Trade names

I realized sometime in the wee hours of the morning that Thorazine is chlorpromazine but thioridazine is Mellaril. Ha!

And don’t get me started on clonidine vs. Klonopin (clonazepam) vs. clozapine.

This is why psychopharmacology confuses me. Not to mention that whole “we’re not totally sure how this works but we’re prescribing it anyway.” (Though M. had a decent explanation of the delayed onset of SSRIs, involving neural networks, so I’m mollified. For now.)

Story time!

A visiting attending today told us a true story.  Once upon a time, there was a psychiatric emergency room in a busy city hospital.  One night in said psych ER, there was no attending on duty.   Just a PGY-2 and PGY-3. (At this point, my attending, who was also listening to the story, put his head in his hands and groaned.)

Psychiatry?

Psychiatry has been a much more complicated rotation than I had thought.  The hours are light — pretty much 8:30 to 6 — but it’s so emotionally draining that I feel just as tired as I did on neurology. I’ve been stress-baking, much to my roommates’ delight.

One thing I will say for psychiatry — you really get to know your patients.  I spend anywhere between a half hour and an hour with each of them every day, and they stay for at least a week.  One of my patients has been on the unit since mid-July; he’s probably going home early next week, and he’s so excited he apparently did a jig. (The nursing note said “breakdance,” but this is a frail man in his 70s.  If he’d busted out moves like this, I’d want to get paged.)

Today, though, I finally sat down and busted out this presentation I’ve been “working on” for two or three weeks.  I’m going to be speaking on “Delusional Misidentification Syndromes,” which is a fancy term for the Invasion of the Body-snatchers. (Oh, the 1950s, you and your sci-fi horror!) Capgras, Frégoli, Intermetamorphosis, and Subjective Doubles: bizarre delusions in which the patient thinks that family members — or even themselves — have been replaced by imposters.  There’s no consensus about the etiology — it’s either organic or psychodynamic (what else is new?); at least one case of ECT-induced psychosis — but it’s pretty fascinating nonetheless.  And I managed to cite some literary criticism, which always makes me happy.

Next up: practice questions for the shelf!  What are the side effects of mirtazapine, hm?
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Now playing: Bond – Quixote
via FoxyTunes

HM and AV

Patient HM died today.  The NYT has a nice summary of his life and contribution to science.  Sad story, but so fascinating.  I think the best “Neuro is weird” tale is of Phineas Gage, the railway worker who ended up with a spike through his head — and lived.

In totally unrelated news, I am pretty sure that there is a poltergeist or goblin hanging out in the second-year lecture hall.  Every day, the audiovisual equipment breaks down.  The best was during our psychiatry exam: we were supposed to do a write-up on a videotaped patient interview, but the video was at first inaudible. The write-up would have been very short: “Patient mumbles for half an hour.  Diagnosis: speech disorder not otherwise specified.”  Sweet.

(But then they got the sound working, and we had to actually pay attention.)

Freud

In this morning’s (21st century, electronic) New York Times: Psychoanalytic Therapy Wins Backing.

We’ve had a series of psychotherapy lectures recently: psychoanalytic, psychodynamic, cognitive/behavioral.  I am still not sold on the whole thing.  I have no doubt that it works, especially for chronic mental illnesses, but I am not convinced that it is medical.

Plus ça change

After a week of school, I have to say that I’m a little disappointed.  There were all these promises that second year was going to be all exciting and doctor-y, but really, nothing’s changed except the classroom location.  (Yes!  I no longer have to cross the Street of Death, where city buses and gypsy cabs — which my mom calls the Mafia-on-wheels — like to feint attack pedestrians.)

Just like last year, we have several hours of lecture a day, in which people with lots of letters after their names tell us Important Things.  The material’s still very basic-science oriented; they do throw in a disease or two from time to time, just to keep our attention.

Our child psychiatry lecture, in particular, was more of a child psychology lecture.  Blah blah Erickson Piaget.  On an intellectual, “all learning is good” level, I know it’s important, but I would much rather hear about ADHD and autism than the age at which a child will hunt for a hidden toy.

And don’t get me started on immunology.  Do I care about B and T cell combinatorial gene rearrangement, other than being aware that it exists?  Apparently, getting back into the groove of things is definitely an adjustment after this summer.

Yesterday, my path lab professor launched into a bit of a diatribe about how students always want to know what is “testable.”  For me, the motivation is not so much figuring out what is testable as figuring out what is applicable.  So far, I’m not really seeing a lot.  (Although I bet by the end of the month, I’ll look back and laugh at my naiveté.)

However!  It’s the weekend now, and I’m going on a picnic tomorrow, so things are looking up.

MSE

I’ve been back for a week now. Without anatomy (I passed!), I have copious amounts of free time, which I fill by watching videos on youtube and strolling around the city. It’s wonderful.

We started psych med on Tuesday and have thus far learned about the Mental Status Exam. The examples given in the book are very novelistic (“She seductively sweeps her bangs away from her face….”) and so I present for your amusement a quick game of Guess the Patient.

Patient X is a student (age debatable), about 5’10 and 160 pounds. His facial appearance is marked by distinct pallor, which contrasts sharply with the inky black of his open doublet and dirty socks that fall around his ankles. He enters the room in a distracted fashion, looking around him as though afraid of being followed. The knocking of his knees also suggests fear. As the interviewer rose to greet him, Patient X drews his right hand slowly to his forehead, then extended it in a flowing motion to meet the interviewer’s outstretched hand. He then sank into a chair, where he remained for the duration of the interview.

The patient answers all the interviewer’s questions readily. His speech pattern alternates between slow, monotonous responses and garrulous outbursts. When asked about his mood, he says that he is “very like a whale.” On being asked to explain, he winked at the interviewer but did not elaborate.

He has a full range of affect, although occasionally a question about his family causes a shadow to pass over his face and shuts down his emotional response. This is brief, however. Thought process is circumstantial and tangential; long digression of the death of an older man who played with him as a child and appears to have been a surrogate father figure. Some loosening of associations. Thought content is obsessive, centering on the recent death of his father and his mother’s subsequent remarriage. Grandiose delusions of his “destiny” as the savior of his family and friends. His girlfriend recently broke up with him, an event he attributes to the influence of her father, a friend of his stepfather.

Some evidence of visual and auditory hallucinations, primarily of his father. These hallucinations command him to avenge his father’s death. Admits to passive suicidal ideations (longing for the “sleep of death”) but has not made a plan due to fear of the afterlife he believes to exist. He also shows evidence of homicidal ideation against his mother, stepfather, and girlfriend’s father.

Cognition: fair. Alert and oriented to self; described interviewer as “fishmonger.” Recalls 3/3 objects in two minutes. Digit span 7 forward, 5 reverse. Does not know own age or age of father at death. Frequently confused two childhood friends. Fund of knowledge good on current events, somewhat shaky on chronology and dates of the past. Above average intelligence, reflected in sophisticated vocabulary. Occasionally invents words.

Poor insight. Patient is aware that his friends and family are “concerned” about his recent behavior. He insists that he is “but mad north by northwest.”

Judgment: Patient does not appear to understand the need for treatment. Recommend hospitalization for suicidal and homicidal ideations.

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I just got back from the psychoanalysis conference. It was pretty fascinating, and it was wonderful to meet other students who are interested in psychiatry. (We had a day-long student session, followed by a general talk about the history of psychoanalysis.)

What I liked most about psych (-iatry? -oanalysis?) was its focus on story and narrative. As a literature major in college, I’ve been searching for something that gives me the same sort of thrill I got when immersed in a character or a plot. Some of the speakers shared stories from their own practices (properly disguised, of course) that really brought me back to that place. The focus on the past and the iceberg of the Unconscious — really just the concept that a person’s motivation is deep rather than superficial — are also appealing, as is the interdisciplinary synthesis that informs much of psychoanalysis. But most of all, I really enjoy the prospect of getting to help make sense of this crazy arena we call Life. As one of the speakers put it, psychoanalysts “help people create cohesive narratives of their lives.”

Unfortunately, psychoanalysis is an additional four years of training after a psychiatry residency. Although the traning is part-time, the opportunity cost is high: you could be seeing and helping your own patients in that time. Also the elitism aspect of it, the notion that psychoanalysis is for neurotic rich housewives on the Upper East Side. One of the speakers said he uses a sliding scale, but I’m not sure I like that idea (although it’s better than shutting the poor out entirely).

And lastly, my god, did they adore Freud. I was surprised, because Freud’s theories, while obviously influential in creating the field, are a century old by now. I know, from my literature training, that a lot more work has been done in psychoanalytic theory — there’s Lacan, and Derrida, and a whole slew of feminist psychoanalysts — that were just trampled on in the rush to worship at Freud’s altar. To analyze the analysts a moment: it’s almost as though they are using the approbation of a dead master to cover the disrespect that psychoanalysis gets from just about every other field.

Honestly, though, if psychoanalysis is discredited as “not real science,” it is at least partially their own fault. I’m not talking about the historical lack of evidence-based studies that psychoanalysis actually helps — those are coming out recently, with support from neuroscience, fMRI, etc — but rather the apparent disowning of any attempts at progress in the field. Can you imagine medicine practiced as it was circa 1905? “Here you go, Farmer Jones, have a poultice for your infected boil, and we’ll have to amputate next week. If you’re still alive, that is.” So why is psychoanalysis so adamant that Freud Got It All? That’s practically dogma.

I think that psychiatry is just about the most fantastic thing I’ve considered right now, and especially in minority communities, where psychiatric disorders carry a stigma that “regular” medical problems do not. And one can certainly use psychodynamic thinking and “talk therapy” in regular psychiatric practice (i.e. it’s not just about Xanax and Zoloft). Although psychoanalysis is kinda cool, I’m not convinced that the extra time and training are worth it.

Career development?

I just attended a talk about trauma surgery. It was less about what it’s actually like being a trauma surgeon (though he addressed that during the Q/A at the end) and more “This is what you need to do to pass your surgery boards.”

He also had a ton of frightening pictures of people with mangled body parts and poles sticking through them and whatnot. It was not a pleasant sight. Trauma surgery certainly sounds kind of cool, and I’m sure it’s incredibly rewarding, but I’m not exactly thrilled at the thought of gashes across faces.

There were several pictures of failed suicide attempts (slit wrists, one throat cut so deeply that they were able to intubate directly through the wound, etc.) which just reminded me of something a friend of mine, who used to work with a crisis hotline, told me. They got several calls about suicidal ideations, and once they established that it wasn’t an imminent danger and that the person really just needed to be talked out of it, they would “de-glamorize” suicide by talking about what would happen if it went wrong. Such as, “If you slit your wrists, you could end up with necrosis or sepsis in your fingers and would have to have them amputated.” Apparently it worked quite well.

What interests me more than the immediate surgical intervention is the longer-term psychiatric implications that would lead someone to suicide. As a matter of fact, I am going to the student section of a psychoanalysts’ conference on Saturday. Although of course I don’t know that I want to become an analyst, or even that I like psych that much (though on paper it sounds fascinating), I figure it can’t hurt to explore a little before third year. Also, this is New York City, where even analysts have analysts. It should be a good program.