Friday, June 25, 2010

Language in the Clinician's Office

This week I return to my favorite theme -- the power of language.  Those of us who have a mental illness deal with the power of language every day.  Notice I didn't call us the mentally ill.  Language forms who we are in this world.  It underpins the terms of our treatment.  It structures how we pay for our treatment.  Diagnosis is where language meets money.  And money is power, power over our lives.

Reframing is a process of becoming conscious of the power of language.  This is a standard tool in Cognitive Behavioral Therapy.  The term is used in a variant of CBT called Neuro-Linguistic Reprogramming (NLP).


When you reframe, you look at an event and the way you describe the event in a different way to discover a different meaning.  My thesis is that language itself is an event.  When you speak a word, you assign a meaning.  You create a reality.

I know a mental health professional who calls the DSM The Book of Behaviors That Make Therapists Nervous.  That is an example of reframing.  It invites one to turn the process of diagnosis on its head.  Instead of asking what is wrong with the diagnosee, what would happen if we ask what is going on inside the diagnoser?

This mental health professional also said that the personality disorder section of the DSM is useful as an examination of conscience. -- For those of you who don't speak Catholic, examination of conscience is when you compare your thoughts and behaviors to your values and beliefs, in order to find, repent and address the discrepancies.  One often uses some sort of list, such as the Ten Commandments, to assist bringing these thoughts and behaviors to mind.

So when you examine your conscience while reading the symptoms of personality disorders, you reframe the diagnostic categories, as behaviors to be repented and resisted.  In this case I suspect the dart hits the diagnosee again.  But it was intended to refer to everybody.  Try it some time.  Actually, I think the DSM's whole personality disorder section is about what the diagnoser dislikes about the diagnoseeSymptoms of various personality disorders sure sound like character defects to me: impulsive, aggressive, clinging...

A Prozac Monologues reader brought my attention to the work of Mayer Shevin, who has a PhD. in Psycholinguistics -- my kinda major, doncha think?  The following is a compulation of lists he uses in inclusion training.  Those of us who have a mental illness have heard these phrases before, from our families, friends, mental health professionals.  I recognize some of these.  What about you?

The Differences Are Obvious -- 
                    The Art of the Convenient Reframe

You like things --
          I obsess on objects.

You try to make friends --
          I display attention seeking behavior.

You take breaks.
          I display off task behavior.

You stand up for yourself --
          I am non-compliant.

You have hobbies --
          I self stim.

You choose your friends wisely --
          I display poor peer socialization.

You persevere --
          I perseverate.

You like people --
          I develop dependencies.

You go for a walk --
          I run away.

You insist --
          I tantrum.

You need time to yourself --
          I am being anti-social.

You move on to better things --
          I run away from problems.

You change your mind --
          I am disoriented and have a short attention span.

You dislike being mistreated or disrespected --
          I am overly sensitive or paranoid.

You ask people for help --
          I use people as a crutch.

You are human --
          I am ???

by Mayer Shevin, Syracruse University.
His profile is found here.
from Autism Voices and Choices Yahoo! Group.

Time for some reframing?

Photo by Ed Yourdon, available through the Creative Commons.
I have cropped the original to make my point.
The photographer has a lot to say about the photo
and what it meant to him to take it.  Read the story here.

Thursday, June 17, 2010

Summer Reading Picks from Prozac Monologues

Last winter I did the blog piece on movies for surviving the family holiday scene.  With or without family issues, here come my picks for summer reading.  This is an all purpose list, for normals and the mentally interesting alike, and just for fun.   Books to take to the beach -- or the backyard, should the beach be out of reach.

The following is my opinion.  Strongly-held, but my opinion.  Feel free to have your own.  That's what comments are for.

I asked friends for their input in two categories: lovable loonies and alternate worlds -- fiction, unless they could make a very compelling case otherwise.  Now I have a new reading list, too.

We begin with lovable loonies.  My all-time number one favorite book, perfect for beach, book club, hospital bed, you name it, is Lamb: The Gospel According to Biff, Christ's Childhood Pal by Christopher MooreYou know, there were other gospels that didn't make the original cut.  I don't think this one would have, either.  Nevertheless, it had me at this sentence: The first time I saw the man who would save the world, he was sitting near the central well in Nazareth with a lizard hanging out of his mouth.  It seems Joshua (Jesus) was entertaining his little brother, who kept smashing the lizard's head with a rock, whereupon the savior of the world would put it in his mouth, bring it back to life, and hand it back to his little brother.  Practice for later.  This gospel fills in the missing years of Jesus' life and explains the invention of cappuccino, judo and grace.  A loonier evangelist you could not find.  So that's number one.

Another Christopher Moore pick, though out of season, is The Stupidest Angel: A Heartwarming Tale of Christmas Terror.  It reintroduces a character from Lamb.  And boy, is he stupid.  The lovable loony is the sheriff's wife, a former actress who played a Xena-type warrior and never quite got out of character.  In a sub-plot and nod to O'Henry, she quits her meds to save up for her husband's Christmas present, while the sheriff plants an acre of pot.

Actually, the whole purpose of this blog piece is to get more people to read my second favorite book, Lucky Dog by Mark Barrowcliffe -- a talking dog named Reg who helps a helpless loser win at poker -- the helpless loser being the only one who can understand what Reg is saying, of course.  After first meeting him, Dave goes on meds.  So Reg gives Dave the silent treatment, because his feelings are hurt .  Notice the running theme, meds.  This is a Prozac Monologues list.  Eventually Dave misses Reg's conversation, quits his meds and figures out that Reg gives him an advantage at the gaming table.  It's all about smell.  You've got the mob, a rich old lady, a love interest, the world from a dog's point of smell and redemptionWhat more could you want for summer reading?

A friend reminded me of Kurt Vonnegut -- whom I already started rereading a few months ago.  Vonnegut makes reference to his lovable loony, Eliot Rosewater in a couple of books.  Rosewater gets his own book in God Bless You, Mr. RosewaterMaybe he has a touch of psychosis (but only some of the time.)  Maybe he is a hopeless idealist.  Maybe he just needs to say no.  But he is indeed lovable and a volunteer fireman.  Bonus loony: Kilgore Trout.

Also in the lovable loony category is The Hitchhiker's Guide to the Universe by Douglas Adams.  Couldn't we all use a book with Don't Panic on the cover?  Hitchhiker's Guide is the first of a triology with five books.  I think the second volume, The Restaurant at the End of the Universe is where I learned that every planet in the universe has a drink called gin and tonic.  You make it differently on every planet.  But there you are.  You can get the perfect beverage to accompany your summer reading, assuming the ingredients don't mess with your meds, on any planet in the universe.

I haven't read The Eyre Affair by Jasper Fforde.  Yes, I spelled his name correctly.  Another friend, a bookophile who knows loony recommends it.  It is the first of Fforde's loony alternate reality series, starring Special Operative Thursday Next, a literary detective who is chasing down the evil Acheron Hades who has stolen... It's a Lost in Austen/Inkheart kind of alternate reality, blurring the boundaries between the world of normals and the many worlds of books.

Hitchhiker's Guide and The Eyre Affair are my segue into alternate worlds.  I was heartbroken when we got to the end of the Harry Potter series by J.K. Rowling and lost that annual Hogwarts fix with its witches and wizards, port keys, Marauder's Map and all the rest.  According to a Face Book quiz, if I were a Hogwarts teacher, I would be Remus Lupin.  I may reread all seven books in preparation for the last two movies.  And I am delighted that seven books became eight movies.

Another friend fave and mine, too, is The Wrinkle in Time series by Madeline L'Engle.  These are cross-over youth/adult sci-fi, but you don't have to be a sci-fi fan to appreciate them.  One summer vacation/road trip, my six-year-old listened to Wrinkle on tape.  Every time we stopped for lunch, he wanted to discuss it.  Every time he got to the end, he started again at the beginning, and I was happy to listen with him.  I wonder if this was the root of his vocation as a philosopher.  The misfits are the heroes who save the planet from IT, the force that wants to eliminate unhappiness by eliminating deviance in the universe.  (I suspect that IT really just wants to get rid of deviance.  The unhappiness thing is just part of the sales pitch.)  In the first volume Meg figures out, same and equal are NOT the same thing.  Bonus: it turns out that It was a dark and stormy night is a great way to start a book, after all.

Michael Chabon rewrites history in The Yiddish Policemen's Union.  Imagine that at the end of World War II, Jewish people went to Alaska instead of Israel.  Fifty years later, Alaska is about to revert to the United States.  Enter your basic hapless detective.  Combine a murder mystery, political intrigue, orthodox Jewish mobsters, chess and a red calf.  Shake vigorously.  Serve on the rocks.

Chabon provides another alternate world in a tale of two Jewish adventurerers, Gentlemen of the Road.  Set in 10th century Khazaria, two con men/bodyguards/swashbucklers star in a dime store novel with elegant prose, inadvertently fighting for justice and the rightful heir to the Khazarian throne.

Not all alternate worlds are fantastical.  Like Gentlemen of the Road, books set in real times and places can sweep you up so that you leave your own world and enter the author's.  The day my mother left her third husband, the good stepfather, separating hers and theirs from his, I postponed going crazy by moving to China via Pearl Buck's The Good EarthNever mind the 1931 copyright.  It won a Pulitzer Prize, and seventy years later, Oprah made it a Book Club pick.

Lately I have been living in nineteenth century England.  Jane Austen's biggest hit is Pride and Prejudice.  I haven't tried the graphic novel nor the sequels it inspired, including one with zombies.  You're on your own there.  Currently I am doing the Bronte sisters.  Emily Bronte wrote Wuthering Heights.  That link takes to you the edition that is easy to read in bed -- whatever that means.  Jane Eyre by Charlotte Bronte has inspired the same kind of take-offs as Pride and Prejudice.  All of them have been made into multiple movies and mini-series, if you want to extend your reading experience into other media.

Rounding out our alternate world category, Ellis Peters takes us to a Benedictine monastery in twelfth century England, in the midst of a civil war.  Cadfael is a second career monk, a crusader turned herbalist and forensic scientist detective. The series starts with A Morbid Taste for Bones and goes on for nineteen more volumes -- God bless Ellis Peters.  This series has also been filmed, with Derek Jacobi as Cadfael.

Douglas Adams and Hebrew poetry have both inspired me through the years.  I told you I had two categories.  So here is a third -- compelling nonfiction.  These two are on my own to read list:

The first is friend-recommended The Spirit Catches You and You Fall Down by Anne Fadiman. It is a tragic story of the clash between two cultures, that of the Hmong and that of Western medicine. The parents say Baby Lia Lee's soul is outside her body, captured by an evil spirit.  She needs a shaman.  The doctors say she has epilepsy.  She needs medication.  The doctors win.  The results are not good.  I haven't been reading biographies of people who live with mental illness lately.  But I might make an exception for this one.

The second and last is Invictus: Nelson Mandela and The Game That Made a Nation by John Carlin.  This edition has pictures from the movie.  The original edition is titled Playing the Enemy: Nelson Mandela and the Game That Made a Nation.  Combine the typical sports narrative structure: loser team triumphs, with that incredible, grace-filled moment in human history: oppressed people triumph and don't wreck vengeance on the oppressors.

So there are more than enough books to fill out my local library's summer reading club requirements.

What are you reading this summer?  Enjoy.

photo by Molku, who placed it in the public domain

Friday, June 11, 2010

Welcome Amazon to Prozac Monologues


This week continues the evolution of Prozac Monologues as your resource for reflections and research on the mind, the brain, depression and society.  Evolution -- platypus -- get it?  Okay, have you ever tried to find public domain images that illustrate the concept of evolution?  Besides, I do think these guys are kinda cute.  Is it platypuses or platypi?  The spell check says platypuses.  But the spell check can be idiosyncratic at times.  Anyway, after the last few weeks, I need to lighten up.

In anticipation of next week's post on my summer reading picks, I have added amazon.com widgets to the page.  I already send you to amazon.com regularly by links within my posts.  The widgets allow you to search for related books and other stuff directly from this site. 

So on the left, below Resources, are my recommendations.  I have read them and found them helpful, inspiring, life-saving, whatever.  The tag lines are mine.  On the right, under Labels -- the tag cloud, are Amazon's recommendations, based on what I told them about the blog.  I have not necessarily read them.  So you are on your own.  And for now, to inaugurate the feature, there is a simple Amazon search engine in the top left hand corner.  You can use it to look up your own titles, authors, products.  This widget might find another home at a later date, though I don't think I will send out change of address card at the time.

Another previously existing widget, a list called A Good Read is now on the right under the blog archive and an ad.  These books are also on my I recommend list for the most part.  But the links here take you to blog posts about the titles.

Maybe sometime I will add another widget for the music I put on the site.

This is what amazon.com wants me to tell you: Willa Goodfellow is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com. 

Just so you know.  With my other attempt to "monetize" the site, the contract says I can't tell you about it.  This silence has been so successful that I have earned $1.14 since initiating the contract, not enough for them actually to cut me a check.  In any case, I am not expecting the revenue to disqualify me from disability payments, should I ever get disability payments.  I simply seek to serve...

Next week: summer reading picks.

sketch by John Gould in the public domain.

Friday, June 4, 2010

PTSD: Prevention -- Sort Of


Readers will know that I am firmly in the camp that calls for  the "trauma" in Post-Traumatic Stress Disorder to include more than war and rape.  Nevertheless, as I write this third in my PTSD series on Memorial Day weekend, I write with love, honor and respect for my parishioners, friends and family members who have served this nation in combat.  As it happens, all of my people have come home.  But none of them ever really.

Now know this.  It frames the whole conversation about research into prevention of Post Traumatic Stress Syndrome.  All the efforts currently being studied and tried for prevention are about preventing PTSD in those who have already experienced trauma.  (That's called "secondary prevention.")  They are not about preventing the trauma in the first place.  Read it again and remember that point.  I shall return to it.

[If you want to skip the research, you can scroll down from here to the **** where I take up my conclusions.] 

A number of medications are being tried post-trauma (the "morning-after" pill) to interrupt stress mechanisms and to impede the particular memory consolidation that leads to PTSD.  If memories of the trauma, including sights, sounds, smells, sensations are not associated with the conditioned fear response, then triggers will not elicit symptoms and PTSD will be prevented.

One strategy is to damp down the activity of the adrenal gland.  Propranolol is a prime candidate for this use.  It is used now to treat hypertension and anxiety disorders, because it reduces the fight or flight mechanism, the release of catecholamine from the adrenal gland and speeding up of the heart rate, among other things.  Propranolol interferes with the memory of emotional events, because the mental image is not "consolidated" with the bodily experience of adrenaline.

Studies of propranolol have been conducted on trauma victims.  Usually it is administered in the emergency room, within a few hours of the trauma, and then continuing over the course of several days.  The results are mixed.  In some studies, those who received the medication experience fewer PTSD symptoms one or two months later.  A NIMH study in 2007 did not replicate these results.

Another approach is to address the damage done farther downstream, by changing the balance of neurotransmitters.  Neurotransmitters sit in the space between brain cells (called synapse) and help messages move along from one to the other.  Serotonin (of Prozac fame) carries the messages and is the best known by the general public, but there are several others, as well.

Glutamate is a neurotransmitter that speeds up the action between brain cells.  There is a lot of glutamate in the hippocampus, where it helps develop long-term memory.  GABA slows down the passage of messages, which gives it a tranquilizing effect on glutamate.

The balance of these two affects the health of neurons.  Persons with PTSD have more glutamate and less GABA on board than those without PTSD.  The Defense Department is currently funding a study to discover whether an intervention to redress the balance might make communication between brain cells less efficient -- again, interfering with the consolidation of long term memory.

Another option is an earlier and more aggressive use of serotonin.  Serotonin supports brain-derived neurotrophic factor (BDNF).  So it indirectly helps the brain repair itself, reversing shrinkage in the hippocampus.

The neurotransmitter Neuropeptide Y (NPY) inhibits the release of stress hormones norepinephrine and corticotropin releasing factor.  There is some evidence that enhancing the production of NPY might reduce the problems caused by stress overload.  But there are no such medications available yet.

Then there are the opiates, such as morphine.  It would be unethical to conduct the typical research using morphine, i.e., giving the medication to one group and placebo to another.  This January, the New England Journal of Medicine reported an "observational study" of morphine use in the battlefield.  The medical records of 696 injured military personnel were examined after treatment.  Those with moderate or severe traumatic brain injuries were excluded from the study, because severe brain damage protects against PTSD.  How's that for irony.

The study concluded that morphine does provide some protection against PTSD.  Among the patients in whom PTSD developed, 61% received morphine; among those in whom PTSD did not develop, 76% received morphine.  The odds of this difference occurring by coincidence are less than one in a thousand (odds ratio, 0.47; P<0.001 in statistics-speak.)  Severity or mechanism of injury, age and amputation -- none of these factors made a significant difference in the findings.

It is speculated that morphine has this protective effect because severe pain increases the trauma of the injury, and hence of the memory.  I wonder if it might prove more effective in nonmilitary use, among those whose brains are not being primed for PTSD every single day.

Okay, the limitation of any of these medications is that they are directed at single event traumas, rape, injury, one time devastating experience.  The brains of soldiers and abused children are injured and prepared for PTSD daily.  What are we going to do, sprinkle propanolol into the cornflakes of everybody deployed in a battle zone, make it part of school lunches?

There are also more creative, nonpharmocological approaches being explored.  Louisiana State University Health Sciences Center is going to study hyperbaric oxygen treatment for those with traumatic brain injuries. TBI has been called the signature wound of the wars in Iraq and Afghanistan. A RAND Corporation study released in April estimates that about 320,000 service members may have experienced a traumatic brain injury during deployment. 

In hyperbaric oxygen treatment, burn and carbon monoxide victims are placed in a pressure chamber to increase oxygen in the blood stream, and hence in the brain.  Think of deep breathing to relieve your anxiety attacks.  LSUHSC will compare TBI victims who receive or don't receive this treatment, in hopes of discovering a new approach to help this subset of injured soldiers.

Like the medications, hyperbaric oxygen treatment (if it works) will be given to those with one time traumas, not so useful for continuing trauma.  Here is another approach that might work on a daily prophylactic basis.  Tetris!

An admittedly small study conducted at the University of Oxford examined whether "visiospatial cognitive stimulation" could provide a vaccine against flashbacks.  It was based on the capacity of the brain to process just so much stimulus at one time.  If that capacity is used up by the intrusion of non-traumatic images, then perhaps the traumatic ones would be encoded in memory less deeply. 

So they showed the Trauma Film, a twelve minute piece that is known to produce flashbacks.  After thirty minutes, ten subjects played Tetris, and ten sat quietly.  Tetris was chosen because it is known to intrude upon image-based memory (people see images of the game at a later time after playing).

In fact, these intrusive memories are why I stopped playing it.  It was additively soothing, but I kept seeing the Tetris shapes around me in everyday objects.  Like, the silhouette of a head and shoulders became that L-shaped piece.  At one point I asked my young son to hide his game-boy, so I couldn't find it!  Now I play other games that intrude on image-based memory.

I digress.  Anyway, in the following week, the Tetris-playing group had fewer flashbacks to the Trauma Film than the others.

Now this is an application that could be used in the battlefront.  I understand that soldiers often play computer games when they return to base, though usually they are war games.  Tetris or maybe some other matching three type game could push the day's images out of their brains.

***********

Okay now, I have spent months gathering these studies of secondary prevention of PTSD, and struggling with two issues regarding the vast numbers of new sufferers of PTSD who are created every day in Iraq and Afghanistan.

The first is a dilemma.  After we have put our young people in harm's way, after they have been injured in the service of their country, surely they need -- and deserve -- the best medical care we can give them.  And better.  Surely we need to do more research for better medications and better treatments.

What troubles me is that the medications and treatments are designed to obscure from them the horror of their experiences.  While we treat them, we are creating more effective soldiers, soldiers who can do more and more terrible things, because we have undone part of their most human response to these terrible things.  And we are creating in ourselves denial about what war is.  The healthy human being would go crazy.

And we can't do this so selectively as we would like.  When we interfere with the consolidation of traumatic long term memories, we also interfere with all long term memories.  Which, ironically, is what PTSD does.  Part of how the brain protects itself from horror is to go numb to all feeling.

And yet, their suffering is real and urgent.  How can we not relieve their pain by any means possible?

See what I mean?

My second issue is this.  All the medications and treatments I have described are secondary prevention. -- I said at the beginning that I would return to this point.

What is primary prevention?  It's what we do with lung cancer.  We don't invent treatments that intervene between inhaled carcinogens and the lungs.  We conduct public campaigns against smoking.  We don't make the liver more efficient in processing poison.  We prohibit the use of lead-based paint.  We don't prevent Froot Loops and the sugar in even salad dressing from overwhelming the pancreas and kidneys.  We educate about high fructose corn syrup and our epidemic of diabetes and obesity.  -- Okay, there's a little hypocrisy in that last one, when we compare the money spent on health education to the subsidies given to produce high fructose corn syrup.

What about primary prevention of PTSD?

When is the Surgeon General of the United States of America, Vice Admiral Regina M. Benjamin going to stand up and tell us the truth -- that war is a health hazard?

The frontal cortex of the human brain, the part that comprehends the consequences of actions, is not fully developed until age 25.  When are recruiters going to be banned from high schools and college campuses and malls?  Or federal funding refused to schools that permit ROTC programs?  When are those ads for the Marines going to be banned from the Super Bowl and other sporting events?  When are parents going to teach their children, Just say no?

Defense Secretary Robert Gates said recently that leaving aside “the sacred obligation we have to America’s wounded warriors, health care costs are eating the Defense Department alive.”  Imagine how much money we could save is we stopped putting them in harm's way.

Before automated warning systems were developed, coal miners used to take canaries with them into the mine.  When the canary died, the miners knew the air was poisonous.  It was time to get out of the mine.

So here is the last thing I am going to say about PTSD for a while:

We gotta lot of dead canaries.  When will we get out of the mine?