Dying in balance and my organ is more important than yours-managing treatments from different specialties. from Psychiatry in Techno Colors

Dying in balance and my organ is more important than yours-managing treatments from different specialties
When I was an intern in Internal Medicine, my training director was highly influenced by House of God by Samuel Shem. His sense of humor was often not appropriate for patient consumption. He claimed that all patient problems could be summed up in two general categories, WTD1 and WTD2. WTD1 was short for "weak, tired and dizzy" while WTD2 was "waiting to die." The internist was successful when the patients' symptoms resolved or they "died in balance." The latter referred to all their lab values and numbers looking good just prior to the time of death. Samuel Shem became a psychiatrist and I believe he would agree with my goal, normalizing lab values is less important than the patient feeling better and if they happen to die, it is with a smile on their face for a life worth living.
I note the above because many efforts in modern medicine seem focused on "normalizing" numbers rather than treating the patient. Whenever a patient asks me the result of their lab tests, especially for medication blood levels, I always ask them "how are you doing?" The lab result is less important than the results of the treatment. Labs are for guidance. If the blood level of a medication are too high I might want to reduce the dose to prevent side effects. If the levels are too low and they are doing well, I don't care. I might ask if they are really taking the medication and if not, tell them that that's OK if you are doing well. I don't treat lab values, I treat patients. I don't get any satisfaction from patients being compliant with medications that are not helping them or are causing untoward effects.
Physicians have embraced using evidence-based treatments which on the surface is a noble aim. This means that physicians should prescribe the best treatments for each condition based upon the best scientific evidence. The best evidence is from large double blind studies in which active treatments are compared to each other and placebos. Unfortunately, these are very expensive studies to do, so most are funded by pharmaceutical companies who are able to design studies which can favor their medication by under or overdosing comparator medications or not enrolling enough patients to receive alternative medications so that true differences can't be proven. Additionally, it is difficult, if not impossible, to do statistical analyses of multiple variables in sub-populations of patients. For example, in studying a medication for high blood pressure they haven't differentiated patients with other conditions like depression or anxiety since the focus is on disease states associated with high blood pressure such as heart attack and stroke. Only recently was it demonstrated that depression was one of the greatest risk factors for heart attacks. This would suggest that additional studies should be done to look for the best anti-hypertension medications for the subpopulation of patients with depression and anxiety. Instead some of the most commonly used medications indicated by evidence based medicine to prevent heart attacks can worsen depression and interfere with antidepressants.
Jill was a 45 year old married woman with a long history of anxiety and depression. She was treated by her primary care doctor with Cymbalta (duloxetine) for her depression and pain from arthritis. She was doing well for several years but had a panic attack when her teenage son got into a car accident while texting his new girlfriend. No one was hurt but she thought she was having a heart attack and went to the hospital emergency room. She was given an extensive work up including EKG, blood work and was referred to a cardiologist. He ordered an echocardiogram and stress tests which were all normal. Her blood pressure and pulse were high so the ER physicians began her on metoprolol and the cardiologist raised the dose. She continued to feel ill and in fact was feeling worse with fatigue and loss of drive. She couldn't concentrate. Now worrying that doctors had missed some serious problem she complained to her primary care doctor who told her that everything was normal and that the only thing he could suggest to her was to see a psychiatrist.
Reluctantly, after several weeks of resistance, she made her appointment to see me. I reviewed all of her symptoms and history. She was not the best student in school but managed to get by because most subjects seemed easy for her. Her son was similar and was recently diagnosed with attention deficit disorder but was refusing to take medications. She saw some of the same obstinacy in herself agreeing to the Cymbalta only because she didn't want to get addicted to pain medications for her arthritis. The improvement in her mood was an added bonus which she appreciated. Careful questioning revealed that the worsening of her fatigue began after going to the emergency room and worsened more after seeing the cardiologist. This correlated with her beginning the metoprolol and the subsequent dosage increase. I suggested that this medication should be changed but she didn't want to call her doctors about this. Knowing that her cardiac work-up was negative I told her that I could give her an alternate medication that was similar to the metoprolol but would not get into the brain as easily. I prescribed atenolol as a substitute. She called me a week later telling me she was back to her old self.
Metoprolol and atenolol are both medications of the class of beta blockers that are selective to the heart (Beta 1 selective). Metoprolol was approved more recently and the manufacturer did more studies to prove its superiority for certain heart conditions. My impression of some of the studies and experience switching people between these medications is that the dosage equivalencies used were not accurate. Most reports suggest that atenolol should be dosed about half as much as the equivalent dose of metoprolol. In my experience patients needed the same dosage of each medication to get an equivalent effect on blood pressure and heart rate. More importantly, metoprolol is lipophilic, which means it dissolves in fats and thereby may enter the brain more easily than atenolol. Beta blockers block the effects of adrenaline which is a hormone that in the body raises heart rate and blood pressure. In the brain this neurohormone helps concentration, drive and mood. Metoprolol blocks some of the effects of Cymbalta which raises adrenaline in the brain. We give medications that enhance adrenaline to patients with depression and attention deficit disorder so a beta blocker in the brain can reverse these benefits.
Is metoprolol a more effective beta blocker than atenolol for preventing heart disease? Or would the depression worsening side effect of metoprolol make it less effective in patients with depression or for patients on antidepressants. As far as I know, no one has studied this. This leads me back to my internship. Do I follow evidence-based studies that call for metoprolol and have my patient "die in balance" having done everything by the book, or do I risk following a patient-centered approach that may cause my patient to die with a smile on her face? Having changed Jill's medication, she now can make a choice with personal evidence of her own trial comparing the effects and side effects of both medications. She can, with this firsthand knowledge, make a more informed decision about her own treatment.
Feeling better, Jill decided to have her primary care physician continue to prescribe all of her medications including the new medication I started her on. Five years later she returned for another evaluation. She has gone through menopause and now has a number of new problems. She has to urinate frequently and often can't make it to the bathroom in time. She was referred to an urologist who diagnosed her with over active bladder and prescribed oxybutynin for her. The urinary urgency is better but she has gotten more forgetful and more tired again. She associates her memory problems with menopause. Sleep has been poor due to night sweats and hot flashes. All of this is making her more depressed and she is anxious that she might lose her job due to poor performance. She needs this job as her husband's business has not been well lately. She went to her gynecologist who advised against hormone replacement therapy due to a family history of breast cancer.
Jill is typical in many ways and is a setup for bad pharmacology based upon evidence-based medicine. Oxybutinin is a standard medication for over active bladder that works as an anticholinergic medication. Many of our old antidepressant medications had anticholinergic side effects which included difficulty urinating, dry mouth, blurred vision, constipation and rapid heart rate. In the brain, anticholinergic medications cause memory loss and confusion. In Alzheimer's dementia the cholinergic system deteriorates. Several medications approved for Alzheimer's, such as Aricept work the opposite of Oxybutynin. Oxybutinin is another lipophilic medication that gets into the brain easily, worsening memory. I switched Jill's oxybutynin to trospium (Sanctura) , which is also anticholinergic but is not lipophilic and can effectively treat overactive bladder without the cognitive side effects, but is not widely marketed. Some medications seemed to have flopped due to bad timing in their release when cheaper equally effective medications were available. Only later, after a medication has gone generic, did we appreciate certain differences that gave some medications an advantage. When a medication has gone generic there is no drug company who will want to spend the money to market it to prescribers. This knowledge has to be spread by word of mouth or through small case reports.
Jill was happy with the change in medication. Her bladder symptoms were as well controlled on the trospium but she was still disturbed by her hot flashes and poor sleep. Sweating is another adrenaline symptom that can be helped by medications that block this hormone's action on the alpha receptor. Above we noted she was using a beta 1 adrenaline receptor blocker, atenolol, which controlled her rapid heart rate. There are several alpha blockers available and some psychiatric medications have this as a side effect. This mechanism was responsible for lowering patients' blood pressure causing dizziness. This may not be a problem if the dosage of the alpha blocker is low but might be a problem when combined with another blood pressure lowering medication like atenolol. There is a blood pressure medication, carvedilol, which has both alpha and beta adrenaline blocking activity so could help both sweating and rapid heart rate, but it gets into the brain more easily than atenolol. Terazocin (Hytrin) is an alpha blocker that is approved for both blood pressure and male urinary symptoms due to benign prostatic hypertrophy. At low doses it helps reduce sweating from multiple causes without lowering blood pressure significantly. Blocking the alpha receptor in the brain doesn't seem to cause the same psychiatric problems as the beta receptor.
I didn't go over all of the possible treatments with Jill, but she might have noticed the smoke coming from my ears as I ran through the multitude of possibilities and drug interactions affecting multiple bodily systems. I settled on a simple one, trazodone. This is a medication that came out before Prozac (BP) which never hit it off as an antidepressant. Its sedating side effect was so strong that few patients were able to tolerate enough to get an antidepressant effect. I was working at a Veterans hospital when I began using it for depressed veterans with post traumatic stress disorder and substance abuse. The sedation allowed me to taper patients off their sedating addicting medications and I published an article on this. What I didn't realize at the time was that trazodone's alpha blockade effect might also help sleep, nightmares and night sweats as much as the sedation in these patients. So I decided on low dose trazodone for Jill as it could help both her night sweats and sleep. This improved her sleep but she still complained of night sweats and hot flashes. Adding one milligram of terazocin twice a day resolved them. She was so pleased with the results that she referred her husband, George, to me as he was sleeping poorly and disturbing her now.
George was 55 years old and has always been a hyperactive independent guy. He ran his own business which had its ups and downs until he hired Jill to do his bookkeeping. When she was not doing as well he became more aware of his short comings. This caused him to become increasingly anxious which led to troublesome urinary frequency. He drank a lot of coffee to keep up with his workload but felt his need to leave meetings with clients to urinate was unprofessional. His primary care doctor told him that his prostate was not enlarged so diagnosed him also with overactive bladder. He gave him some Myrbetriq to try since he had samples in his closet. George felt that this didn't work and maybe made him worse. He was hoping that I could help him as I had his wife.
I have sympathy for primary care physicians. They have so many disease states to learn about and treat. They get bombarded with drug reps peddling the latest, greatest medications for existing and sometime new seemingly made up conditions. It is impossible to keep up let alone learn the differences between treatments based upon mechanisms of action. The FDA approves medications for specific conditions defined by a set of symptoms and the medications clearly help these conditions. This is the definition of evidenced-based medicine. Several years ago with the new healthcare program, ACA, I was incentivized to start prescribing electronically instead of by paper prescription. This had two effects besides making my prescriptions more legible. I needed to get internet access for my prescribing and I was able to see what other physicians had ordered for my patients. Once I had the internet, the power of Google allowed me to look up details about all the medications I was prescribing as well as what other doctors had given my patients.
I looked up Myrbetriq. It is an interesting medication as it is not anticholinergic like most of the medications for over active bladder. It works on adrenaline, cool. I know adrenaline and its effects. It happens to target a different adrenaline receptor the beta-3 receptor which is focused in the bladder but instead of blocking it like the medications noted above, it stimulates them. Looking at the side effect profile in the package insert, it might not be as specific as it professes since it may raise blood pressure as you would expect for a drug that stimulates adrenaline. I learned from a drug rep (see chapter Marketing of a slightly better medication) that medications that stimulate adrenaline produce a "pseudo anticholinergic" effect. In other words like the anticholinergic medications they slow urination and cause dry mouth. But they do not cause the memory problems associated with true anticholinergic medications.
Obtaining more history from George suggested that like his son, he probably also suffered from attention deficit disorder since childhood. He compensated for this by drinking a lot of coffee and when he was younger he was very active in sports. He would always do things at the last minute and thrived on the anxiety that it produced. All of these things raise adrenaline. His urinary problem was not caused by too little adrenaline, but by too much causing a pseudo anticholinergic side effect such that he never fully emptied his bladder. He needed a medication that blocked his adrenaline in his bladder but not his head. Tamsulosin is such a medication. Also the excessive amounts of caffeine were irritating his bladder and causing sleep difficulty. I gave him atomoxetine (Strattera) a medication that stimulates adrenaline, for his ADHD symptoms so he could reduce his caffeine intake and be less anxious. Without the tamsulosin, the atomoxetine would have worsened his bladder problem. I was able to give him the adrenaline he needed in his brain for concentration with atomoxetine, while blocking its effect in his bladder with tamsulosin. If his blood pressure went up or he developed sweating from the excess adrenaline, I could switch his tamsulosin to terazocin which would block the adrenaline effect in the bladder, blood vessels, and sweat glands without impacting the brain. If instead he had tremors and increased heart rate, I could give nadolol which is a beta adrenergic blocker that doesn't get into the brain easily. Isn't pharmacology fun?
In summary, I want to impress upon prescribers and patients that mechanism of actions as well as evidence-based studies comprise a starting point of medications that might be used to treat a specific problem. In order to find the best medications to treat individual patients we need to understand the pharmacology of each medication and how it might impact any concomitant medical or psychiatric conditions. Everyone is complicated by the fact that they have multiple conditions and different metabolisms which warrant individualized treatments. Medications have more than one action which can result in side effects, but sometimes these side effects can be used to benefit co-occurring problems. Alternatively, specific side effects might be ameliorated by other medications creating a cocktail of sorts. Specialists would be wise to consider co-occurring conditions when choosing medications rather than reflexively selecting the "best" "evidence-based" medication for the condition that they are called upon to fix or giving samples of the latest medication left by a pharmaceutical representative. When in doubt, Google is your friend that can help you rapidly find out all sorts of interesting facts not only about mechanism of action but also drug interactions, side effects, and duration of action which makes everyone a more informed prescriber.
And by the way, the brain is the most important organ!
Reference note:
As a psychiatrist I must note that the worst beta blocker for patients with psychiatric conditions is metoprolol. It penetrates the brain easily (highly lipophilic) causing fatigue and reverses the norepinephrine benefits of many antidepressants and stimulants (i.e. causing depression and cognitive impairment). Two good alternatives are atenolol for beta 1 selectivity and nadolol for non selective use (eg tremors). These beta blockers are hydrophilic and don't cross bbb as easily) The original studies comparing atenolol with metoprolol were flawed in that they under dosed atenolol. The potency should be 1:1 published in 2012https://www.ncbi.nlm.nih.gov/pubmed/2891183 vs earlier studies presumably paid for by manufacturer of Toprol in 1981 https://www.ncbi.nlm.nih.gov/pubmed/7308277 which dosed 2:1 metoprolol to atenolol.

Psychiatry in Techno Colors: A Psychiatrist's Memoir of Lessons Learned About Diagnosis and Treatment of Anxiety and Depression second edition is available

Finally finished my updated and expanded second edition of PSYCHIATRY IN TECHNOCOLORS: A PSYCHIATRISTS MEMOIR OF LESSONS LEARNED ABOUT DIAGNOSIS AND TREATMENT OF ANXIETY AND DEPRESSION
Now available on Amazon.com in both paperback and kindle and lower price than first edition with 9 additional chapters.

CONTENTS
Acknowledgements 8
Preface to second edition 10
Forward (By William Glazer, M.D.) 12
Preface: Extending the boundaries by getting real about stigma and patient advocacy 16
Introduction: The phoenix rises from the academic ashes 21
Ode to Freud and latter day disciples 30
The evolution of my psychiatric faith 39
Battle of the titans and how I survived my psychiatry training in turbulent times 48
Seeing is believing, and why I stopped listening to Prozac 58
Psychiatry in techno colors 64
Bad drugs, good medications 76
Marketing of a slightly better medication 89
What’s my diagnosis, does it matter and who cares? 96
Confessions of a reformed bipolar over-diagnoser and how to see residual ADHD 109
You can’t teach old dogs or neurons new tricks- when undesirable medication combinations maybe best 119
The RAM Hypothesis and why remembering everything may make you depressed 124
Origins of panic 131
Life, liberty and the pursuit of happiness; assessing risks and benefits 138
“I must be the worst patient you’ve ever seen”: My theory of relativity 144
Suicide and the need for hope 154
A danger to others 161
Study conclusions, lies and statistics 171
Afterward-the future 185
Appendix: Depression Treatment Paradigms 190
How to understand psychosis-we all can speak schizophrenageeze 203
The clinical relevance of differentiating obsessing and dwelling in patients with anxiety and depression 213
Dying in balance and my organ is more important than yours-managing treatments from different specialties 218
Complex or Difficult cases: Assessment strategy 227
Treatment non-compliance or failure to gain acceptance of illness? 235
The first shall be last: An alternative approach to the psychiatric intake evaluation 241
The role of the not so simple 15 minute "medication check" 247
A Multiple Models Assessment and Treatment Strategy for Depression and Anxiety 250
How to do a medication trial 266
Choosing medication cocktails: Top shelf brands “neat” vs. mixed generic “well” drinks 271

How to understand psychosis-we all can speak schizophrenageeze

The prejudice against people with mental illness is most apparent towards people who have had psychotic symptoms. These are the people most referred to as "crazy." We might not be so prejudiced when we realize that almost all of us have had psychotic symptoms but don't label them as such. Psychosis is defined as being out of touch with reality. In our DSM terms we think of hallucinations and delusions as the hallmark of psychosis. These might be visual or auditory images that others don't experience or misinterpretations of signals leading to mild paranoia or more elaborate schemes that require extensive stretches of the imagination connecting far away dots of information. How many of us have had these experiences while asleep and woken up not sure if things that occurred in the dream actually happened? What about religious experiences many refer to as feeling the presence of God? What about the belief in a all knowing omnipresent being who may decide the fate of mankind? People have fought wars over beliefs that their invisible "Being" wanted others to die or convert to believing in their version of this invisible deity. How many have felt that their boss, parent or friends were out to get them when the support for this belief was thin. How can two individuals on opposite sides of the political spectrum have vastly divergent interpretations of the same facts presented to them? Depending on how strongly felt these beliefs are it might be difficult to find the border between strongly held beliefs or intuitions and psychotic delusions.

We experience the world through our five senses of sight, sound, smell, touch and taste. We have receptors to pick up these senses that send nerve impulses to the brain where they are interpreted. The body also has sensors in our internal organs sending signals of pain and discomfort which might alert the brain to address a concern about breathing, digestion or other physical issues. We in addition have thought processes which we engage in for interpretation of social interactions, dietary needs and future planning. Our brains must be able to sort out all of this data and determine its sources or origins. It must determine whether the signals are coming from one of the five external sensing organs or are images from a sleep state or an awake but contemplative state. We interpret these signals using knowledge obtained from past experiences or early learning. But what if we encounter new novel signals that we can't interpret having never experienced them before? Individuals who have certain types of seizures or migraines might experience auras during which sensations occur without an external stimulus. People who have lost limbs have phantom limb pain. After some surgeries or injuries where nerves have been damaged may lead to similar phantom sensations.
What would happen if the brain got flooded with too many inputs and could no longer determine if the data was coming from outside or inside the body? Those inputs might be from both external clues and thoughts or worries. We would lose touch with reality. We might misinterpret a thought as an external voice. Or we might over interpret an observation such that it coincided with a thought or fear that we had. If we were concerned that people didn't like us and thought about the many reasons for this, we could interpret a nose rub by a coworker as a signal that we must be putting off an offensive odor. Or we might hear a boss speaking loudly on the telephone and think he is expressing discontent with your performance and discussing a plan to fire you.

Patients with psychosis usually report "racing thoughts." Many of us have had a similar experiences of being overwhelmed with too many things to do or problems that need to be processed and decided upon. Racing thoughts in psychosis are often so fast that the patient can't keep up with them let alone articulate them verbally to someone. They may be going so fast that the individual may not even be able to talk coherently. If the thoughts are so rapid only bits and pieces of them might be articulated giving the appearance of a "flight of ideas" or jumping from one topic to another without apparent connection between them. Sometimes the thoughts are going so fast that the patient can't speak at all and may only gesticulate or freeze. This used to be called "thought blocking" where the individual might stop in mid sentence and jump to another topic. The freezing up in extreme form can result in catatonia where the individual becomes mute and immobile. It was recognized many years ago that patients with catatonia who seem shut down and non verbal are racing inside. They race so fast that they can't communicate with the outside. It would be like trying to enter a revolving door that was moving too fast for us to enter. Many creative individuals have flurries of ideas. Society values individuals who make new connections leading to discoveries or new insightful ways of thinking. Where is the border between extreme creativity and psychotic thought process? Kay Jamison, a noted psychologist with bipolar disorder, wrote about this in her book, Touched by fire. She documents many of our brilliant creative people having mania but they usually are only able to be productive during relatively well periods between episodes.

Individuals with psychosis are trying to make sense of their misperceptions. They are making hypotheses for the unusual stimuli and impart special meaning where one doesn't exist. This leads to extreme vulnerability which requires some form of self protection. If you feel vulnerable you might project this fear onto others. If unconsciously you know that your work performance has been deteriorating due to your difficulty thinking you might project this fear onto your boss or co-workers and think they are out to get you. If you hear voices, maybe god or the devil or dead relatives might be trying to communicate with you. As your function deteriorates from your inability to sort thoughts from outside conversation, it wouldn't be unreasonable to think that these outsiders are trying to control you. If your thoughts are so loud you might think that others might be able to hear them. Schneider in 1959 wrote of schizophrenic first rank delusions of thought insertion, thought withdrawal, and belief that one's thoughts were being broadcast to the outside world.

When I was a resident on a research unit I had the rare opportunity to work with patients who came off all of their medications for up to several months while participating in double blind placebo controlled studies. One of my patients was a middle aged woman whose depression was not being adequately treated as an outpatient. She was an executive secretary for a medium sized company. Over the course of several weeks she developed a Capgras syndrome. This is a rarely seen syndrome where the patient believes that individuals have been replaced by imposters. She thought that her bosses had set up the unit to appear like a hospital but none of the people were really nurses, doctors or patients. I asked her what evidence she had for this. She noted that the nurses and doctors didn't wear uniforms and the patients didn't seem ill. She didn't see diplomas for the doctors either. I had her get up from her chair and look at my diplomas that were hanging on the wall behind her. She said, "maybe you are a doctor, but no one else is." I tried to have her tell me why her employer would go through so much effort and spend so much money on setting this up. She didn't know why but believed she was such a poor worker over the past year that they must have been upset and wanted to humiliate her. I informed my attending of her emerging psychosis so that the study would be terminated and she could be put on appropriate antipsychotic medication. The delusions cleared fairly quickly and it was apparent that her prior medication, while not completely effective, had given her some relief.

The longer the psychosis is allowed to persist the more likely these delusional beliefs are to become fixed into one's memory. I had a woman who thought that she controlled a major company by her thoughts. This went on for many years and she never told anyone as she thought everyone already knew. When I gave her medications these telepathic communications stopped. Then I asked her why they had stopped she said, "the medications stopped the communications." But she quickly added, "you don't believe that I did that?" Just because the medications stopped the acute misinterpretation of sensations doesn't mean the past memory of these beliefs would be changed. After all they have become memories and to change these memories would have been a blow to her self esteem and required her to think of herself as "crazy" rather than superbly helpful. Unfortunately, many prescribers misinterpret the persistent memory of delusional ideas with continuing psychosis and try to increase antipsychotic medication to the detriment of the patient. The clinician must ask "do you think these phenomenon are still occurring?" and not ask "do you still think that these phenomenon occurred?"

Over medicating a patient with psychosis results in worsening cognition and other serious side effects. These side effects often lead to non compliance with taking the medications, not realizing that many of the delusions have become memories and are tied to the person's sense of self and self esteem. Asking the patient to deny these beliefs could result in lack of acceptance of illness or even worse, severe depression with suicidal ideation. Compassionate psychotherapy is needed to help the patient introduce doubt of their past beliefs or at least not to carry them forward and use these beliefs to interpret current events so that they avoid making poor decisions in the future. This is no easy task. I will tell family members that trying to convince someone that they were delusional would be like trying to convince the Catholic Pope that Jesus was not the son of God. You wouldn't even think of doing this. Many patients feel that their psychotic experiences brought them closer to god. Why would you want to undo this?

Most grandiose delusions on the one hand make the patient feel special but on the other it causes an extreme burden. I had a patient who came to the "New Haven " (Connecticut that is) because god told him to run for president of the United States. I pointed out that he was only 33 and the Constitution stated that one needed to be at least age 35. He told me that they would make an exception. No logic was able to convince him that this was a delusional idea for which he needed treatment. But then I thought about what it might feel like to be asked by god to travel down to DC and overcome extreme obstacles in order to run for president. "Wow," I told him, "that must put a tremendous burden on you." He began to cry after I said that. Here was a manic patient, who is grandiose and supposed to be in a state of euphoria, crying. The psychoanalysts viewed mania as a defense against underlying depression. But I think I did something else. It was the first time I spoke schizophrenageeze to a psychotic patient.

When speaking schizophrenageeze you respond to the emotion or feeling that you would anticipate having if you were experiencing the activities presented in the delusion. For example, if the individual felt that the government had implanted electrodes in their brain and were listening to all their thoughts, I would want to also know if the government was also controlling him. This would lead to a discussion of how it felt to lose control of one's body and mind. You might feel angry and frightened. You want to know how to ignore what was happening to regain a sense of control. From there you find out if he was obligated to do something against his will and maybe encourage him to resist. Medications could be offered to help with the overwhelming anxiety associated with this loss of control. You could try to find out what things were going on in his life where he felt he was losing control. This might lead you to real things that were happening for which you could give appropriate advise.

A middle aged African American woman came to me upset because White men were following her everywhere. She didn't see them but they spoke to her. She couldn't take it and was refusing to take her medications since she saw the solution was to escape from these men. She decided to sell most of her possessions so she could buy a plane ticket to California to get as far away from them as possible. She returned several weeks later. She told me that the men had followed her to California and it took her several weeks to get enough money to pay for a bus ride back. I spoke to her about the fear she was experiencing and that medications could help her be less frightened. She agreed to take the medication. I never tried to convince her that the men in her head were not real as this would have ignored her reality. I used her logic that since the men would follow her wherever she went, it would be best to figure out how best to live with them. Medications would help her cope with this. Within a few weeks the "men" stopped talking to her but she had no explanation for this happening. I tried to reassure her that the medications would let her cope and may prevent their return. As she was improving she was able to articulate her fear of men in general and the fear she experienced when "white men" had taken her against her will to the hospital in the past.

There is usually a kernel of truth in every delusion. The individual has an exaggerated emotional response to this event which leads to an over interpretation of the event. As speculation occurs this leads to false beliefs in an attempt to explain the reason for the extreme emotional reaction. Anyone who has watched Fox News can see how they feed into people's fears and add to conspiracy theories. When four soldiers were killed in Benghazi Libya speculation flew as to inappropriate actions by the secretary of State, Hillary Clinton. Any tidbit of fact was twisted to fit into a conspiracy theory. Months of Congressional investigation found no conspiracy but by then Fox had made so many speculations and wove them into a seemingly coherent story that they had the force of delusions which became resistant to the facts. Many of their listeners became believers tainting her election.

It's fairly easy to see how a delusion can be formed by making distant connections based upon limited information in the context of highly charged emotions. Take someone's fear of harm, or unexplained depression or free floating anxiety and project the cause on outside forces. Introduce vaguely related details and connect dots that shouldn't be connected and you have the makings of a conspiracy. Have an individual whose thinking is impaired by overwhelming situational factors and the delusion becomes real. Think of all the parents afraid that their children may develop autism and introduce them to a discredited study linking autism to vaccines and you find delusions in individuals who do not have major psychotic disorder. You can't convince many of these parents that the study was flawed and retracted. Conspiracy theories protected them from hearing the truth by introducing the notion that you can't trust the establishment including physicians, pharmaceutical companies and especially government. The only counter is to acknowledge the fears and provide support for how to cope with them. There have been outbreaks of preventable diseases now due to lack of vaccination and this fear is more real. The parents were presumably vaccinated and survived. I have treated some of these individuals overwhelmed by one conspiracy theory or another and I often have to resort to low dose antipsychotic medication. This usually reduces the intensity of the fear and slows their thinking enough to suggest they don't need to worry about the conspiracy. The medication won't eliminate or change their mind, just like a delusion, but they can move forward without adding new irrelevant data points to reinforce the belief. Also the medication may not be needed for more than several months similar to treatment of a brief reactive psychosis. I "sell" the medication as a way of reducing their anxiety and "not to treat psychosis." I point out that the dose prescribed is lower than that used to treat psychosis and that low dose antipsychotic medications have be helpful to treat depressions with severe anxiety. Remember that the patients didn't present to me because of their delusional beliefs but because they felt anxious, depressed and overwhelmed by their fears which they feel are justified by their beliefs. They didn't want me to argue against their beliefs and if I do, I may become part of the conspiracy to cover up "the truth" that they know is real.

There needs to be a discussion of obsessions as distinct from delusions. Individuals suffering from obsessive compulsive disorder (OCD) don't speak schizophrenageeze. They are aware that their obsessions and compulsive rituals are irrational but feel too much anxiety to stop them. They haven't created elaborate conspiracy theories to justify their irrational behaviors and trying to give meaning to their actions only serves to give rationale to continue them. The person with OCD needs to just resist the compulsions and obsessions and learn to cope with the ensuing anxiety until it passes. The anxiety associated with delusions doesn't pass and logical reasoning often feeds in to paranoid ideation about the person trying to dissuade them. Telling the delusional person that their ideas are "crazy" only makes them distrust you because to them they are real. The feelings behind them are real and only compassionate acceptance of this fact will allow an outsider the ability to present more logical explanations to re-interpret the data upon which the delusions are built. The best that can be expected is to spread doubt on the delusional beliefs. There are no logical explanations for OCD as the individual already is aware that they are irrational.

Thought processing for these two conditions is also different. In psychosis thoughts jump from one loosely connected thought to another like a discordant symphony. Obsessive thinking is more like a broken record skipping in the same groove unable to advance to the next track. The delusions flow too freely sweeping up ideas and events along the way like a funnel cloud only to pile the debris in a totally distant spot. The obsessive never leaves the spot where he started. Jane was a 40 year old married woman whose OCD got out of hand. She began checking the door locks 10 times but this didn't satisfy her needs. It spread to the garage doors, then the car doors, the stove, the faucets and furnace. The rituals ended up taking several hours per day such that she couldn't leave the house. If she had to leave, she instructed her husband to assist in her rituals to try to shorten the time but each instruction led to more time. She knew these were irrational and had no explanation for the need to do them except that it felt bad if she didn't do them. But it also it took more and more time to reach satisfaction. She was given medication to reduce her anxiety and instruction to limit each ritual. Her husband was discouraged from participating and to remind her that performing the rituals only led to worse anxiety. Eventually she reduced her time in ritual to under an hour and was able to participate in activities outside of the home again.

John worked for an IT company and was sent to do repair work on various computer equipment. He noted that some of the repair work was unnecessary and thought the customers were scheming to get new equipment. He began to get concerned that the customers were setting him up and he would be accused of defrauding the company. However, his bosses seemed content with his work and he was providing good customer service. His fears got so great that he began to suspect other coworkers of setting him up so they could take his job. He then wondered if this wasn't a money laundering operation for his company and he was being drawn into an elaborate illegal operation. He got depressed and panicked and came to see me. I began him on antipsychotic medication and his fear began to diminish. I was able to provide alternative interpretations for the events he observed. This included the notion that the company was willing to accept some losses to encourage good customer relations which might lead to more business. His delusions had only been present for a short while so they were not so impervious to re-interpretation. He was able to accept that he might have over interpreted the situation. But residual doubt persisted such that he chose to leave this company and take a different job. My work with him validated his feelings that things were not being managed the way he thought they should be but I was also able to provide reassurance that he would not get blamed for this. This allowed enough time for him to find a more suitable job that didn't compromise his integrity.

Some of my patients often ask me how they can deal with a psychotic family member. I tell them that first they can't argue with them over any delusional ideas. Then provide empathic support for any feelings that might be associated with the delusions. Try not to be sucked into the delusional net by doubting its reality but this doesn't mean you have to go along with it either. Remain neutral and provide sympathy for their plight. While medication may make the individual less prone to add to the delusion going forward they may not accept that they were wrong in the past. Medications may take weeks to months to soften delusions. Leave the past in the past and don't challenge what the patient felt happened. They have no way of knowing what really happened since their perceptions were distorted. You can only talk of the present and that the delusional ideas are not still happening. Have sympathy for the anxiety, fear and humiliation of not knowing what really happen in the psychotic state. Challenging the beliefs and actions may lead to defensive maneuvers and hostility. Provide support for having survived and moved forward despite overwhelming feelings. Remind them of the relief of agitation and anxiety provided by the medications. And that is how one speaks schizophrenageeze.

A Market Forces Approach to Gun Regulation

A market forces approach to gun regulation It took decades of lethal accidents before cars were regulated but now laws affecting vehicles and our concern for securing WMDs can serve as a models for gun control On vehicles there is a two part regulatory process: 1)A series of stepped licenses for vehicles with greater requirements to operate larger more potentially lethal cars, trucks or planes, and 2)Liability insurance requirement to own and operate any vehicle in the US. Insurance companies, through actuarial data, determine the cost of liability insurance based upon risk of each vehicle type, age, experience and past history of operator. Requiring all gun owners not only to be licensed to purchase and own a weapon, but to have liability insurance for each weapon in case of misuse, accident or if the gun is stolen and used in a crime would introduce market forces into the gun debate. This insurance coverage must be high enough to cover the risk of these weapons, i.e. at least one million dollars and be a national standard. Insurers would price high risk individuals out of the market especially for high lethality weaponry in the hands of untested operators. Potential criminals who would be unlikely to obtain coverage could be charged with crimes of lack of licensure and insurance prior to even committing crimes, similar to how use of tax evasion is used to prosecute criminals in organized crime gangs. Individuals who own weapons must be held responsible for securing their weapons. Guns, especially those capable of multiple rounds are weapons of mass destruction. Guns are responsible for over 10 times the number of deaths per year than occurred in the World Trade Center attack. Our government keeps careful track over countries that possess weapons of mass destruction (WMD) and hold nations accountable for their possession. We should make gun owners accountable for possessing and securing their WMDs. All thefts must be reported to police but won't exonerate the owner for liability and multiple thefts would be evidence of irresponsibility in securing of weapons which could result in revoking of licensure and penalties. The weapons in the Newtown massacre were clearly inadequately secured and her estate should be held accountable for this to set a precedent. It is probable that only a select few would qualify for licensure and insurance for the high capacity magazines currently sold requiring current owners to turn in their stockpiles. This would help reduce the number of WMDs that are currently in people's homes and at least cause a consideration of the relative risk of liability and penalties versus perceived need for protection. Unlike state laws governing vehicles, the second amendment implies that these be federal laws consistent with "a well regulated militia" that doesn't prevent the ownership of weapons but makes gun owners accountable to sensible regulations consistent with the lethality of these weapons of mass destruction.

New lower price for Psychiatry in Techno Colors

Happy New Year.  May you new year be filled with health and happiness. 
Take advantage of new lower sale price for paperback edition.
buy Psychiatry in Techno Colors at discounted price.

Next book signing at the Big E, West Springfield in the Connecticut Building

Meet the Author

Psychiatry in Techno Colors: a psychiatrist’s memoir of lessons learned about the diagnosis and treatment of anxiety and depression is a collection of easy to read essays which explain the life of a psychiatrist and the medications available to help those with anxiety and depression. Anyone who knows someone with depression or anxiety can benefit greatly by his lifetime experiences with patients. It is easy to read and once you start reading it, you can't put it down.  The author, Neil Liebowitz, MD is the director of the Connecticut Anxiety & Depression Treatment Center in Farmington, CT and will be signing his book at the Connecticut Building at the Big E on Saturday September 24^th from 4 to 7pm and Tuesday September 27^th  from 7 to 9pm.