Lockup Doc

Psychiatry needs a new marketing campaign to improve its credibility and appeal as an interesting and respectable career option for medical students. Also, exposing those who may be going into primary care to “bread and butter” psychiatry would enhance patient care since a large percentage of  psychotropic medications are actually prescribed by primary care doctors.

During the third year of medical school, students rotate through several required clinical clerkships, one of which is psychiatry. Since I started medical school 20 years ago, I have spoken with very few students and doctors who have had positive experiences with their psychiatry rotations. Read more…

We probably all know people who seem out of touch with their emotions. We may suspect that they are distressed, but typically they say that they feel fine emotionally.

I’m not talking about people with social anxiety issues or stoicism who hold back their feelings and simply need to learn to express them. I’m referring to those who truly don’t know what they’re feeling. Or, if they do, they have great difficulty putting those feelings into words. The lightning bolt of major depression could strike them, but they would be clueless to articulate how they felt. In fact, they may be more likely to seek medical care for somatic symptoms if clinically depressed. Read more…

Medical training is filled with many memorable moments, some of which we probably wish had never happened.

In academic medical centers, med students are at the very bottom of the hierarchy. (In this case you’ll see that I was indeed literally at the “bottom.”) Therefore, if there is any “scut work” to be done, the buck is usually passed to them.

I’m sure you’ve heard the metaphor about how bodily waste flows downhill. Well, I’ve got a story to tell that will show you that it is indeed true part of the time, but it doesn’t always flow downhill or sometimes even “flow” at all for that matter. You’ll understand in a minute. Read more…

In 1971 a psychology experiment at Stanford University occurred that would be considered too unethical to conduct today. It was supposed to last 2 weeks, but it got out of hand and was stopped after only 6 days. The “prison guards” exhibited very demeaning and even sadistic behaviors. The “prisoners” eventually became very inhibited and showed signs of severe stress.

It was the Stanford Prison Experiment. A mock prison was created in the basement of the psychology building. Male undergraduate students were carefully screened, and 24 ultimately were chosen. They were randomly assigned to be either guards or prisoners. The guards worked 8 hour shifts, went home, and then returned the next day as typical shift workers do. The prisoners were “arrested” by police at their residences and then transported to the makeshift prison. The prisoners were not allowed to leave. Read more…

The relationship between a psychiatrist and patient must be different from that between two friends. Friends share problems and concerns with each other because of the mutual give-and-take foundation on which friendships are based.

A psychiatrist-patient relationship is very different. A patient comes to and pays a psychiatrist for professional services. While a psychiatrist is probably going to be more effective by showing some human qualities and not being a completely blank slate, there is still a necessary professional veil that the psychiatrist must wear.

What I was always taught and still believe to be solid advice is that a psychiatrist should not disclose any significant personal information to a patient unless the intent is for that disclosure to help the patient. That’s been a great barometer that I’ve used with myself over the years. If I find myself beginning to talk about my own life, I stop myself and double-check my intentions. Read more…

Can you imagine doctors referring to patients as idiots, morons, or imbeciles? And, doing so not because of disliking their patients but as actual diagnostic labels?

It is difficult to conceive, but just a few decades ago the use of these particular terms was completely acceptable. Each was used to describe individuals with varying degrees of mental retardation (MR).

In my work with some older individuals with developmental disabilities, I have had the opportunity to review medical records from 50-60 years ago. (I know it’s difficult to believe, but some records that old still exist!) It is a surreal experience to see these terms used as casually as “depression” or “diabetes” is used in charts today. Yes, that’s correct, progress notes began with phrases such as, “This 18 year-old female moron,” or “This 22 year-old male imbecile.” Read more…

He grew up on the streets, sold drugs, was involved in gang violence, sneaked drugs into prison for his father, became an addict himself, and aspired one day to go to prison. But his own path to healing from this violent upbringing began the night that he and his gang were beating up a homeless man.

The victim looked into his eyes and told him, “Please help me…You’ve got more compassion in your eyes than any woman I’ve ever met.” His life was rocky for several years after that event, but it was never the same.

His name is Vinny Ferraro. He has devoted his life to working with the Mind Body Awareness Project (MBA) in California. He teaches mindfulness and emotional-intelligence exercises to at-risk youth so that they can make better life decision and learn alternatives to violence, drugs, and other self-destructive ways of living. Read more…

It’s probably happened to all health care professionals at some point: Patients, especially those considered “difficult” for some reason, fail to improve despite our best efforts. Eventually we become frustrated enough that we then blame them for their lack of progress.

There are endless possible scenarios where this might occur:

• A depressed patient, who transiently appears to have a personality disorder because of her inadequately treated depression, is not progressing in psychotherapy and has not responded to two different medication trials.
• An elderly man bounces back for readmission to the hospital for a CHF exacerbation. He arrives in the ER with a pack of cigarettes in his shirt pocket.
• A morbidly obese woman continues to have poor control of serum glucose, blood pressure, and lipids despite aggressive pharmacotherapy. Yet the patient has lost no weight despite being counseled for years about the need to do so. Read more…

Antisocial personality disorder (ASPD) and psychopathy have similarities, and there is overlap between the two diagnoses, but the diagnosis of each of the two conditions is made differently.

Before I describe these two conditions, I want to clarify the terminology further.

In psychiatric language, ASPD, or describing a patient as “antisocial,” has nothing to do with whether one socializes with other people. Of course in everyday language, the term antisocial is often used to mean just that. In psychiatry it means to go against the rules and norms of society.

Likewise, the term psychopathy is not related to the term psychosis. Psychosis refers to a break from reality. The vast majority of psychopaths are fully aware of their actions.

Antisocial personality disorder is a diagnosis described in the DSM-IV TR, the current diagnostic manual for psychiatric diagnoses. It is a diagnosis mostly reflective of a person’s behavior.

Patients diagnosed with it may exhibit any of the following: repeated acts that violate social norms (i.e., illegal activity), deceitfulness, impulsivity, aggression/irritability, repeated disregard for the safety of self or others, irresponsibility, and lack of remorse. For the sake of brevity, I am not including the full DSM description. Click here to view the full DSM-IV TR criteria. Read more…

The below YouTube video is a decent overview of how, since the deinstitutionalization movement of the 70’s, the prisons and jails in the U.S. have been housing a large percentage of people who previously would have been in mental insitutions. It explains some of the challenges of providing mental health treatment behind bars. What it does not address, though, is the significant problem many mentally ill inmates face continuing their psychiatric treatment in the community after they are released. Read more…