From our anonymous insider…
Psych week. Based upon my M3 mentor, I am using the DSM-5, also known as the “Holy Bible for Psych” and the First-Aid psychiatry chapter to study. Straight-Shooter Sally: “I’m surprised we have only one week of psychiatry. Mental health has become a prominent national issue.” Lanky Luke: “Doesn’t surprise me. Step 1 doesn’t give much weight to psych.”
A quirky spaced-out 60-year-old psychiatrist introduces basic psych terminology and substance abuse disorders. He joked about the number of psych drugs. “There is a website that tests you on if a name is a drug or a Pokémon. Our former residency director is proud of getting 60 percent. Get ready ladies and gentleman for psych week!” The psychiatrist emphasized the diagnostic criteria for psychosis: presence of a delusion, hallucination, or disorganized thought. A delusion is a fixed, false belief. He gave several examples: “I’ve had patients who think they have Michael Jackson’s baby or are the president. Somewhat more common is a referential delusion. While they drive, they believe a billboard is speaking about them, or a TV is speaking to them directly.” Lanky Luke: “Is #NotMyPresident considered a psychosis?”
He began the substance-use disorder lecture by playing a BBC video of vervet monkeys getting drunk off stolen liquor from unsuspecting tourists on the beach in St. Kitts. “Among adults, 8.5 percent qualify as alcohol dependent or abusers. Think about that when you drive home tonight.” He continued: “Why do we have 10 percent of our human population with [genetic] phenotypes that make them susceptible for this dependence?” Students responded: “Alcohol is important in certain cultures to build social interactions”. Another student added, “Mating ritual.” The psychiatrist added, “I do not think I would have met my wife without alcohol. I have terrible social anxiety meeting new people. Alcohol certainly helps!”
“What about heroin? Did the poppy seed hijack the reward pathway to disseminate its euphoric seeds around the world or was it coincidental? Cocaine, amphetamines, heroin, fentanyl, and coca leaves all activate the dopamine reward system. The Incas built an empire on drugs. Mail carriers chewed on coca leaves for more energy while traveling across the 1000-mile empire. Why did they not knock down and steal coca from ancient 7-11s?” Students responded: “They did not make coca illegal”; “It was not purified”; “It was chewed through saliva.” He continued, “Right. Cocaine was purified in the 1880s. Sigmund Freud still has the best pharmacodynamics measurements for cocaine. When I was in medical school, they tried to replicate his experiments. They asked four volunteers to do cocaine and monitor blood levels for $500. Ninety-six people volunteered, but unfortunately I was not selected.”
He digressed on the history of drug use in America. “In 1970s cocaine was $100 for a gram… so about $50 to get high. Then we developed crack in the early 1980s and a rock was about $5. This spread like wildfire among the urban poor. With good intentions we tried to stamp down on it, but the result was mass incarceration. It’s tough to get a job after incarceration, so these former inmates are on disability with psych issues now.”
[Editor: Who has better mental health, the person who goes to school for 28 years and takes on $500,000 in debt in hopes of getting a job as a doctor, or the person who gets monthly SSDI checks without working?]
He continued, “We are seeing a similar transformation in opioids. You need poppies to make heroin so it gets expensive when the supply is reduced at the poppy farms. Fentanyl is completely synthetic; you can make it in your basement if you have basic understanding of chemistry for a lot cheaper. People are dying now from fentanyl, not heroin.”
He continued: “When you come to my floor your job is to understand the mindset of an addict. Most of you guys plan about five years in advance. You imagine a family, a house with a picket fence. A heroin addict can plan only a week in advance. Someone on methamphetamine plans nine hours ahead. Good luck getting a meth addict to come for a follow-up appointment in two days.”
He concluded, “We see that addiction spreads in culturally demoralized communities. I worked for two years on an Indian reservation, part of my penance for being an aging white male and therefore partly responsible for the introduction of alcohol in North America. What you quickly realize is the Navajo community has relatively low alcoholism compared to the Sioux because of their economic and cultural cohesion. With the decline of the coal industry, you see the same pattern in Appalachia versus the rest of the U.S.”
[Editor: Appalachian coal shipments to China are up in 2017 and 2018, but Americans still love their opioids just as much!]
Straight-Shooter Sally: “I wish we had a Drug Use 101 lecture. Terminology, ways to use it, cost, demographics, etc.. This was close, but no cigar.”
A tall 45-year-old child psychiatrist with a slight Eastern European accent briefly introduced Conduct Disorder. This is essentially the same as “sociopath” (also known as antisocial personality disorder), but the profession refuses to apply that label to anyone under 18. She spent the rest of the 100-minute lecture on attention-deficit hyperactivity disorder: “ADHD is a developmental disorder of inattention and impulsivity. They have task-irrelevant motor/verbal behaviors and delays in motor inhibition. A common observation from teachers is that the child will get derailed by any disturbance outside of the classroom, such as a squirrel climbing a tree or a cell phone ringing. Most kids will notice and get distracted, but they refocus on the task at hand.” If teachers can pick the ADHD kids out of the class, what is the role of the psychiatrist? “My job is to look beyond the obvious. There are a lot of disorders that have attention deficits. Individuals with ADHD frequently have other development delays such as language and social interactions. Classic case is a patient with ADHD and oppositional defiant disorder [ODD, cognitively inflexible child that deliberately annoys others and cannot think of compromise out of dilemma].” Persevering Pete whispered, “ODD sounds like a fancy way to call a kid a brat.”
She showed a slide with CDC data: 11 percent of school-age children and 20 percent of high school age boys have been diagnosed with ADHD. This is a 16-percent increase since 2007, and a 41-percent rise in the past decade.
She briefly described an emerging theory about ADHD. “ADHD patients whose mother smoked have a tuned-down dopamine reward system. They are hardwired to search for new things because the world around them is not interesting to them. These were the explorers of new worlds in the era of cavemen. When we force the child with ADHD to listen to boring lectures all day, they find it impossible to focus. However, when they find a passion, they can focus without difficulty. Stimulants such as Adderall [amphetamines] and Ritalin increase dopamine signaling causing them to be more interested in the dull activities.”
[Editor: Are there vats of Adderall and Ritalin sufficiently large to get Americans interested in computer programming? And maybe we all need Adderall and Ritalin during tax filing season.]
Once a patient has begun stimulant treatment for ADHD, they have regular check ups to assess attention, sleep, appetite, headaches, and mood changes. “We do drug holidays every two years. This usually happens when the child is learning to drive. When you ask children how they are doing, they will always say okay. Ask their parents how they are driving. People with ADHD [off the meds] have a much higher rate of car accidents.”
Pinterest Penelope asked why the United States treats way more ADHD than any other country. “I’ll try not to be too blunt. It’s several reasons. First, I think we have a greater demand for attention than we used to. I have parents and young adults come to me saying they need to pay attention for 16 hours per day [e.g., school plus music lessons then homework or a college student with an evening job]. It’s just not going to happen. Attention is a finite resource. Second, we do not train our children to delay any sort of gratification. The French use very strict schedules. Eat at this time with no snacks between. Third, other cultures are less willing to call this a disorder. The willingness of parents to give medications to young children astounds me.”
( “The worldwide prevalence of ADHD: is it an American condition?” (Faraone, et al. 2003; World Psychiatry) concluded that ADHD symptoms are actually just as common among children in other countries, though diagnoses may differ.)
My small group waited 10 minutes for IT to come deal with our projection difficulties. Type-A Anita used the downtime to ask if we watched the State of the Union speech, which she characterized as “disgusting.” Adrenaline Andrew, an aspiring EM physician whose family immigrated from Kurdistan: “I thought Trump was hypocritical. He was touting all these immigrants that he brought in, but he wants to keep them all out.” Straight-Shooter Sally commented on the Arizona policeman and wife who adopted a child from a heroin-addicted mother. “Oh my God! You do not know if that baby will be f***ked up. I could never do that.” Jane had watched some highlights on Facebook: “It was mostly a celebration of America, just a lot of patting ourselves on the back. I am not quite sure why we are celebrating so much.”
We changed the subject when Fashionable Fiona walked in late, waving a beautiful diamond ring, to announce her engagement to an MBA two years her senior. We all congratulated her. Type-A Anita announced, “I have to be the primary breadwinner before I get married.”
[Editor: Congratulating Fiona would have been considered a terrible faux pas in the 1950s; one congratulates the groom, not the bride, so as to avoid the implication that the woman was desperate to find a man. Separately, given that physicians have much longer careers than MBAs, let’s hope that she reads Real World Divorce and settles in a state that won’t offer her spouse the opportunity to tap her for a lifetime of alimony!]
Our small group facilitator is a brilliant personable EM physician married to a head and neck surgeon. She has been out of clinical practice for three years while taking care of two young children. “Don’t do the double doctor thing. It ends with one supporting the other.” She has to recertify her boards two years from now, and enjoys facilitating to prepare for her studying. “It is amazing how much more you guys have to know. All these genes, drugs.”
She recounted her medical school quest to get right-to-privacy rules altered in the state of New York. “When I was in residency in New York, we were not allowed to get a HIV or hepatitis test on a patient to see if we were exposed by a needle stick. We would have to weigh the risk of the patient to decide if we should go on these serious antiviral drugs. Imagine being on those drugs while doing residency. Fatigue. It was crazy. California and New York had these crazy antiquated laws. We lobbied [successfully] to get that changed. If you were exposed you could require a patient to get blood drawn to test for virus.”
Thursday morning, our last lecturer for the week is a 65-year-old psychiatrist who became blind after medical school. “Most specialites have diagnostic imaging and tests. Psychiatry doesn’t, with the exception of some new expensive functional imaging. Think of psych disorders like trying to treat heart or kidney disorders 100 years ago. We barely understand them. We are in the Caveman age of psych drugs. We are just beginning to tap into the mechanisms of the brain disorders.”
He described anxiety disorders: “The frontal cortex and amygdala are at war with each other. The amygdala is the old part of
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