, another chance may not come. If I say it in this particular way, will he react well or badly?

It's perhaps funny to imagine that human interactions could be condensed down into a set of algorithms. One would like to think that individuals are so very different from each other that one size could never fit all. And it's true that one needs to apply one's interpersonal intuition to an extent. But only to an extent. There are definite ways to bring angry or frustrated patients back to a state in which they can engage in rational conversation.

And it doesn't only work in the controlled environment of a hospital or clinic. I've used some of the basic techniques we're learning with other angry, irrational people in my life (mainly frustrated residents from other services) with excellent results. Secret weapons! Psychiatry is incredible.

Next entry: Getting people to be rational is both easier and harder than it seems.