It has been quite a long time since I have posted on this blog. Alas, I went to Africa in the summer of 2012 and got malaria while I was there. It took me almost a year to return to my normal state. During that time, I unexpectedly, but excitedly changed residences, and had to deal with changes in all the psychiatric CPT codes (current proceedural terminology) which tell insurance companies what services we have provided patients, as well as changes in documentation requirements for those services.

It seemed that there never was enough time to tackle my pile of articles that I wanted to review for this blog. The longer that went on, the easier it was to avoid it altogether. New patients to my practice told me they had read my blog and really enjoyed it.


So there was an article in the Wall St. Journal this weekend, Our amazingly plastic brains , about the effects of exercise on the brain. (If you have read my previous and now antique posts, you would know that I get most of my medical news from the WSJ. I thought it an interesting article about the changeablity of the brain, as researchers are actually discovering. When I trained, the brain had a million or more cells, and that was it. No more. no healing, no dividing or regenerating like the liver or the skin if injured, we were told. Yet now, researchers are able to find stem cells for the brain.

In previous articles that I have commented, topics have touched on the brains capacity to learn, or change.We humans are evolved from beings that were constantly moving — gathering in tribes, in hunting, in finding shelter. We didn’t always sit behind desks or aspire to be couch potatoes. I have always felt that exercise is under-rated and very important in our physical and mental health. It helps with sleep promotion, anxiety reduction, and effect moods. It has a profound impact on the state and shape of our bodies — weight reduction, blood sugar regulation, some effect on blood pressure and pulse. I encourage all people, not just my patients to get as much aerobic exercise as they can. Now researchers are starting to say the same thing, and in this article — exercise leads to less dementia, less Parkinsons, stroke recovery…..Hmmm.

So with everything else I am juggling, I guess I need to add more exercise. And hopefully, if I have time left over, it won’t take me almost 2 years to post the next entry here.

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I know. I know. I’ll get to the title and the article in a minute, not trying really for any theatrics here, but I can’t believe it has been a year since my last posting. What happened? Well, first there was this pile of articles on sleep apnea, acupuncture, medical marijuana amongst others that I just never seemed to be able to get to in a timely fashion. Then there was this photoblog that was infintely more enjoyable and way easier. My subscription to the Wall Street Journal expired (no joking) on top of it all, and then there was just life.

Don’t they say– good things happen to those that wait, LOL?

Well, I finally restarted my subscription to my biggest article source, the WSJ a couple of weeks ago. In it was The Plight of the Pregnant Man. It wa very interesting to read that “pregnancy symtoms” in men whose mate or partner or wife or whatever PC lingo one uses today — nausea, fatigue, food cravings, odor aversions, mood swings, weight gain –are actually caused by a rise in the level of the hormone Prolactin in the man! Prolactin is responsible for many of the physical changes women experience during pregancy, especially breast enlargement and weight gain. In men, it is also responsible for a lowering of the testosterone level, and a lesser interest in sex.

It is interesting to note that psychologists in the 1800’s came up with the term “couvade” for male pregnancy symptoms (french for “to incubate” or “to brood”, like a mother bird) and Freudians attributed couvade to “fetus envy”, but this has been around since antiquity. Oh where would Woody Allen be without all of that?

It turns out, that males with pregnant partners that experience pregnancy symptoms have been shown to have an elevated prolactin level, and the higher the prolactin, usually the more in sync they are with the expectant mother and the more “maternal” they are after the birth. Higher levels also cause more symptoms, of course.

It wasn’t quite clear how or why certain men got elevated prolactin levels and perhaps others no elevation. But, the take-away message for me is how many other “psychological” conditions are really chemically based, but we have yet to figure out how to assess or measure it? Psychodynamic psychotherapy has no place here, except to be supportive of the symptoms and only tends to pathologize something apparently biological or even evolutionary.

PS – I gained 15 pounds when my ex-wife was pregnant the first time!!!

Now I am mad. I finished an article last week that I was reading to review for this blog, and set it down because I wanted to re-read parts of it before deciding about how to write it. After procrastinating for days, I am up against a self imposed deadline (end of the weekend) and I can’t find the friggin’ article anywhere. I never throw anything away inadvertently, and this is so unlike me. It probably got mixed up with a batch of other newspapers and wound up in last Thursday’s recycling, Greenie that I am.

But we know what THEY would say. Lost the article on purpose. Expressing some inner conflict about the review, or the article, or the blog itself, and IF you could come to terms with those feelings, you wouldn’t need to lose the article in the first place. Aha! Go figure that the article was on psychoanalysis! My Life in Therapy–What 40 Years of Talking to Analysts has Taught Me –— was a funny, enjoyable, yet painful summary of Daphne Merkin’s run-in with psychoanalysis. At first, I couldn’t decide if the article was some sort of comedic rant on the subject, as– she just wasn’t serious, was she? Her experience couldn’t have gone that way could it? One begins to realize that she recounts things that really one could only know if they had been in analysis themselves. So she had been there, but……

Through comedy and humor, Ms. Merkin writes about alot of different situations during her decades of psychoanalysis.Not all were funny, though. Although from the patient’s perspective, this well written article interestingly serves as the counterpoint, or bookend to the last article I reviewed, the psychiatrist who could only give meds. Here it is the psychiatrist who could only analyze–the polar opposite. Being a New Yorker myself, I suppose I can say, “Only in New York,” as the association to as lengthy an analysis in our popular culture leads to Woody Allen, who likewise in interminable analysis, in this article actually offers her a referral to his analyst.

My Life in Therapy recounts what is both good and bad about psychoanalysis. The psychiatrist as analyst takes a neutral stance and through tthe results of their training uses techniques so as not to inject themselves into the treatment. In this way, the motivations, wishes, decisions can wholly be understood as belonging to the patient. It can allow for a much more intensive understanding of one’s internal self. However, Ms. Merkin sometimes finds herself on the short end of that “neutral” stick–an analyst is closing his practice due to terminal illness, and instead of simply informing her of that when she applies to be a new patient,  he tells her that he cannot invest his time into her care. She is left wondering all kinds of things about her acceptablility as a patient, rather than the fact that the decision had nothing to do with her at all.

In the end, Ms. Merkin decides after 40 years, that maybe she doesn’t need to talk all of her issues over with an analyst, that it is not worth the time or the money or the emotional investment, and that she could do reasonably well on her own. It could be said that her analysis had a reasonable outcome on that basis–she was able to reach a psychological independence, finally. My beef is that the analytic stance would not allow the question to be asked, “After all this time, why are you still here, and what has happened that you can’t do this on your own?” My agenda perhaps, not hers, it would be argued – if she wants to come, let her come. But I think to allow her to come and take her money after all that time, without asking that question, is almost like taking advantage of her conditionand repeating something from her past.

When I did my psychiatric training, we learned both psychodynamic principles and medication treatment and how to blend them together. But the king of the hill back then was the psychoanalyst, who commanded the highest regard due to the mystique of psychotherapy and the often-inabilty back then to treat psychiatric problems ably with medications.  I decided not to trek up that hill, but to dwell amongst the “regular” psychiatrists. Regular enough to learn to try to distinguish what was pscyhologically based, what was biochemically based, and to be able to talk about whatever was necessary without having to tell the patient that I couldn’t help them because my appointment structure for medications only wouldn’t allow it.

I had to go around my house and look for the article one last time. Of course, now that this review is finished, I did find it under a mass of papers I was sorting on my dining room table. I guess you could say that I didn’t need it any more.

I had the notion that I would slowly attack the pile of articles that I had amassed over the last 7 months and be able to comment about them fairly easily in this blog. I did not consider the possibility, or rather the actuality that there would be additional articles demanding my attention as well.

And so it is with Mind Over Meds — How I Decided My Psychiatry Patients Needed More From Me Than Prescriptions, a recent article from the Sunday New York Times magazine section. I have so many reactions, it is hard to organize them in a coherent fashion. But, I will try.I will have to leave my pile of other articles for another time. This article is written by a psychiatrist, self defined as a psychopharmacologist, who comes to realize that focusing on medications only, may not be in the best service of the patient! Duh, is all I have to say. Actually, I have a lot more to say on the subject than that.

I trained as a psychiatrist before the coming of Prozac and most of the other newer and fairly effective medications that are used in 2010. In the early 80’s when medications did not seem to work as well, one was left with having to sit with the patient and talk to them to try and help them get better. I went to a psychiatric training program, University of Colorado Health Sciences Center, that focused on teaching psychodynamic psychotherapy, but also incorporated medications or psychopharmacolgy into the treatment as an intrinsic part of the whole. It was in the early days of the rise of the primacy of medications in psychiatric treatment, even if way before Prozac. My training taught me how to talk with patients and how to listen to what they were trying to tell me.

There is no question that medications can cure or treat certain psychiatric symptoms. I still remember working with a very suicidal patient years ago, when medications could just not relieve his depression or  suicidal thinking. We spent session after session developing a checklist of things to do for distraction when he became suicidal. But, we could talk til doomsday and never really impact the depression or the suicidal thinking. Along came the new SSRIs and guess what?  The new class of antidepressants not only eliminated the depression, but completely wiped away the suicidal thoughts as if they had never been there.  Without a trace! As a psychiatrist, and as a psychotherapist, the results were incredibly powerful — medications had a life changing potential.

But just as similarly, the person who comes in who may have some trouble with sleep, motivation and sadness, may not quite benefit from an antidepressant, and instead, need some time in psychotherapy to sort out what in their life may be causing her to feel out of sorts, and what might they want to about it. Providing medications and psychotherapy, in this instance, I can assess whether the psychotherapy is allowing the complaints to remit, or whether a medication needs to be added.

Dr. Carlat indicates in this article that it is easy to learn  the science: the criteria, diagnostic categories, differential diagnosis and match it all up with medications. He recognizes that learning psychotherapy is another story. It is not my purpose in this article to review the pressures he touches on in this article that have pushed the psychiatrist to become a psychopharmacologist. However, I strongly feel that medications and psychotherapy are just two of the  tools found in my tool bag that are used to help a person when the situation warrants. Just like the washing machine repairman, who needs the very large pliers and belt to remove the drum when it is not working (and only that tool will work for to fix this problem), the psychiatrist should be able to apply their art and know what is called for in the situation: medication, psychotherapy, both, or even neither.  Patient sessions can be 15, 30 or 45 minutes to tailor the appointment to the need of the patient. It does not have to be “one size fits all” and say “over the course of 15 or 20 minutes, this is about all I can offer” ! (exclamation point is mine)

It alarms me that I get referrals for treatment where the patient or referring party comments on the fact that they can’t find a psychiatrist who provides both medications and psychotherapy in a combined treatment. Dr. Carlat relies on studies and statistics to back up his conclusions. While that approach may be helpful to the general public (e.g. only 29% of psychiatrists provided psychotherapy in addition to medications in 2004, or that it is more cost effective and decreases the number of sessions when the psychiatrist does both the medications and psychotherapy), it all seems so far removed from my everyday reality. Ultimately I feel that it is the patient that suffers.

After reading this article, I really feel like a not-quite-extinct-yet-prehistoric-animal, or perhaps a lonely voice from the wilderness. Thankfully, Dr. Carlat adds his voice to the mix that there is value and benefit for a psychiatrist to be able to prescribe medications and perform psychotherapy. I am very worried that the coming changes in healthcare, which have yet to unfold, will not support this benefit and push more of us to have to provide medications only.

for further thoughts on this subject, see my entry “What is a Psychiatrist ?” on the home page of my website:www.abetterstateofmind.com

I have seen a lot of patients with traumatic brain injuries. So when I saw this article, I thought, oh no, not another brain scan to come on the market. As it is, SPECT scans and PET scans are still somewhat controversial in regard to the definitive diagnosis of brain injury. I was very much surprised to read in New Test for Brain Injury on Horizon that the reference is to a blood test that would be able to detect proteins released in to the blood stream produced by an injured brain. Wow! This blood test would operate on the same model as proteins released by an injured heart muscle in the hours after a myocardial infarction (heart attack). This simple blood test revolutionized the detection and treatment of heart attacks, and if this brain injury blood test bears out in clinical trials, should save lives, direct treatment, and lessen injuries that until now, may be overlooked or incorrectly treated. The Department of Defense will be conducting the trials, and look for FDA approval as they hope for a blood test that they can “carry onto the battlefield”.

I have worked with a tremendous number of people who have the history and clinical symptoms of a traumatic brain injury or a carbon monoxide exposure, but have no “objective” test to document and verify their condition. Here’s to hoping that perhaps this blood test can one day be used to help out in all these situations.

A Look at Head Trauma

  • About 1.7 million people annually in the U.S. suffer a traumatic brain injury. Some can lead to long-term difficulties in functioning.
  • Most common causes among civilians are falls, car crashes and assaults. Blasts can cause brain injuries in soldiers.
  • About 75% of brain injuries are concussions or “mild” brain injuries.
  • 52,000 people in U.S. die from brain injuries annually, and 275,000 are hospitalized.
  • Most commonly affected age groups are children up to 4 years old, and teens 15 to 19.
  • More than 3 million Americans have long-term need for help in daily tasks because of brain injury.

Sources: U.S. Centers for Disease Control and Prevention; Brain Injury Association of America; WSJ interviews.

There has been some amount of controversy about adults being newly diagnosed and then treated for Attention Deficit Disorder, when it is a disorder that is “supposed” to be present from childhood. Mind Games –Attention Deficit Disorder Isn’t for Kids. Why Adults are now being Diagnosed Too was an article that tries to explain it, and does only a fair job of doing so.

Needless to say, there is much apparent uncertainty in the general public already with the diagnosis and medication treatment of children and teenagers of ADHD, and now many college campuses are filled with stories of Adderall or Ritalin for sale for student usage before finals. However, in the mental health community, the criteria for ADD/ADHD (the H, for hyperactivity can be a separate part of the disorder) is well established in the DSM – IV and does a fairly good job at identifying the spectrum of symptoms found whether for children or adults: forgetfulness, lack of focus, tuning others out, lack of organization, difficulty with planning, hyperactivity or impulsivity.

Adults sometimes get diagnosed when one of their children gets a diagnosis of ADD, as it very often runs in families and can be manifested in one or both parents (“So that is why I always seem to have trouble with….”). Some adults may find that they never could really focus, and never thought about ADD, and still others had adopted a variety of coping methods to deal with their difficulties, and find that their system no longer works like it used to (increased demands at work or home, juggling more things, emotional stress). The screening test that the WSJ includes doesn’t work well for me because it includes too many questions about emotional up and downs that could be due to many problems other than ADHD (anxiety, bipolar, depression). I prefer the diagnostic criteria provided by DSM- IV and find them pretty reliable. I would echo the article in that medications tailored to the individual, behavioral treatment, and an ADD coach can truly make a difference in the person’s life.

I often find the Wall Street Journal medical articles informative, even for me, and very accurate. In this instance, I was very disappointed by the whole thing.

It has been more than many months since I last posted something on this blog. Alas, time commitments have not allowed me the time I wanted to do this in the manner that I wanted. So, I stacked the articles that I was interested in reviewing, and even took them with me in on one car trip, hoping that I would finally get to them. I never did.

My stack is pretty high. The articles may be old, but the ideas in them are not. So, starting today, while waiting for the Fourth of July holiday festivities amidst the pouring rain and furious hail, I am going to read an article from that pile. I begin in a random fashion, simply with whatever article has indiscriminately landed on the top, mixed and remixed like a deck of cards in Las Vegas, as I shuffled the stack over the last 6 months.

New Findings Boost Theory that Infection Causes Schizophrenia from March 2010 was an article that I pulled because it is fascinating to me that an illness like schizophrenia, around with us for a very long time, etiology never really determined and now accepted to be mediated by some brain chemical imbalance often thought to be dopamine, could actually be caused by an infection. Infection?!

Actually, what was most fascinating to me from everything in this article, was that if toxoplasma parasite should  infect a rat (it normally infects cats), it should normally end there, with the rat and toxoplasma parasite unable to reproduce and complete its lifecycle. But, toxoplasma renders the rat “crazed” so that it becomes attracted to cat urine, gets nabbed and devoured by the cat, allowing the toxoplasma parasite to gain entry to the cat bloodstream where it thrives and reproduces. This evolutionary adjustment to ensure its survival in the cat is caused by excess dopamine production in the rat caused by the toxoplasma parasite. Now isn’t that something?

The author indicates that perhaps 30% of all schizophrenia could  probably be eliminated by infection control (toxoplasmosis, influenza, peri-conceptional genital-reproductive infections), but obviously there must be a complicated interplay between environment and susceptible genes or else schizophrenia would be a lot more prevalent than it is. No question that what we see is the symptom, which is the end result of a myriad of factors, and only time will tell whether etiology is really important in the final treatment of the illness/syndrome/symptom. In the meantime, schizophrenia prevention is certainly worth the time and effort, and I guess it is important to keep in mind that nothing may be what it appears!

It is that time of the year when things get hectic and there is not enough time to get things done. So, I went to a cabin several weeks ago, to get away from it all, and slow things down. And while I was there, outside of Rocky Mountain National Park, I read an article in the Denver Post that blurs the boundary between reality and science fiction. Robotic Hand in Mind’s Grasptells of a fascinating experiment where the electrodes of a robot hand are simply inserted into the nerves of a man who had previously lost his arm. This is more fantastic than the real experiment conducted with stroke victims who are able to regain function of a paralyzed limb by tying back the good or functioning limb. Talk about mind over matter! Or is this how the borgs first got started?