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Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.


Saturday, January 24, 2015

Gene Kelly At The Waldorf



This is the main lobby at The Waldorf. The clock is taller than it seems in the photo. That's probably why I never noticed the little lady liberty at the top.

I want to write about one of the discussion groups I attended, the Service Members and Veterans Initiative that I mentioned in my previous post, Waldorf 2015. As preparation, I watched "Combat Fatigue Irritability",  a short film directed by and starring Gene Kelly, which was made for the Navy, to make people aware of symptoms of PTSD. The film was only referenced, not shown, during the group discussion, but it was interesting to hear from his daughter, Kerry Kelly Novick, who led the group. I kept wanting to ask her the completely irrelevant question of, "What is it like to see your father on the big screen?"

She did mention that her father was quite steadfast in his insistence on an accurate portrayal of the main character, Seaman Lucas', symptoms and behavior. He even had himself admitted to a psychiatric hospital to prepare for his role.

In the film, Lucas had worked on a ship that was blown up. His job was to monitor the pressure valves. He never went topside as part of his work. He never knew what was going on. He was not a gunner, so he had no active outlet. All he did was monitor the valves, and feel increasingly frightened and helpless. When his ship was destroyed, and he found himself in the water, he felt relieved, but also horrified at watching his buddies die around him.
After he is rescued and recovered, he has a 30 day furlough, and he returns home. At first things go well with his family, but he feels increasingly isolated and not understood, has trouble reuniting with his girlfriend, startles and gets angry when her little brother throws a paper airplane at him, gets into a fight with a bartender, and starts to shake uncontrollably when he goes hunting with his father, after which, he is hospitalized.
The film shows his coming to terms with some of his feelings in group therapy. The psychiatrist is portrayed as kind but somewhat patronizing and paternalistic, and places an emphasis on "fear that wasn't handled properly" as the origin of Lucas' symptoms. He is also shown sedating him, immediately following Lucas' breakthrough in understanding.

There were a number of interesting points made by various people, most of whom work with soldiers or veterans regularly. One idea that I hadn't considered is that the characters portrayed in the film, like most men in the military during World War II, were just regular guys who were drafted. Whereas today, we have an all-volunteer military, so those who have chosen to serve have done so with the intention of making it their career. They want to remain in the service, which makes them that much more reluctant to acknowledge when they are having emotional difficulties.

There was discussion about Lucas acting as "bad" as he felt he was, for his wish to escape from the boiler room, and then watching his comrades die. And of guilt as a defense against helplessness. Someone noted Freud's comment about the soldier's conflict between the wish to live and the wish to be a good soldier.

Isolation was another topic that came up in the discussion group, as illustrated by the sense Lucas has of not being understood by anyone who hadn't had similar experiences. The idea was that it's important for the clinician and for family members to recognize that this is so, but that those suffering from PTSD symptoms can use this isolation to defend against acknowledging feelings of guilt at their reactions to traumatic events, and feelings of loss-that to truly return to their former lives, they need to recognize that they have lost the versions of themselves that existed before the trauma.

One analyst has been working on petitioning the AMA to include military history as part of the social history for the E/M CPT code. Her group wanted the wording to be, "Have you or a loved one been in the military?" So far, they've gotten "you", but no "loved one".

An unfunded (by the military) area that someone brought up was pets. He said that the military has put together some research to show that pets are not that helpful in recovery for veterans, despite having evidence to the contrary. Basically, the military just doesn't want to pay for it. I don't think I came across this document when I wrote, The Comfort of Dogs.

The question of funding is an interesting one, especially in light of the opinion piece published in the NY Times a couple days later, After PTSD, More Trauma, written by a veteran, David Morris, who sought therapy for PTSD, and was placed in Prolonged Exposure Therapy, heavily promoted by the VA for its effectiveness. In this type of treatment, the patient repeatedly reviews his traumatic experience, over the course of a number of sessions. This turned out to be a bad choice of therapy for him, and he got worse, until he dropped out. He later underwent the VA's other PTSD therapy, Cognitive Processing Therapy, which he found helpful.

Morris notes the VA's contention that 85% of PTSD patients are helped by Prolonged Exposure Therapy. He cites a 2013 JAMA Psychiatry paper, Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care, that demonstrates evidence supporting the use of this treatment. It's open source, so you can read the whole thing, if you like. As usual, I'm skeptical about research that involves nothing but before and after checklists to establish efficacy, and a treatment for which the clinicians received 4 days of training, and then provided 8-15 sessions of therapy including, "(1) imaginal exposure or systematic and repeated exposure to the traumatic memory; (2) in vivo exposure or systematic and repeated engagement with nondangerous activities and situations that have been avoided because of trauma-related distress; (3) psychoeducation about treatment and common reactions to trauma; and (4) breathing retraining," to treat something so complicated.

Morris then goes on to state:

After my experience with prolonged exposure, I did some research and found that some red flags had been raised about it. In 1991, for example, Roger K. Pitman, a professor of psychiatry at Harvard Medical School, conducted a study of exposure therapy on Vietnam veterans and observed some troubling complications: One subject developed suicidal thoughts, and others became severely depressed or suffered panic attacks. A similar study, published in the Journal of Traumatic Stress in 1992, found that Israeli army veterans experienced an increase in the “extent and severity of their psychiatric symptomology.”

My concern is that the military has strong motivation for funding the most cost-effective, and not necessarily the most effective, treatments. No doubt it feels compelled to conserve its financial resources for use in war-related technological advances that will create more soldiers with PTSD.

It's also interesting to think about the contrast between what the military thought was useful treatment for PTSD back in 1945, and what it thinks now.

It was quite moving to hear people speak about their work with soldiers and veterans. Here's a link to the Service Members and Veterans Initiative page, if you want to learn more about the program.







Sunday, January 18, 2015

Why I'm Not A Scientist

Well, my first day at the Waldorf convinced me that it's a good thing I'm not a scientist, because I would drive myself and everyone else crazy.  I'm just referencing one of the discussion groups I went to last week, Neuroscience Perspectives on Psychoanalysis.
The way the discussion groups work is that there are the same groups every year, give or take a few, and they have the same titles, but cover different topics each year. So this year, this group was conducted as a journal club. A week or two ago,everyone registered for the group got an email from the guy running the group that included 4 articles-one main article, another written about the main article, another that was a supplement to the main article, and another that we would get to if there was time. 
The main article was, "Subliminal Unconscious Alpha Power Inhibits Supraliminal Conscious Symptom Experience", by Shevrin et al, published in Frontiers in Human Neuroscience in September 2013.

It's a bit of a fiddly article to read, and I think it's easier to understand if you read the article about it, from JAPA, first, but since that's not open source, I'll try to summarize it, before I get to my issues with it,

The idea was to find some kind of specific EEG correlate for the unconscious underpinnings of the clinically observable phenomena of repression and avoidance in social phobia. They looked at 10 subjects with social phobia, and the first thing they did was interview each subject at length. Then they picked out 21 words or short phrases from the interview, per subject. 7 reflected the interviewer's understanding of the unconscious conflict that was driving the phobia (the assumption was that there WAS such a conflict), 7 reflected the subject's conscious experience of symptoms, and 7 represented "negative" words that had nothing to do with either symptoms or unconscious conflict.  Supposedly, the underlying conflict for one subject was anxiety about a homosexual seduction. One unconscious conflict word was, "paddle me", one conscious symptom word was "public talks", and one negative word was "atomic bomb". Just to give you an idea.

They then used a tachistoscope to flash words at the subjects, in a sequence of two, a primer word, and a target word. Some were flashed subliminally, and appeared for 1ms, some supraliminally, for 30ms. They measured alpha rhythms after each word was flashed. Stop me if you already know this, but alpha rhythms are between 3 and 13Hz. They referred to them as alpha power.

What they found was that there was high alpha power after subliminal unconscious conflict words, and these corresponded with high alpha power after conscious symptom words, when the latter followed the former. And they didn't have any significant findings with any other combinations. 

The positive findings look like this:


Where each plotted point represents a subject.

What I like about the study was that it had some actual findings. One person in the group commented that people who don't make a living listening for other people's unconscious conflict would be shocked that there were any findings at all.

What I didn't like about the study was a lot of the methodology, and what the authors extrapolated from the findings.

The guy who ran the group is a neurologist, and he pointed out some problems that I would never have been aware of, since I'm not a neurologist. First, alpha rhythms are typically measured with closed eyes. In this study, of necessity, they were measured with open eyes. Second, alpha rhythms are typically thought to represent arousal, while the authors were using them as a marker of inhibition. Third, the authors didn't look at any other rhythms on EEG.

My methodological difficulty has to do with the choice of unconscious conflict words. Each point on the graph above represents a subject, so there's some kind of average or composite of the alpha power generated. There's no raw data to indicate what the alpha power was for each word. So suppose 1 of the 7 words generated very high alpha power, for a given subject, but the other 6 didn't generate much. You could still end up with the same graph, but you wouldn't be able to tell if the 6 "wrong" words were off because they weren't related to unconscious conflict, or if those 6 WERE related to unconscious conflict, but what you were measuring was something else. Since the purpose of the study was to demonstrate the unconscious conflict involved in social phobia, and since a lot of people probably don't believe the symptoms of social phobia are generated by unconscious conflict, to begin with, this matters.

Then there were the conclusions. The authors extrapolated from alpha power as an inhibitory process, to repression and avoidance. They claimed that the inhibition, as demonstrated by the alpha rhythm, following the unconscious conflict words, represented a repression of the anxiety-producing conflict, and could only be noted subliminally, i.e. unconsciously. They went further, suggesting that this is observable clinically, when a patient stumbles across an area of conflict, then quickly forgets what he was talking about, or changes the subject without realizing it.

To me, this seems like a pretty big leap. Could it be true? Sure. It could even be true if alpha power was thought of, as it normally is, as a mark of arousal-the conflictual word evokes anxiety and arousal, which is quickly followed by repression or avoidance. But they haven't demonstrated this.

Finally, the JAPA article, Research on the Relation of Psychoanalysis and NeuroscienceClinical Meaning and Empirical Science, by Barry and Fisher, goes even further. It describes a "repression index" created by the study authors, to examine the differences in individual degrees of repression. They found a lot of variation among subjects. The authors hypothesized that those who repressed the most would not benefit that much from CBT, which all of the subjects received, while those who didn't repress that much would:

The results were spectacular. Unconscious repression clearly impeded recovery, and those who exhibited the most repression benefited hardly at all from exposure treatment. It was hypothesized also that unconsciously these subjects were unable to tolerate the treatment and so could not benefit from it. Those who showed little repression not only could tolerate the treatment but greatly benefited from it. With the repression index, the researchers could explain two-thirds of the variations in treatment outcome. If these results can be replicated, the index can be used as a diagnostic test to indicate the best treatment option in a given case—who would benefit from CBT/exposure therapy and who would require psychodynamic psychotherapy. 

To me, "spectacular" seems like a bit of a stretch for a study with 10 subjects.

This is why it's a good thing I'm not a scientist. I'd never get anything published, because I'm such a stickler. I'm very disappointed in this study, because it actually had some findings that are worthwhile to try to understand, and that can be further explored experimentally. But the grandiose conclusions, or predictions, if you will, undermine the credibility of what is otherwise interesting and promising work.



Sunday, January 11, 2015

GASP!


I got one of those conference brochures today, "Comprehensive Training Course in Acupuncture for Physicians", which is really a multi-phase course, with phases 1 and 3 online, and phase 2 for 10 days, on site, at UC Irvine.

I'm not attempting to write about acupuncture. I'm not even qualified to begin thinking about acupuncture. I didn't even spell it right, initially. I'm simply going to quote from the "Statement of Need".

"Acupuncture treatment is extensively sought by a vast segment of the patient population. A significant and growing body of evidence also indicates the efficacy of such complementary treatments for a wide variety of clinical indications. Acupuncture is now, in many cases, a physician reimbursable procedure with third-party payers, thus reflecting its acceptance as good medical practice..."

GASP!

I'm finding it difficult to form my thoughts about this into sentences. Granted, it's not claiming that the fact that a procedure, in this case acupuncture, is reimbursable implies or proves that said procedure is good medical practice. Nor is it claiming that insurance companies get to decide what is and isn't good medical practice (not officially, anyway). It's simply claiming that acupuncture is widely accepted as good medical practice, and this is reflected in the fact that insurance companies are willing to reimburse for it.

The statement DOES imply that if you, as a physician, want to make money, one way to do this is to do procedures, such as acupuncture, that insurance companies classify as good medical practice and are therefore willing to reimburse. But that's not what bothers me. I have, on several occasions, expressed the opinion that it isn't evil for doctors to want to make a good living. It's simple supply and demand with a third-party twist: people want acupuncture, someone else will pay for it, so give them acupuncture.

What bothers me is the casual lumping together of "good medical practice" and "reimbursable". I keep wondering when the lightbulb will go on, and people will realize that, like casinos, insurance companies are not in business to lose money. They care about "good medical practice" only insofar as that practice costs them less or makes them more money than another practice. They are not kind friends happy to help in your hour of need.

And boy do they love a quick fix. 15 minute med checks? Yes, please! Integrated care, with no psychiatrist in sight? I'll take some o' that! Years of painful, soul-searching struggle to unlearn a lifetime of pathologic interactions with the world, and no PHQ-9? Bad practice!








Thursday, January 8, 2015

Waldorf 2015

APSaA Annual Meeting


It's time, once again, for the annual meeting of the American Psychoanalytic Association (APSaA), at the Waldorf Astoria. It runs next week, from January 14-18.

I'm taking off two days for the conference. These are a few of the classes I've signed up for:


Service Members and Veterans Initiative

The Role of the “Archaic Superego” in Individual and Cultural Pathology

 Neuroscience Perspectives on Psychoanalysis

Psychoanalytic Family Therapy

The Application of Psychoanalytic Thinking to Social Problems: Dehumanization, Guilt, and Large Group Dynamics with Reference to the West, Israel, and the Palestinians

Psychoanalytic Treatment of Patients with Psychosomatic Symptoms

Plenary Address and Presentation of Awards: Jonathan Lear, Ph.D. - "The Fundamental Rule and the Fundamental Value of Psychoanalysis”

Community Symposium: Gun Violence in the US: "The Active Shooter"-A Psychoanalyst and the FBI Discuss the Increasing Violence and Possible Models for Reduction

Special Symposium: Left to Our Devices: The Impact of Digital Conversations


There are maybe 5 or 6 other classes I'm registered for. I'm not going to make it to everything I signed up for. But there are some pretty interesting offerings.

I'm particularly curious about The Service Members and Veteran's Initiative, which is APSaA'a approach to adding:

 a psychoanalytic voice to the public's response to a growing mental health crisis among service members, veterans and their families — a crisis that is widely recognized by policy and mental health experts... APsaA's SVC emphasizes two core contributions that psychoanalysts can make in the context of this crisis:
  • A focus on the impact of war on families and children, including across generations.
  • A focus on the need for long term treatment and/or long term access to treatment for war injuries.

This year's group is based on a WWII Navy training film, "Combat Fatigue Irritability", directed by and starring Gene Kelly, the father of the presenter, Kerry Kelly Novick, who will compare and contrast approaches to PTSD, then and now. It's a 35 minute film, quite interesting as a window into the military's approach to PTSD during WWII. It illustrates the use of psychoanalytic principles, together with medication.

Having recently written, Behind the Violence, a post about Adam Lanza, I'm also very curious about the gun violence symposium.

I'll try to take some notes and let you know how it goes.


Monday, January 5, 2015

The Montillation of MOC

Supposedly, the last week and a half has been a vacation for me. True, I wasn't working. And I watched a lot of dumb TV. Baked bread. Etc. But I also attempted to study for boards. I did this by running through questions in the Beat The Boards question bank. And I made a list of factoids I thought would be important for me to remember for the exam-important either because I got the answer wrong, or I got it right but the information still seemed to just be hovering on the edge of my memory's awareness, not reliable enough to count on in a pinch.

Some of the factoids:

5-10% of whites are poor CYP 2D6 metabolizers.

Lifetime prevalence of alcohol dependence is 12.5%.

8% of non-twin siblings of someone with schizophrenia will develop schizophrenia, but 12% of dizygotic twins and 47% of monozygotic twins.

Not all of the factoids include statistics, but the ones I have difficulty remembering do. I'm not even sure if they're true.

In fact, I've been doubting the accuracy of a number of review questions. For example, this question came up:


A phase I clinical trial is conducted to accomplish which one of the following goals?
 

A - Permit safety and efficacy data to be collected for new drugs

B - Compare the results of people taking a new treatment with the results of people taking the standard treatment

C - Determine if a treatment results in fewer or more side effects

D - Evaluate side effects of a new treatment that were not apparent before

E - Determine the effects of drugs in populations which were not originally tested


Now, feel free to look this up, but I'm pretty sure the purpose of a Phase I Clinical Trial is to take a drug that some company is trying to get FDA approval for, and which has already been tested in animals, and to try it in healthy volunteers, to see if it's safe for humans.

None of the above answers is correct. Consider:

Choice A is wrong because the purpose is to collect safety and not efficacy data. In fact, it makes no sense to collect efficacy data in healthy volunteers.

Choice B is wrong because that's not the function of a Phase I trial, and in any case, to get a drug approved by the FDA, you just need to show it's better than placebo, not than some other treatment that works perfectly well, which is dumb but that's how it is.

Choice C is wrong  because "fewer or more side effects" than what?

Choice D is also wrong from a test-taking standpoint because "not apparent before" is one of those phrases you're not supposed to choose, and before what?

Choice E could be correct, if what's meant by it is testing for tolerability in human rather than animal populations, but clearly, they don't want you to pick E.


You can decide which one you'd choose, but the answer they listed as correct is, "A-Permit safety and efficacy data to be collected for new drugs".

Well, it occurred to me, maybe thy Beat The Boards people know it's wrong, but they're using a question from an actual board exam, and that was considered the right answer. In which case, that's the answer I want to choose.

But what if they don't know it's wrong?

So I emailed them and asked. That was on December 29th. Their support people got back to me right away, and said they'd pass on the question to the education department people, who will get back to me within 72 hours. I'm assuming that means business days, because I haven't heard from them yet, and New Year's Day intervened. Clearly, I'm being generous.

I started to muse about this issue in a broader way. There's the obvious question: What do I get out of an exam if all I'm doing is giving them the answers they want, even if they're wrong or meaningless? It reminds me of:

The Montillation of Traxoline  

It is very important that you learn about Traxoline. Traxoline is a 
new form of zointer. It is montilled in Ceristanna. The 
Ceristannians gristeriate large amounts of fevon and then bracter it 
to quasel traxoline. Traxoline may well be one of our most lukized 
snezlaus in the future because of our zointer lescelidge. 

Questions: 
1. What is traxoline? 

2. Where is traxoline montilled? 

3. How is traxoline quaselled? 

4. Why is it important to know about traxoline?

Could you answer all the questions about Traxoline? I bet you could.








Wednesday, December 17, 2014

RxNT in Progress

I thought I'd follow up my previous EPCS post to let you know how things are going with RxNT.

I had a bit of a problem setting up the soft token, which is generated by an app called, Safenet Mobilepass. In order to get started, you need to send in an activation code, which shows up on your phone screen. The instructions tell you to take a screenshot so you don't lose the code. My iPhone takes screenshots by pressing the little round button and the top right button simultaneously. My timing was a little off on my first attempt, and I lost the screen. I tried to go back one step, but it wouldn't let me, and I had to get out and start over. It worked the second time, but gave me a new ID. I still can't get rid of the original ID, "Token 1", but I can't use it, either.

My first attempt at sending in a prescription for a controlled substance didn't work. It seemed to go through fine on my end, but then the pharmacy called and said they were getting a message that I wasn't set up for controlled substances. So I emailed support at RxNT, etc. Turns out, the problem was on the pharmacy's end.

Support got back to me the next morning-so that was good. they suggested I delete the "Token 1" ID, but didn't tell me how. I wrote back that I had already tried, and there's no obvious way to do it. Haven't heard back from them on that point yet.

Suffice it to say, all beginnings are difficult.

Other topics of interest:

There's no way to pay RxNT online. No PayPal or anything like that. You have to email or fax a credit card form. That seems like a pretty easy thing to rectify. I mean, I even take PayPal in my office.

There's a "recent rx" tab that lists recent prescriptions (duh) if you click on it. But I can't figure out how to set a date range for how recent I want it. It seems to default to the 4 most recent. You can generate a Rx Report, where you can set the date range as you see fit. But that's just for a reportnot the "recent rx" page.

Similarly, I can't find a screen that simply lists my patients alphabetically. I don't have the EHR set up, so that may be the reason.

Refill requests don't have a direct link to editing. I had to go through the patient link to edit. Maybe I need to practice more, here, and there's something I'm not noticing.

I get a "data could not be loaded" message a lot. But then the data seems to load normally, so I'm just ignoring it.

Finally, this is my silly hangup, but the app icon for the soft token:



Reminds me uncomfortably of the logo for Panera Bread:





I don't know why this bothers me. Something about the relationship between a big, mediocre food chain, and the company that allows me to prescribe controlled substances.



Sunday, December 14, 2014

Ziprasidone and DRESS

In case you haven't seen it, the FDA released a safety communication about Ziprasidone (Geodon) induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). The FDA reviewed 6 worldwide cases of DRESS temporally associated with initiation of Ziprasidone, specifically, within 11 and 30 days of initiation of treatment. There were no fatalities. In 3 of the cases, Ziprasidone was initiated, the patients developed DRESS, Ziprasidone was discontinued and later restarted, at which point, the patients re-developed DRESS, only faster than the first time around. 3 cases reported concomitant use of other drugs associated with DRESS. (I believe, based on the ambiguous FDA description, that) all 6 cases were hospitalized.

To review, mostly from UpToDate, DRESS is rare-anywhere from 1-5/10,000 in patients taking carbamazepine and phenytoin, and 1/300 adults or 1/100 children taking lamotrigine. Mortality is 10%. The most common associated agents are carbamazepine, phenytoin, lamotrigine, phenobarbital, and allopurinol. Etiology is unclear. Reactivation of Herpesvirus or EBV infection concurrent with drug hypersensitivity is common.

DRESS usually begins within 2-6 weeks of drug initiation, and most commonly presents with fever, malaise, lymphadenopathy, and skin eruption. There is liver involvement in 60-80% of patients. Kidney and lung are also frequently involved. Hematologic abnormalities include leukocytosis with eosinophilia and/or atypical lymphocytosis.

Treatment consists primarily of withdrawing the offending agent, with systemic corticosteroids for severe cases of tubulointerstitial nephritis or interstitial pneumonitis. Skin eruption and visceral involvement resolve gradually, within 6-9 weeks. In up to 20% of cases, the disease persists for several months, with a succession of remissions and relapses. The long-term, natural course consists of spontaneous flares.

One more thing to discuss with patients before starting them on ziprasidone.