pontificatrix's Open Salon Blog

beauty and age

Tue, 28 Sep 2010 13:09:47 -0400

The patient before me is seventy years old. She wears enormous starlet sunglasses and a sleek pageboy wig. Her mouth is pursed, plaintive. As we talk she touches her wig every few minutes and apologizes repeatedly for her appearance, which gives no cause for apology other than that she is seventy, and a woman.

She quickly tells me that she used to be a model. She compliments my appearance. She apologizes again for her own. In the space of a few minutes, the frame of reference for her world becomes obvious.

I see this in women of beauty, and of former beauty, in our society that worships youth but ridicules age and dismisses experience. Accustomed early to the admiring glance and the extended hand, such women become dependent upon these things. Enfolded in admiration, they expect at some level that it will be there for them always. All their manners and concerns are enmeshed in this identity: I am a lovely woman. They adopt the secure and easy laugh, the slow knowing whisk of the eyelashes. For many years, these devices serve so well as to become nature itself: not tools or toys but the woman's very person.

Then when the facade begins to crumble, so too does the human being beneath. What am I now, if not lovely? Who am I?

Some successfully adopt other identities for themselves: wife, mother, grandmother; artist, healer, traveler. Others, like this woman in the sunglasses and wig, do not. She hovers forlornly over the carcass of her own beauty. She seeks at every turn to remind others of her former glory, hoping that they will now accord her just a fraction of that beauty's due. She cannot accept that she and loveliness have come unbound. Have the longing glances really evaporated so? Can she not recall them with a well-timed reminder of what she was?

The woman is labile, irritable, angry. She lashes out easily, then instantly begs forgiveness. At one moment imperious and demanding, the very next she turns and asks for mercy.

Better to praise and placate, or to reason and limit? This patient nurses a deep wound. Though her hurt seems cheap and reasonless, to her it is despair. She will be comforted only if I can conjure up the eager appreciation, the limitless sympathy which she came in some past existence to expect. But to what end such falsehood? Should I better demonstrate to her what she can expect to see from others? Explain that her treatment will be neither better nor worse than that of the fellow next to her? Upset her with the purpose of pushing her to understand?

I choose to soothe with admiration. I ooh and aah at the dog-eared photos of a slim young girl in a high-waisted Fifties bikini. We become friends, the former model and I. I give her what she wants, and she gives me what I do not want: a window into the future, a lesson to be tucked away for now and drawn out when I enter my own old age.

to be or not to be?

Wed, 25 Aug 2010 15:08:02 -0400

The young woman who sat before me seemed childlike in her baggy sweatshirt, her gaze inscrutable beneath long lashes. Her story was a common one, though, like all human stories, unique in its details. In her case: The long-distance relationship. The unexpected visit. The empty box of condoms. And then, the two pink lines. The girl torn, attached already, her emotions wrapping themselves tightly about the thought of that small cluster of cells that slept deeply buried in her body. The boyfriend scared, unready. The girl’s parents disappointed, disapproving, pushing for a swift and discreet end to this shame.

Knowing only the bare outlines of her tale, the thought, “Don’t let them push you around! You can make it!” rattled around in my head. I had been where she was, staring at two wholly unexpected pink lines. I’d reacted with a stream of unprintable words. I’d agonized over a seemingly impossible choice. And ultimately, I’d found myself grateful a thousand times over for having chosen a family.

Patients often have an intense curiosity about their therapists. They want to know if the therapist can truly, truly understand them. They yearn to know that the empathy is coming from a place of knowledge and commiseration, not just imagination and formulaic response. I felt this girl’s despair, along with a powerful urge to reach out by revealing more about myself and my own unplanned and much-loved child.

But such a move would make our session about me, not about her. And the last thing she needed was a counselor who would make her patient’s problems all about herself. She needed to have her own thoughts and values reflected back at her with compassion, maturity, and with some degree of objectivity and distance. I couldn’t help her reach a decision if I imposed on her my own values and desires.

At first I offered mostly a listening ear. She was leaning towards having the child. Her thoughts centered on her fear of having an abortion, and worry that she might regret the abortion in the future. Her friends and parents had emphasized the difficulties of caring for a young child, which paradoxically only made her more determined that she could do it. I reflected these thoughts for her, offering support for her feelings without any judgement or opinion.

After some time, I began to probe gently to uncover her imaginings about the other possible future. What were her plans for raising a child, should she keep it? I was surprised to see that she had given this aspect little thought. One one point she was clear: She was certain she wanted to finish her graduate degree. So then, about the baby. At first she’d thought she could give the child to her mother to raise… but it turned out her mother had refused. She paused. It seemed her thoughts hadn’t moved past that point.

I encouraged her to continue. Well, perhaps she could send the child to day care and continue on in school. All right, and how soon would she be willing to do that? Would she take any time off from school at all? Maybe a few weeks, she thought.

What about support? Would she and her boyfriend marry, or at least move in together? She thought not. He was in school elsewhere and wasn’t any more interested than she in dropping out of his program. Her parents also lived a plane flight away.

And the financial issues, then? She was living on her student loans. Her boyfriend was as deeply in debt as she. Her parents had other children to launch and were not in a position to help her.

She spoke slowly as we worked through these concerns, as if they were entering her thoughts for the first time. It was becoming clear that this young woman was terribly unready for the task she faced. If she chose to have the baby, she would have to do an enormous amount of growing up in an extremely short time. She didn’t realize it, but her life would change radically, in ways that she couldn’t now imagine.

Of course, she would also do a lot of growing up if she chose to terminate. Perhaps she would, as she feared, regret it forever. If it happened that way, it would be something she’d have to live with. Either way, she wouldn’t again be an unencumbered girl.

I didn’t offer my opinion. I did continue to reflect the girl’s own thoughts on both sides of the issue. On the one hand the thought of being scraped hollow and empty of life felt horrific, nauseating, something one might regret in a thousand different ways over the years to come. On the other loomed overwhelming logistical concerns, the total responsibility for a new life when one was only beginning to imagine the direction of one’s own.

She thanked me for having given her a lot to think about. She didn’t reach a decision that day, but I heard from her later that she had decided to terminate. It was a decision to close the door on this baby, in order to give future babies a better shot at life with stable, loving, and present parents. It wasn’t the decision I’d made for myself; but it was a decision I might have made had I been in her shoes, with an unwilling partner and no means of financial support. She and I were not alike, and I was glad I hadn’t pushed my experiences onto her.

I felt some relief knowing that she wouldn’t have to undertake the struggle of raising a child alone, and also some sadness for the process she faced and the repercussions it might have on her relationship and her psyche. I invited her to come back anytime to discuss these or other issues, but I didn’t hear from her again. Perhaps she hadn’t connected with me or hadn’t found our work helpful, or perhaps life just got in the way. Either way I wish her well: success in her career, stability in her love life, and all the babies she wants to have whenever she is ready to have them.

reefer madness

Mon, 9 Aug 2010 14:08:39 -0400

“Doctor, I’m afraid I might have ruined my brain.” Mr D’s wide brown eyes bore a pleading expression. He was a young law student with a cherubic dimple set in his left cheek. He had had no history of psychiatric issues until six months prior to our appointment. Then, one Saturday evening during his winter recess from school, he’d celebrated the end of the semester with friends by smoking an enormous amount of marijuana and attending a 3-D movie.

During the movie, he told me, he had a terrifying experience. “It was as if I’d lost all of my memories. I knew nothing. I was nobody. I was starting over.” During the course of the movie he gradually regained his memories but retained a feeling of foreboding. Ever since that time he had been having episodes of déjà vu in which otherwise innocuous situations would give him the sense that he was about to be catapulted back into the memoryless state he had experienced in the movie.

Simple triggers like buying a cup of coffee at his favorite stand would give him a sudden, horrifying feeling that he had been there before, and that he knew what would happen next: He would be thrown back to the place of no memories. Or, he was having a dream and he would be forced to relive this same sequence in an endless loop, forever. The feeling would last a few minutes, and then dissipate as surely as it had come.

He’d been having experiences like this up to thirty times a day, ever since that night at the movies. They were interfering with his sleep, his work, and his love life. He hadn’t touched marijuana again since that night. Still, they weren’t going away. Finally he decided he needed help. Could I help him? He spread his hands nervously on his lap.

Marijuana use has long been associated with increases in psychotic manifestations. (For many years it was unclear whether marijuana truly tilted the brain towards psychosis, or whether marijuana was simply more appealing to the psychosis-prone brain. Earlier this year, the results of a decades-long study of marijuana use and psychosis in 3800 individuals were released (McGrath et al). They confirmed the results of two other large cohort studies that found the longer people had been using marijuana, the more likely they were to report psychotic symptoms. In addition, this most recent study analyzed sibling pairs and found that the same relationship held true – weakening the argument that some other, unknown genetic or environmental factor might be stacking the deck.)

However, Mr D.’s symptoms weren’t the classical psychotic signs of hallucinated voices or paranoid delusions. The déjà vu reminded me more of neurological oddities such as temporal lobe epilepsy than of any psychiatric syndrome. But this patient had neither a history of epilepsy nor any risk factors for seizure, and the link to marijuana use was too clear to ignore. I decided to offer Mr D. an antipsychotic – the very sort of drug we give to people who insist that the aliens are after them, or the CIA has bugged their hospital rooms, or they are the Messiah.

I made the offer tentatively, worried that the very word ‘antipsychotic’ would set alarm bells ringing in Mr D’s formerly entirely sane and rational young head. I more than halfway expected him to refuse it. But to my surprise he accepted it eagerly. “I’ve been living with this for six months,” he explained. “I just need it to stop.”

And stop it did. Two hours after his first dose, Mr D reported to me the next week, he could feel the grip of his illusions relaxing. Within a few days he went from having thirty episodes per day to having fewer than ten. After two weeks on the drug he felt he was his old self. He discontinued the medication without incident.

There is much we do not know about the neurobiological effects of marijuana. The psychoactive ingredients, cannabinoids, come in dozens of varieties whose relative proportions vary from plant to plant, presenting a complexity of Gordian proportions to the would-be researcher.

Our bodies’ cannabinoid receptors (built to respond to our own endogenous cannabinoids but, happily for college students the world over, also responsive to the herbaceous variety) are found generously distributed throughout the brain (Glass et al.), including the frontal cortical areas that are implicated in psychosis. They seem to act as local modulators, damping the strength of signals coursing through the brain’s circuits – including the frontal dopamine circuits in which hyperactivity seems to underlie psychotic episodes. Tire out the endocannabinoid ‘braking system’ by flooding it with ganja, and you have an unchecked river of dopamine signaling leading to hallucinations and paranoia (Fernandez-Espejo et al.).

Why should this cause psychosis long after the marijuana is gone from the system? I don’t know the answer, but I do know that for Mr D., the way to fix it was to use a dopamine-blocking antipsychotic. He’s doing well so far, though perhaps a bit wiser and warier.

designer brains for all!

Mon, 19 Jul 2010 19:07:12 -0400

So let me say up front that this is a Rant, one inspired by the fifth young go-getter this week to walk across my threshold demanding I diagnose him with AD(H)D and prescribe him Adderall to get him through his dissertation/term paper/research proposal/whatever.

In my (not so) humble opinion, AD(H)D is not so much a disease (in the sense of a physiologic malfunction) as an unfortunate interaction of personality x environment. Certain personality types just don’t do well with being required to sit in a chair for 8 hours a day. A lot of those same people would probably do phenomenally well at running around outside spearing buffalo (Kuo and Taylor, ), but sadly for them, that’s not the environment in which they find themselves.

So, we have medication that can alter these people’s brains so they conform more acceptably to the society where they do find themselves. We could have another very long and involved discussion about whether that’s a good choice or not but my feeling is, if a pill is the difference between good function and borderline or poor function, then please, weigh the pros and cons and make your own decision. It’s your brain. Not my business to dictate whether you ‘need’ it or not.

What I really don’t like is the cultural apparatus that is telling us the suboptimally attentive have a Disease, because the only legitimate reason to take a drug is if you have a Disease, and therefore that these people who take stimulants so they can function more effectively at work or school must have a Disease, because that is the only socially acceptable way that they can take their medication.

And what I really, really don’t like is that as a physician I am being put in the middle of this. I am being told that the only way these people can have their medication is if I diagnose them with a Disease and prescribe them the medication to Treat it. There’s no box to check that says “This could help you do better than you are doing now, and I don’t mind if you take it, so long as you understand the risks and benefits.” There’s only the Disease box and the No-Disease box. And I can’t give out the drug unless I check the right box.

The thing about treating this Disease with stimulants is that, in the right dosage and formulation, they are going to be performance enhancers for most people. How many thousands of students and professional writers have used a jot of speed to get them through that important deadline? I’m currently working in our university’s student health center, where I see a lot of people who are coming to me for stimulants so they can make their already excellent function even better. I honestly do not mind if people want to take brain-altering chemicals to help them write their papers – I’m swigging a bolt of caffeine as I write this post – but I do get a squicky feeling when I’m asked to write a doctor’s note about their ‘disease’ and a prescription so that they can ‘treat’ it.

So in my perfect world there would be public recognition of the wide latitude of uses for psychotropic medications, the terribly broad and nonspecific symptom clusters that constitute what we refer to as psychiatric disease, and the many reasons why people might want to take a drug that improves their ability to get their work done (see some interesting viewpoints on this issue from Nature and the Guardian) - even if their current abilities are well within the broad range of normal. Will the public accept the availability of a smorgasbord of designer psychotropics for your business and recreational neuroenhancement needs? Maybe, maybe not. But please, let’s stop putting doctors in the middle by maintaining the fiction of a ‘disease’ for which stimulants are the ‘cure.’

family matters

Sat, 3 Jul 2010 21:07:36 -0400

Mrs U first came to my attention some time after the birth of her first child. She was a stately woman, dark and slender, dressed always in brightly colored robes. Her husband brought her to see us because she had stopped speaking. Ever shy, he reported that she'd become gradually more and more taciturn, and at the time of our first meeting she hadn't said a word in several weeks.

At first we were uncertain of the cause. Was she so depressed that she had withdrawn entirely? Did she perhaps have a medical issue, such as insufficient thyroid activity or a vitamin deficiency? Mrs U's thyroid levels, as well as the rest of the blood tests we ran, were entirely normal. We started her on a small amount of an antidepressant, and soon added an antianxiety agent. She started speaking again, though she still had periods of mutism, often when she was stressed or upset.

Around this time, Mrs U and her family took a trip home to Africa, to visit her large and close birth family. They spent several months there. When they returned, Mrs U was a different woman. She smiled pleasantly, laughed at her recollections of her trip, planned eagerly for some classes she intended to take. She remained somewhat shy but the episodes of speechlessness had vanished.
"I could see her getting better by the hour on the plane trip over," Mr U told us. "It was amazing, Doctor. In the airport on this side she seemed anxious, terrified, looking here and there, speaking little. As the hours on the plane passed she began to smile a little. By the time we reached her childhood home she was almost entirely herself again, so that even her own mother could barely notice anything amiss!"

We smiled and nodded, happy to see Mrs U doing so well. She weaned, uneventfully, off her antianxiety medication, though she continued to take the antidepressant. Things remained this way for several months. Then, slowly, she began to deteriorate again.

Her eye contact was the first sign. Though always retiring of manner, when well she met my eyes in conversation, with an occasional frank and open smile. As time passed, though, her eyes began to slide past me even as she answered my questions. They would be fixed on the floor, or out the open window. She maintained our conversation appropriately. Nonetheless she seemed to be elsewhere. I filed that under 'to be kept track of' in my mental cabinet.

Soon after that I began to receive concerned calls from Mrs U's husband. She had begun to say strange things. One day she was convinced that she should leave her husband for a stranger she had seen on the street. Another day she became obsessed with a cartoon she had seen on the television, referring to it over and over. She was unable to keep up with her classes and had to drop them. However, she
always said her mood was fine. She didn't seem anxious or sad in the least, only... strange; and increasingly so. She continued to care for her son ably and with great patience, according to her own word and to her husband's observations. Our original diagnoses of depression and anxiety seemed less and less satisfying.

Ultimately things came to a head when Mrs U began to have frank hallucinations, horrible ones of vermin in her mouth and people under the stairs. That sealed her diagnosis as a psychosis of some form. We started her on an antipsychotic and slowly, things started to improve.

After a couple of weeks of treatment the floodgates opened. Though she'd never before put more than ten words together in my presence, she was fluently talkative. She revealed that she'd been having horrific religiously themed nightmares for a year. Voices of people in her house. A chip implanted in her head. CIA cameras hidden all around her. All very, very classic psychotic symptoms.

I felt silly that I hadn't recognized this before. Mrs A, in her early twenties, was the right age for a first psychotic break. It's very common for schizophrenic patients in the throes of their illness to withdraw completely from the world, unable to give voice to the phantasmagoria in their heads. Easy to recognize after the fact; but since social withdrawal can also reflect depression, anxiety, and other common woes, things are not always clear in the moment.

She did reasonably well on her antipsychotic, though she was still somewhat odd. She would laugh at inappropriate moments and stare vacantly through the window when you talked to her. Her husband was frustrated with our inability to return his wife to her old self. We were frustrated with it as well.

Shortly after starting the antipsychotic, Mrs U took another long trip to her home country. Once again, her symptoms improved. Although she was not able to wean off her medication, she appeared to recover a good deal of her old personality. She was able to interact normally with her family and friends and handled her domestic duties without difficulty. Ultimately her husband decided that his family was best served by staying in their home country. As of this writing Mrs U remains well.

Mental health and mental disease are defined largely by functional capacity. If a person can live, love, and work, we consider him well. But the level of function required for love and work may differ radically from society to society. The 'basic capacities' required to live among secure and supportive extended family, and perhaps do some simple labor under supervision as necessary, are quite different from the 'basic capacities' required to live alone, maintain employment, and manage personal finances complete with lines of credit and other pitfalls.

Schizophrenic patients exist at all levels of functioning, ranging from those who require ongoing institutionalization to extremely high-functioning and high-achieving individuals. The differences among them may be partly due to severity of disease and to innate psychological reserve, but are also strongly dependent on the environment surrounding each.

Over the past six decades, the increasing availability of medication for psychiatric illness, along with factors such as social change and cost concerns, have led to the deinstitutionalization of the mentally ill. In the US, where strong and supportive extended families are not the rule, this has often led to the need for a sort of wraparound care, where a cadre of social workers and psychiatrists helps to guide each patient through the complexities of daily life. In the crudest sense they are functioning as a paid family - much as we in the US have outsourced other former family domains such as child care and elder care. This outsourced domestic work then counts as part of the GDP, and to the economic might of the nation. What isn't clear to me is whether - acknowledging such clear improvements as the reduction in social stigma that attaches to mental illness - such a solution is a gain overall for the mentally ill themselves.