Tag Archives: psychiatry

“What Is the Function of the Brain?” by Laura K. Kerr

29 Jan
reblogged from Trauma’s Labyrinth
If you haven’t checked out Trauma’s Labyrinth yet, DO IT.  Its curator, Laura Kerr is a psychologist specializing in trauma and her blog is a must-read for anyone in the process of recovery. Her writing is academic but accessible, a great balance of scientific evidence and artistic/literary sensibility. Go read it, please.

Based on her ethnographic study of psychiatric residency programs, anthropologist T.M. Luhrmann concluded psychiatry is “of two minds”: one “mind” emphasizes the role of neurochemistry, while the other “mind” places more importance on the context of our suffering, including relationships past and present.

Identifying the origins of mental illness likely depends on both interpretations. There is an undeniable organic component to mental illness, just as psychological and social conditions are inexorably linked to mental well-being. But like the Democrats and Republicans, these two approaches are often pitted against one another, often leading to that old, tiresome nature versus nurture debate.

Unfortunately, in a world of limited resources, including limited time, the implicit guiding question — Where should we place our focus? — naturally divides our attention. Is it helpful to explore genes and neurobiology in our efforts to reach best outcomes? Or is it better to explore the social conditions that contribute to mental disorders? Unfortunately, much like U.S. politics, the treatment of mental illness often is derailed when such questions become fodder for polarizing arguments that serves allegiances and professional agendas more than persons in the throes of mental suffering.

Instead of worrying if nature is more influential than nurture, perhaps it would be more helpful to identify what counts as optimal functioning for the brain. Perhaps we could then focus on the value of combining information, thus leading to better outcomes rather than increased competition (and often, market share). I think the significance of function often gets overlooked because we aren’t adept at looking at any issues from multiple levels. Although the term biopsychosocial was coined to address the issue of scale and focus in the treatment of mental illness, it often feels piecemeal in approach.

How might we identify the causes of mental illnesses in ways that address their biological, psychological, and social aspects without parodying the impact of any of them?  Furthermore, what stands in the way of answering such a seemingly straightforward and important question?

More than any other arena of healthcare, the mental health field is paralyzed by politics, disciplinary boundaries, and financial stakes competing to define the disorders it treats and studies. I have wondered what it would be like for all of us who either work in the field or receive treatment for a mental disorder (a Venn diagram of these two groups would show a big overlap) to restart our quest for mental health and well-being with the very simple question:

What is the function of the brain?

With this question, I think we might begin treating the brain like any other organ of the body, and not according to its current exalted status. Appropriate treatment would “simply” mean returning the brain to its optimally functioning state. I believe this question could also encapsulate the complex relationship between biology, self, and society that complicates understanding the nature of mental illness as well as identifying best treatments.

Typically, something is perceived as a disease or trauma when it interferes with an organ’s proper functioning. By knowing the function of an organ of the body, it follows that healing that organ involves returning it to its homeostatic, functional state. Thus, what counts as disease or trauma are those things that interfere with normal functioning. For example, we know the function of the heart is to repeatedly and continually pump blood through the blood vessels, and anything that interferes with this process would be identified as disease or trauma. Similarly, the functions of the stomach include storing food during a meal and breaking down food particles into molecules small enough to be absorbed by the small intestine.  Whatever interferes with these functions is treated as disease or trauma.

We can identify the functions of every major organ of the body — the lungs, the skin, the intestines, the skeleton, the immune system — and with this knowledge, both diagnose and treat the causes of disease or the effects of trauma. Whereas there may be many paths to the cure, there is nevertheless a shared understanding of how the organ is meant to function. This simple approach seems to evade the mental health sciences, and I wonder if this is because there is a lack of agreement about the function of the brain.

We know the brain is part of the central nervous system, which functions like a command center for the rest of the body as well as gathering sensory information from the environment. The neurochemical model of mental illness relies heaviest on this understanding of brain functioning, particularly given its focus on neurotransmitters. Having a well-functioning central nervous system certainly seems central to mental well-being, yet it is also likely only one contributor to mental illness, and cannot adequately account for the psychological and social impairment also associated with mental illnesses. Although this model of mental disorders is not necessarily wrong, it nevertheless is too limited in scope to grapple with the myriad phenomena we associate with mental disorders.

An alternative model of the brain has emerged with research into the neurobiology of trauma as well as research into the different regions of the brain. With this model, the brain is understood more in terms of the functions of its components and adaptation to environmental conditions, especially the environments created through our relationships with significant people in our lives. This is an important change in scope from the biochemical model of mental illness that seems to rest on the “command, control, communicate” metaphor that has dominated information systems thinking since World War II.

In contrast, the neurobiology of trauma model examines how specific areas of the brain — often depicted as three primary regions: the cortex, limbic system, and brain stem — take part in the process of gathering information from the body and the environment, synthesizing this information, and then acting in accordance with often implicit needs or desires. In particular, two dominant action tendencies are thought to organize how the brain functions, which also correlate with two dominant environmental conditions:

  • conditions of attachment and normal daily activities, and
  • conditions requiring defense (i.e., fight, flight, freeze, submit, cling).

From the perspective of the neurobiology of trauma, sociality, and the capacity to engage with others in meaningful and pleasurable ways, is inversely related to the amount of traumatic stress a person experiences. Too little of the conditions that contribute to sociality, along with too many of the conditions that activate defense responses (including low levels of chronic stress), lead to poor mental functioning. And yet both functions — surviving in states of peace and in states of defense — are necessary functions of a healthy brain. (Thus an added benefit of the neurobiology of trauma model is that it replaces notions of pathology with notions of adaptation.)

The neurobiology of trauma model of the brain can also incorporate the functions of the central nervous system associated with the biochemical model of mental disorders, especially when the primary function associated with the brain is this concept of sociality. When the brain is seen as primarily a “social” organ, it seems to have two main functions:

  1. to communicate with the rest of the body in the creation of a coördinated response to stimuli (creating an ‘internal’ society of sorts); and
  2. to communicate with the world in the creation of a self among others selves.

When the primary function of the brain is seen as sociality — both within our own psyches & bodies and with other people — mental illness could then be simplified to include

  • interference with the capacity for internal communication that contributes to authentic self-care;
  • interference with the ability to be a self among others, and thus feeling relaxed and safe in the presence of others; and
  • interference with the capacity to maintain meaningful and supportive relationships.

Just as there are many ways for the heart, stomach, or any organ to be diseased or traumatized, there are many ways for the brain to lose functionality. Impairment does sometimes result from genetic predispositions, although typically in combination with physiological stressors such as exposure to toxins, exposure to bacteria and/or viruses, poor diet, high levels of stress, and injuries that alter the physiology of the organ or impairs its normal development. Also included in these physiological environmental stressors are traumas such as adverse childhood experiences, assault, combat, and other situations where people hurt people, thus not only overly activating defense responses, but also altering the capacity to function as social beings.

Both nature and nurture are undoubtably contributing causes to mental disorders. But perhaps we should think of them as either less or more relevant depending on which lens best helps people regain functionality — both in terms of their inner and outer sociality.

Another way of thinking about this would be in terms of integration. Feeling internally integrated lessens the sense of internal fragmentation. And integration is central to mental well-being. Feeling internally fragmented demands a lot of energy and attention, and often leads to isolation and limited integration with the larger community, hence also limiting the capacity for sociality.

Lacking the capacity for sociality seems central to the suffering associated with mental disorders, irrespective of the cause. And isn’t the reason we have any type of healthcare is to help people overcome suffering? Sometimes when overloaded with competing theories, professional agendas, and the potential for large profits, we lose sight of this otherwise straightforward goal. Yet if we can agree on the primary function of the brain, I think we can also be more astute in our choices about what counts as best treatments.

“What is Normal?” by Peter Kramer

11 Jan
Peter Kramer is a professor of psychiatry at Brown University. His article “What Is Normal,” first published in 2009, attempts to address concerns about the impending fifth edition of the Diagnostic Statistical Manual, primarily that expansions in psychiatric diagnostic labels and criteria would result in pathologization of “normal” human affect and behavior. You don’t have to subscribe to antipsychiatry to conclude that some of these concerns have been validated, an oft-cited example being the removal of the “bereavement exclusion” from the diagnostic criteria for major depressive disorder.
Still, Kramer offers a fresh perspective on the issue, arguing that expansions of psychiatric diagnoses not only have the potential to vastly improve people’s quality of life, but can  also alleviate isolation and stigma, provide insight into our sociocultural context, and enhance our understanding of the human condition. He also sheds light on some of these expansions’ epistemological origins.
I’ve included and emphasized what I consider the most salient excerpts from the article, which you can read in its entirety here.

 

I have been thinking a good deal about normality lately. It’s a concern in the medical world. The complaint is that doctors are abusing the privilege…to define the normal. Ordinary sadness, critics say, has been engulfed by depression. Boyishness stands in the shadow of attention deficits. Social phobia has engineered a hostile takeover of shyness.

….

The fate of normality is very much in the balance. The American Psychiatric Association is now revising its diagnostic and statistical manual—the next version, DSM-V, should preview in 2011 and become official the following year. It may, indeed, be that as labels proliferate, mental disorders will annex ever more territory. But claims of a psychiatric power grab are overstated. The real force behind a proliferation of labels is the increasing ability of technology to see us as we’ve never been seen before. Still, the notion of a shift in the normal invites unease: To constrain normality is to induce conformity. To expand diagnosis is to induce anxiety. Is anyone really well?

It’s a short hop from critiquing narrowed normalcy to claiming that we are an overmedicated nation. As [Christopher Lane, author of Shyness: How Normal Behavior Became a Sickness] writes, “We’ve narrowed healthy behavior so dramatically that our quirks and eccentricities—the normal emotional range of adolescence and adulthood—have become problems we fear and expect drugs to fix.” Psychiatry’s critics also complain that doctors medicate patients who meet no diagnosis, who practice what I have dubbed “cosmetic psychopharmacology,” to move a person from one normal, but disfavored personality state, like humility and diffidence, to another normal, but rewarded state, like self-assertion.

Labels matter even when medication has no role in treatment. A wife complains that her husband lacks empathy. Does he have Asperger’s syndrome, a lesser variant of autism, or is he simply one of those guys who “don’t get it,” who simply don’t see social interactions as ordinarily perceptive women do?

Diagnosis, however loose, can bring relief, along with a plan for addressing the problem at hand. Parents who might have once thought of a child as slow or eccentric now see him as having dyslexia or Asperger’s syndrome—and then notice similar tendencies in themselves. But there’s no evidence that the proliferation of diagnoses has done harm to our identity. Is dyslexia worse than what it replaced: the accusation, say, that a child is stupid and lazy?

The question of normality creates strange paradoxes in the consulting room. Often it is relatively healthy people who feel defective. In psychotherapy, patients may perseverate over vague complaints, feeling off-balance and out of sync. The worriers may believe that they have too much or, more often, too little ambition, desire, confidence, spontaneity, or sociability. Their keen social awareness (a strength), when tinctured with obsessionality, causes them to fuss over glitches in the self. For them, a sense of abnormality precedes any diagnosis and may persist even when none is proffered.

In contrast, seriously ill patients may have no such concern. Those who manifest frank paranoia will insist on their normality; anyone would be vigilant in the face of plots directed at them. Anorexics and alcoholics may profess certainty that they’re fine; the degree of “denial” is something of a marker for severity of disorder.

People afflicted by disabling panic or depression may fully embrace the disease model. A diagnosis can restore a sense of wholeness by naming, and confining, an ailment. That mood disorders are common and largely treatable makes them more acceptable; to suffer them is painful but not strange.

In other words, in the clinical setting, the proliferation of diagnoses has diverse effects, making some people feel more normal, some less so, and touching others not at all. There is no automatic link between a label and a sense of abnormality.

Still, diagnosis can seem to confer stigma. I recall a patient, Roberta, who consulted me because her marriage was in trouble. Her husband resisted couples therapy. Might she see me alone?

In my office, Roberta was listless and slow of thought. Her memory was vague. Was the problem thyroid disease—or an occult cancer? Roberta willingly submitted to a workup by an internist. She was devastated when she was referred back for treatment of depression.

To Roberta, the mood disorder label confirmed her husband’s complaint that something was wrong with her as a person. To be called depressed rather than, say, anemic constituted double jeopardy: She was in pain and she was flawed, in judgment and in character. She was unloved—and, now, abnormal.

Despite her misgivings, I asked Roberta to consider psychotherapy, exercise, bright lights (for winter in New England), and medication. I wanted her to be functioning well quickly, before she made irreversible decisions about her marriage.

The case had a memorable outcome. Only when she was better did Roberta reveal that at her low point she had contemplated suicide. Her summary comment was, “The fights with my husband saved my life.” They caused her to be diagnosed—and treated.

When she first spoke with me, Roberta seemed to display normal sadness, that is, emotional disruption in the face of a life crisis. Psychiatry’s critics are right: Roberta experienced the diagnosis as stigmatizing, and it led to her taking medication. But the case also illustrates why, for doctors, making diagnoses and educating patients about them is not a matter of choice; diagnosis can be lifesaving.

Just where does the impetus to expand diagnosis originate? A recent public flap highlights how categories proliferate. Raymond DiGiuseppe, a psychologist who researches anger, made headlines last spring when, at a scientific meeting, he argued that the DSM should add anger disorders, to parallel depression and anxiety disorders. There is a point at which anger becomes harmful, he contends. When scholars immerse themselves in an area—carefully observing research subjects, making note of differences and attendant harm—new sets of diagnosis seem obvious and inevitable. It doesn’t matter whether treatment for the condition is medication or psychotherapy, or indeed, any treatment at all.

….

Critics of psychiatry complain that many patients fit no clear category and, at least on insurance forms, are given labels like “anxiety disorder not otherwise specified.” Such patients nevertheless often remain at risk for an array of bad outcomes, studies indicate—findings that tend to broaden diagnostic categories.

Research technology is transforming understanding of mental disorders. New, more finely grained ways of looking at brains, neurons, and even cell connections, as well as powerful computer models, correlate many observed variations in function with disease and disability. The nerve connections you form, the neurotransmitters you elaborate, the symptoms you suffer—each may be linked to vulnerability to disorder.

One way psychiatry has responded to expansionist pressures is to turn to the concept of dimensions. Imagine compiling a list of all the factors ever associated with depression: irritability, a metallic taste in the mouth, a variant of a relevant gene, a change in size of a part of the brain. The list grows to 300 factors—symptoms, personality styles, gene variants, gene configurations, family histories, protein elaboration, and anatomical differences. Say, you rate a person on each of them.

Then you identify clusters of factors (extreme irritability, mild complaints of “off” taste, moderate levels of brain abnormality) that predict recurring episodes of mood disruption. A computer could identify varying degrees of severity for each of the hundreds of factors, with differing prognoses and treatment options. And then at some point, it becomes logical to dispense with the discrete, categorical have-it-or-don’t-have-it view of depression.

In time, and in future manuals, dimensions may push categories aside. If for many of the factors, difference confers some degree of vulnerability to dysfunction, then we will find that we are all defective in one fashion or another. DSM-V may turn out to be conservative and postpone the inevitable, but it is hard to imagine a future in which abnormality is not much more prevalent than it is today. The shift in perception may become more marked as researchers identify subtle neuron- or gene-based variations with modest psychological consequences—increased risk for one or another condition—in the way that high blood pressure signals increased risk for stroke.

How will it feel to live in a culture in which few people are free of psychological defect? Well, we’ve been there before, and we can gain some clues from the past. The high-water mark for diagnosis occurred in the heyday of psychoanalysis. The Midtown Manhattan Study, the premier mental health survey of the 1950s, found that over 80 percent of respondents—more than triple our own abnormality rate—were not normal. “Only 18.5 percent of those investigated were ‘free enough of emotional symptoms to be considered well,'” the New York Times reported. It even cited a psychiatrist who reasoned that, since health includes awareness of conflict, subjects who express no neurotic anxiety must also be abnormal.

In a forthcoming book, Perfectly Average: The Pursuit of Normality in Postwar America, American Studies scholar Anna Creadick reports that the U.S. hungered for a return to normality in the wake of World War II. Articles asking, “Is Your Child Normal?” appeared regularly in the press.

But being deemed neurotic was hardly a cause for distress. If anything, the affliction seemed to signal opposition to mass culture, as if emotional sensitivity were a protest against Eisenhower-era dullness and conformity. Popular essays and books such as The Man in the Gray Flannel Suit made normal men and women out as saps.

The lesson of mid-century is clear: When everyone is abnormal, diagnosis loses its sting. I suspect that we are entering a similar period in which diagnosis (or dimensional defect) spreads—while its gravity, in terms of social stigma, diminishes. Or else we will redefine normal to include broad ranges of difference.

To some degree, that is already happening. The deaf, anorexics, people with Asperger’s syndrome—groups whose members might otherwise be considered impaired or deviant—have made vigorous claims to represent “the new normal.” The Hearing Voices Network advocates liberation, not cure, for those who hallucinate. Where once people pursued normality through efforts at self-reform, now they proudly redraw the map to include themselves. In this context, diagnostic labels confer inclusion in a community. Today, an emotional or behavioral state can be understood both as a disorder and a unique perspective.

As the experience of mid-century shows, we can hold two forms of normality in mind—normal as free of defect, and normal as sharing the human condition, which always includes variation and vulnerability. We may be entering a similar period of dissociation, in which risk and pathology become separated from abnormality—or an era in which abnormality is universal and unremarkable.

We are used to the concept of medical shortcomings; we face disappointing realizations—that our triglyceride levels and our stress tolerance are not what we would wish. Normality may be a myth we have allowed ourselves to enjoy for decades, sacrificed now to the increasing recognition of differences. The awareness that we all bear flaws is humbling. But it could lead us to a new sense of inclusiveness and tolerance, recognition that imperfection is the condition of every life.

“Conspiracy of Silence: When the Psychiatrist Has BP” by Sara Solovitch

26 Aug
From bp Magazine (www.bphope.com):

One morning when she was 27, Suzanne Vogel-Scibilia, MD, went to work, a young, up-and-coming resident psychiatrist at a major Pittsburgh hospital and left, hours later, as a person with bipolar disorder.

The diagnosis—her own and later confirmed—took place as she was routinely questioning a distraught patient who, after spraying her neighbor with a hose, had been brought into the emergency room by police.

How much sleep had the woman been getting, Dr. Vogel-Scibilia asked. “Not much,” she answered. “Maybe a couple hours a night.”

And I’m thinking, me too.

How about food? Was she eating? “Oh, I had some dinner last night,” the woman responded. “I wasn’t very hungry.”

And I’m thinking, that’s interesting. Same as me.

Was she under stress? “Sure,” the woman said. “But you know what’s really annoying me? They’re talking about me on the PA system.”

And at that moment, I could hear the PA system and they’re not talking about her. They’re talking about me. And I’m not hearing a damn word this woman is saying. I’m just thinking, ‘What diagnosis does this woman have? Bipolar?’ Oh my god! Suzanne, you’ve got bipolar disorder!

Dr. Vogel-Scibilia was convinced that her diagnosis—which she now traces back to age 15, the first time she attempted suicide—would mark the end of her career.

The medical profession doesn’t look kindly on mental illness within its ranks. Michael Myers, MD, clinical professor of psychiatry at the University of British Columbia, Vancouver, British Columbia, and former president of the Canadian Psychiatric Association, argues that the stigma attached to mental illness is greater in medicine than anywhere else. Worst of all, he says, are psychiatrists who suffer from “internalized stigma.”

“Just because we’ve trained in psychiatry doesn’t mean we’ve purged ourselves of out-dated and discriminatory attitudes,” says Dr. Myers.

“I’ve looked after psychiatrists who feel dreadful—-some actually say they feel fraudulent—that they are taking care of depressed people when they themselves are on antidepressants. I say, ‘Hold on a minute, I’m sure there’s an endocrinologist out there who has diabetes.’”

Research shows that doctors in general are at greater risk of depression, mood disorders, and suicide than other professionals. “Psychiatrists commit suicide at rates about twice” the rate of other physicians, according to a 1980 study by the American Psychiatric Association, which found that “the occurrence of suicide by psychiatrists is quite constant year-to-year, indicating a relatively stable oversupply of depressed psychiatrists.”

“It’s an oversimplification to say it’s all due to the stress and strain of practicing medicine,” cautions Dr. Myers, a specialist in physician mental health. “It’s more to do with who we are: Many of us in medicine are wounded healers. We’re interested in practicing medicine precisely because we come from families with problems.”

Higher rates of family dysfunction, parental alcoholism, sexual and physical abuse, parental death, and psychiatric hospitalization were reported among female psychotherapists than in other women professionals in a 1993 study in the journal Professional Psychology, confirming the image of wounded healers.

Continues Dr. Myers: “Coupled with that, there are certain personality traits among people who become doctors. We’re perfectionistic; you have to be if you want to practice proper medicine. And people who are that way are hard on themselves.”

Yet the stigma of mental health continues to create what he and others have called “a conspiracy of silence” among doctors—psychiatrists in particular.

Disclosure

By her last year of college, Beth Baxter, MD, “knew” there was “something wrong” with her brain; during the previous four years, the top student and class president had routinely slept only four hours a night. She would enter the cafeteria only during off-hours, eating peanut butter sandwiches day after day, just to avoid running into her classmates. She fought suicidal urges and had already made several half-hearted attempts.

In her second year of medical school at Vanderbilt University, she became convinced that the songs being played on the radio were carrying messages to her. Her grades began to slip for the first time, so she took a break and visited her grandparents’ cattle ranch in Texas. While there, she went missing. She left on an imagined meeting with friends and followed some “messages” on the radio. Found wandering a day later, she was picked up by police on the side of a highway.

So began Dr. Baxter’s first hospitalization when she was diagnosed as having bipolar disorder. She managed to return and graduate from medical school, hiring a tutor to talk through all of her class notes.

She was accepted into an internship in internal medicine in Memphis, Tennessee. “They accepted me before they knew I had bipolar disorder,” she recalls. “The dean of students told them I’d had counseling, but it wasn’t fully explained, and they were kind of angry when they found out.” A year later when she transferred to Rochester, New York, she changed specialties. “Because,” she says, “I knew how much good a psychiatrist could do and I wanted to do that for somebody else.”

After her residency, her symptoms worsened: she became increasingly depressed and suicidal; she tried to slash her neck and had to return to her hometown of Nashville, Tennessee, where she was hospitalized for a year and the doctors told her parents that the most she could expect was to work on an assembly line. And the diagnosis had now changed to schizophrenic affective disorder.

“I was a pretty sorry sight,” she recalls. “I’d lost 70 pounds and I had a movement disorder—jerky hands and feet.”

By this time, however, her parents had become active in the local chapter of NAMI (National Alliance on Mental Illness). When the local NAMI officers learned that a doctor was hospitalized in Nashville, they approached her with a request: would she write an educational training program for people who have mental illnesses? Baxter completed the project while she was still on suicide watch.

Little by little she began to come back. “A psychiatrist there had a lot of hope in me,” she says, “and that hope was really important.”

Dr. Baxter is still on medication; the last time she was hospitalized was in 2000, when a prescription change failed to work. But today, she runs a large private practice in Nashville, where—just as in medical school, when she hired a tutor—she now retains an older and more experienced psychiatrist “to help me talk through my cases and review how they’re going.”

She talks about her experiences openly, addressing NAMI workshops around the country, speaking at physician conferences, and often sharing her story with patients—“to show that you can recover from serious problems in your life.”

She is famous around town for giving away little clay turtles from Guatemala: she sees turtles as a symbol of perseverance and determination, and has hundreds of clay, plastic, and ceramic turtles throughout her house.

Openness, for Dr. Baxter, was hardly a matter of choice: her medical history made disclosure an all too obvious decision. “But I still think it’s good when people know,” she says. “Then, when I got sick and bad things happened, they were more compassionate.”

Dealing with bp in practice

Mental Health Awareness Week in Canada features an annual campaign called the Four Faces of Mental Health. It’s a way of putting a human face on conditions, such as bipolar disorder, schizophrenia, and depression. For the first time last year, one of the four faces was a doctor.

“I had to convince myself to do it,” concedes Michael Paré, MD, a Toronto, Ontario, general practice psychotherapist. “I’m always telling my depressed patients that they don’t have to feel ashamed: They’re not bad; they’re not crazy; they’re not weak. But doctors—while we’re taught to say that—are not actually following through and admitting it. If it [mental illness] isn’t our fault, then why is it so bad to stand up and be counted?”

After a “very, very difficult childhood,” Dr. Paré sunk into a major depression in his mid 20s. “Literally, every day was like a terror, like being alive was the worst possible thing,” he says. “It’s impossible for me to remember the feeling, but I do remember my knowledge of it. Like when I opened my eyes in the morning, it was like, ‘Oh no, I’m still alive.’”

He swallowed a lot of pills one day and fell into a coma for a week, recovering only after undergoing a lumbar puncture, or spinal tap.

A few years ago, Dr. Paré was invited to address a large group of psychiatrists on the subject of depression. It was a professional talk, but at the end, he impulsively made mention of his own experience.

“I said, ‘Interestingly enough, I’ve suffered from major depression.’ And there was no reaction. No one came up to me after the talk. I thought I was dropping a bomb, but not one person acknowledged it. And these were psychiatrists who work with depression every day.”

Despite his own candor, Dr. Paré typically counsels young doctors against disclosing any history of mental illness at the beginning of their careers.

Most young doctors don’t need to be told. Consider the case of M., a 24-year-old California woman diagnosed as having bipolar disorder during her second year of medical school in Lebanon. She is so fearful of one day being denied a medical license that she refuses to see a psychiatrist now that she is back in the U.S.

Instead, she orders her medications online. They cost $400 a month and they’re generic, but they have one overriding advantage: they arrive unmarked from India and Australia.

“I’d go to any lengths to have my medication,” she says. “If I go to a psychiatrist here, my whole future is ruined—everything I worked for. There are always questions on the residency or licensing applications—do you have a medical condition? That’s why it’s so important to keep it to myself.”

That fear is widespread. A 2001 survey of Michigan psychiatrists found that half of them would rather self-treat than risk having a history of mental illness on their health insurance record.

And with good reason, according to psychiatrists who point to the widely publicized case of Steven Miles, MD, whose own bipolar disclosure turned into a cause célèbre.

In 1994, Dr. Miles, a well-respected gerontologist and professor of biomedical ethics at the University of Minnesota Medical School, had sought help for depression from a psychiatrist who diagnosed bipolar disorder II. After a few weeks on medication—and with no interruption in his teaching or clinical work—Miles began to recover.

But several months later, on filling out the annual renewal form for his state medical license, he answered the questionnaire affirmatively when asked if he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

Though he had never been the subject of a patient’s complaint, and though his name appeared regularly on lists of the state’s “Top 100 doctors,” the Minnesota Board of Medical Practice began an investigation, demanding a letter from his psychiatrist and full access to the records of his psychotherapy sessions.

Dr. Miles refused, and for the next four years he fought the board, arguing that its policy was overly invasive and served to deter physicians from seeking help for mental health disorders. After a protracted standoff and threats of legal action, the licensing board eventually changed its policy.

Today, many state licensing boards have adopted similar changes, but there is no consistent state-to-state policy. Nor is there any specific system for physician health care in the U.S.; the only health programs aimed at doctors are those restricted to drug and alcohol treatment.

In Canada, a physician wellness program has been set up in every province; its directors have joined to create a federal network, Canadian Physician Health Network, to share information and strategies. Under this system, a doctor who has bipolar disorder, for example, can be assisted and will be monitored at least three to five years, after which—if he or she is deemed stable—the monitoring is decreased or even removed.

Here’s how it works for one Toronto doctor, a 41-year-old resident psychiatrist who last year was diagnosed as having bipolar disorder. A., as he asked to be identified, was someone who didn’t “do” just residency. He simultaneously created a banking project for residents, invested $8,000 of his own money into a biotech company, organized a charitable organization for autism, conducted research into schizophrenia, and juggled a series of home renovation projects.

“I always have to self-monitor to slow down,” he explains ruefully, “because the rest of the world doesn’t operate as fast as my world does.”

Then last year, everything crashed. “A secretary made a note saying I was speaking too fast, had taken time off from work, and that I’d asked for a referral to a psychiatrist. And suddenly, there’s this note going around saying I have bipolar disorder—and no one had even diagnosed me at the time.”

After a letter was sent off to the Ontario College of Physicians and Surgeons, the self-regulating body for the province’s medical profession, A.’s first instinct was to fight.

“I don’t want to be labeled just because I’m outside the box,” he says. “No way in hell was I going to have a label like that. I didn’t want someone labeling my enthusiasm—even though I realized some of my experiences were perhaps bizarre.”

His psychiatrist reassured him, however, that he was not alone, that other physicians had similar problems, and that the system’s checks and balances would allow him to continue in his career.

“I thought that was a bunch of hogwash,” A. says. “All my faculties are based on my judgment and if that’s taken away from me how can I practice when people’s lives are dependent on my judgment?”

That insight doesn’t always mitigate the irritating presence of the system’s checks and balances. To A. they feel like an albatross, like he’s being “policed.”

“I have to inform my program director that I have an illness,” says A., checking off the list. And everything I say to my psychiatrist becomes open to the College of Physicians and Surgeons. They want me to see a mood disorder specialist. I have a case manager to keep an eye on me and make sure I’m functioning on all cylinders.

“I also have the people who ‘supervise’ me at work,” A. continues. “So all these eyes are on me. It feels like I’m being policed even though I’m not being policed.”

The choice is no longer his. His behavior had become so erratic that he could no longer deny his problems by working harder and plugging in the answers that he knew would get him off the hook with his fellow psychiatrists.

“With our specialized training we may be able to rationalize or deny our symptoms,” says Mamta Gautam, MD, an Ottawa, Ontario, psychiatrist who restricts her practice to physicians.

“And, a doctor’s ability to function at work is often the very last thing to go. In fact, you see that most people don’t have any idea that a colleague is struggling, because if anything they’re more productive than before. When, really, it’s just a mechanism—to keep working and stay with what’s known rather than stop and reflect.”

Coping and reaching out

Long before Dr. Vogel-Scibilia examined the patient who had bipolar and saw herself reflected back, she had figured out ways of adapting to her seasonal mood swings. Anticipating depression in winter, she scheduled her most challenging coursework for the fall.

“I’d do the research, pick the cards, and do the bibliography,” she says, “so if I had to write the paper I’d just have to write the text out. I would try to compensate for things, study stuff in advance.”

Now a practicing clinical psychiatrist in Beaver, Pennsylvania, she operates an independent mental health clinic and serves as clinical assistant professor at Western Psychiatric Institute, the same hospital where she did her residency and diagnosed herself.

Today, she is president of NAMI at the national level and a consultant for psychopharmacology projects at the National Institute of Mental Health and is a grant reviewer for the federal government.

But at least once a week, she gets a call from a young medical student or resident doctor—usually, she says, it’s a psychiatric resident secretly struggling with mental illness. Some of them offer to fly or drive long distances for a consultation.

“I have this theory,” she says. “If you were a patient before you were a doctor you don’t have so much trouble being in a patient role. But if you’ve been the doctor first and then you get sick, you have a hell of a hard time being a patient.

“You could do a study [about physicians having mental illnesses], but there’d be no sample, because nobody would agree to be interviewed. Actually I could just poll my friends. The trouble is it wouldn’t be a random sample. It would be the friends of Suzanne.”

http://www.bphope.com/Item.aspx/102/conspiracy-of-silence-when-the-psychiatrist-has-bp

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