Involuntary Movement and Medications

Tardive Dyskinesia Awareness Week was May 1-7, 2022.”

This comes at a good time for me as well. Last week I was just working with a patient, “Joe”, who was suffering with an “involuntary movement.” Joe had taken an antipsychotic as an augmenting agent for his treatment resistant depression and had a brilliant response… as far as his depression-disease went. Within one week of treatment, his jaw-breaker-depression started to dissolve small pieces away. He was astounded. 

Truth be told, I get astounded too, when my patients show these kinds of “Whaaat?!” responses. Although it is less than before, still too often (20-60%), patients work hard on getting treatment responses that remain elusive. Too often, I watch someone’s life step down from one loss to another due to their disease process, like a slinky. They start taking days off from work, then weeks off. Their most beloved relationships plunk, plunk, less and less connected. They stop getting out of bed much. And so forth. These are not just words. Brain disease is real. Whether it is depression or psychosis, anxiety or dementia, and more, it’s not any less medical than a deadly cancer. 

But when patients like this, with whom we have determinedly worked toward healing, all the while, together, watching their life losses… well it is grievous.  And miracles, such as Joe experienced, astounds us. 

About a month later, I started to notice that his mouth was moving without his conscious intention. His lips jerked together, like a “purse string” pulled on them. This is one of many early symptoms of dopamine blockade that might happen with antipsychotics. For Joe, it resolved easily by decreasing the dosage of his medication. He was reluctant to do this, considering the benefits he enjoyed with the medication. Thankfully, however, his benefits remained even with the lower dose.

Joe had been experiencing “acute dyskinesia.” If Joe had stayed on his antipsychotic agent over time, or one could say “tardive,” and at the higher dosage, the involuntary movement might have worsened and become more difficult to get rid of. Involuntary movements are also more often experienced in the elderly population and from older classes of antipsychotics, but they still can happen in the newer ones. 

These secondary movement disorders are grouped under the name “extrapyramidal side effects,” (or EPS,) of which tardive dyskinesia is one. And in case you were wondering more about its cause, it is described in PubMed: “The mechanism of EPS is thought to be due to the antagonistic binding of dopaminergic D2 receptors within the mesolimbic and mesocortical pathways of the brain. However, the antidopaminergic action in the caudate nucleus and other basal ganglia may also contribute significantly to the occurrence of EPS.”

For reference, NAMI also has a clean, well described, web-page on tardive dyskinesia worth reading for more details. It doesn’t include all the names of the newer agents which can be hard to keep up with. These “second generation antipsychotics” are frequently increasing in number as our medication options through research increase.

Understand that TD is a movement disorder. Not all movement disorders are caused by medication and deserve a medical work-up. It may or may not be reversible and the risks and benefits of treatment need to be evaluated progressively, over time.

Keep noisy. Keep talking. Keep asking. Keep on!

Questions: Would you please tell us about your involuntary movements if you’ve experienced them? Or seen someone with them?

In the mean-time, Waiting for Treatment Response

A crowd of Neuro-receptors fill our brain like a high school mosh pit. It’s noisy and possibly dangerous up there. It’s hard to focus. The negative thoughts are drumming. Medical treatment for depression is the Arthur Murray instructor to our brain-dance. And it takes time.  

When we take medication, the neurotransmitters targeted in our brain have to respond to the neuro-messengers that are the medication. Some receptors downregulate, i.e., decrease in number or activity. Other receptors likewise, upregulate. Again, this takes time. For example, fluoxetine, or Prozac, which came on the market in the late 80’s, is one of our most familiar antidepressants. When we start the medication, (and please don’t call them drugs because no one is panhandling for fluoxetine… Nor are we taking fluoxetine to get a high, but rather to treat a medical illness)… 

When we start fluoxetine, it can take 3-6weeks to start experiencing the benefits. Furthermore, during the first few weeks it is common to feel worse before we feel better. Worse anxiety, worse depression, this is because the receptors are learning a better dance. And it takes time to learn. And learning in this case feels worse before it feels better. 

You ask, what do we do until the medication takes effect? Marvelous consideration. Because here we are, asking for help, and our psychiatrist gives us something that makes it worse. Ummm. 

In the first couple weeks, which can feel like forever, perspective being what it is, a cloudy lens, feeling worse is described by the health of our brain. The brain, from which all emotions, behaviors, and sense of reality come from, takes time to heal.

We come to the psychiatrist by the hair of our chinny chin chin, almost dead inside. We waited, of course, to make the appointment. Waited for our courage to catch up with our disease. And then we waited for an appointment to open up three months later, seemingly forgotten at the train station scanning the crowd for kindness and help to come. And then? Then we receive treatment that takes another month to start, to start I say, not finish, the healing it promised, (a promise that values at about 50-60% of the time to come through. That’s the statistic for fluoxetine to be effective for each of us with our first trial of depression treatment. Thereafter, the likelihood of responding to fluoxetine diminishes after each trial.) 

This is the lighting on the stage for your question, “What do we do in the meantime?” We survive?

It’s too easy to come up with behavioral solutions that if they were to work, they would have already done so during that waiting – ex: 2 months of worsening mood, 2 months to call the psychiatrist, 3 months to get in for your appointment, 1 month for the medication to start working = 8 months. 

You’re not a dummy. But we’ve been advised as if we were by our community. “Feel better.” “Snap out of it.” “Pull yourself together.” “Be strong.” It’s not like you didn’t think of these on your own and were waiting for someone wiser to tell you to get on with life. But, If you are able to, please do get on with it. Go exercise. Sleep better. Eat better. Look at the world with hope.

For the rest of us with melancholia, ie. major depression, the choice left us when we lost brain health. Similar to the alcoholic choosing not to drink, choosing to feel well isn’t a choice. When the medical illness recovers, we gain our freedom to choose those things back. 

During these “8 months” there are some things that can be done however. 

Go to a psychiatric partial hospital program, (“PHP”).  This is a day hospital where you attend for about 6 hours, 5 days a week, for about 4-9 weeks. It’s incredibly supportive. But more than that, PHP teaches dialectical behavioral therapy, (“DBT”), a type of therapy that has been shown to make changes at a cellular level. There are changes to our automatic thoughts, so that when something triggers us, our pre conscious response is more friendly to “Me.”  It’s not a “stick-shift”, but rather increasingly automatic. The key is to work toward brain health. 

Others will collaborate with their psychiatrist to augment fluoxetine, or whichever antidepressant of choice, with another medication that can help pop you out of depression sooner. These treatments are not generally long lasting and don’t treat the underlying illness. Rather they treat the symptoms here and now. Some examples used include stimulants or thyroid replacement therapy. 

In the end, be in a community of support – be it PHP,  outpatient therapy, or NAMI

Support is the shell to our drippy egg, while we wait for our medical treatments to take effect. 

Question: Have your efforts in treatment worked out? What’s your story?

Self Care Tip: Don’t give up! Pursue treatment. Your illness is treatable. But in the meantime… be in a community of support. Keep on!

Medication: The Good, the Bad and the Ugly

Sometimes, we feel sideways.

Between the loss of control mental illness makes us feel and the quandary of how to go about getting better and staying better.

You’re all welcome to join us tonight for NAMI (National Alliance on Mental Illness). We are discussing this. 🙂

Topic: “Medication: The Good, The Bad, The Ugly”

Time: Jan 19, 2022 06:00 PM Pacific Time (US and Canada)

Join Zoom Meeting:

https://us02web.zoom.us/j/81810597278?pwd=c0lGczZrWjhPeVNjTm5JUDJEdUhlQT09

These meetings (NAMI Temecula Valley Mental Health Speaker Series) occur on the Third Wednesday of every month, 6pm-8pm

Please download and import the following iCalendar (.ics) files to your calendar system.

Monthly: https://us02web.zoom.us/meeting/tZUldumtpzwoHdwRcEPG4eEMsua755Q6tc0Q/ics?icsToken=98tyKuGppjoqH92Ssh6PRpwcGoj4c-_xmGZBgqdKrhzAMwcHZybbJfdDZecqIY7E

Whether we see you there tonight or not, hope you are doing very well in this new year, 2022.

Keep on!
Your Own,

Dr. Q

It is okay to be Wrong …and Fears

750+ [HQ] Fear Pictures | Download Free Images & Stock Photos on Unsplash

There was an exhale. A ripple out, like dropping eyelids, a wave on a slow shore, turning a shoulder away and the head following; this was how her disclosure soundly rolled through the room.

I failed.

I don’t care how cocky you are, everyone fears. In the brain and body, sometimes, the parasympathetic is dominant and one feels calm. Fear isn’t on the mind. Another time, the sympathetic tone rises and you think, “A bear is chasing me!” Or, “That girl is coming to talk to me!” (It can feel synonymous. Wink.) Yes, that is fear. But the kind of fear I’m talking about here is the one germane to our conscious or even before conscious awareness that we will never be enough. There will always be someone. Smarter Her beat Me in AP Calculus. Someone the boy desires… more. The things like food, shelter, clothing, the money, the votes, the power, and someone other will trump Me. This fear comes from the Amygdala, an almond in the middle of the brain that holds our sensitive selves carefully within it’s tiny shell. Others will argue that it also comes from a magical outside-of-biology-morality. A qualifier or quantifier of personal value. Plink. A widow’s mite drops in; an offering of our small or great selves.

But wait. There’s another choker, ring and leash that sparkles around our slender neck; the whole perfectionism culture. This is the psychological influence on what makes us who we are, including our constitution of fear. This is what I wish I gave better to my world, to those I am in contact with. I wish, like Pinocchio, because I believe perfectionism is dishonest and lacks moral fiber. We are made better by our failures rather than worse. And if I were a philosopher, I’d recognize the tiring loop this swings me into… It is a failure to live in shame of my failure to receive the gain that failure brings. Round and round. An ice cream truck sounds music in the distance but I have no change. I’d like to especially tell my kids with my life, my actions, my all – “It is ok to be wrong.” Wrong wrong wrong is just fine. Pause. And then also, “It is ok to not pass, to miss, to play flat notes, to sit alone, to be unchosen, to work hard and fail.”

Beatrice, a graduate of the Medical School of Manila and residency in internal medicine, and later after six years of practice, immigrated to the US of A. She had taken the USMLE Boards Step One, twice and both times, failed. She could not do the training in the states that would allow her to practice here until she passed. In the mean time, her kids back in the Philippines, needed funds to live. Beatrice worked Door-Dash, while she studied and feared.

It would have been clanging “toxic positivity” for me to chirp, chirp, “It takes a lot of failures in order to succeed.” But help me, I wanted to! And forgive me, I have with others. Ugh.

What is the balance? Because there is truth here. All successes are preceded by a large mote of failures, conscious awareness of them or not. However that doesn’t prove that successes will follow. What’s the term in logic that this is in danger of? I think it would be a blend between causal fallacies and a hasty generalization. Sometimes there is just failure. A dump in the mossy monster infested water.

Because we are good psychiatrists, we will shake it down, and dutifully approach fear here with our “bio-psycho-social” paradigm. We have the brain, including the amygdala and it’s influences. We have the psychology of perfectionism. And we have the social of Beatrice’s children’s basic needs to survive.

How do we do self care with all this? If we have enough bank, we go toward the elements, separate and whole, in this paradigm. We pluck away where our suffering calls out to us most. We go forward knowing that whatever it is we are going through, we are not alone. It is common and normal, although unique because we are, each of us, an un-duplicated wonder. We use the reminder this approach offers that things are always more than they seem to our conscious selves and if we give to it, we will weave together a greater hope, with both the good and the bad, all seated at the Thanksgiving dinner table this year.

For Beatrice, we grieve with her the difficulty in her journey. We celebrate her hopes. We encourage without losing honesty. And we give treatment for the biological expression of underlying disease that harms the way she perceives her reality. This is our privilege.

Self-Care Tip: It is okay to be wrong, wrong, wrong. Keep on!

Questions: Would you please tell us about your fear?

Meet Torie and Our New Podcast!

Hello!

My name is Torie and I am a new co-host of Friend to Yourself Podcast.

Dr. Quijada and I are thrilled to be launching this podcast, and we’re so excited for you guys to see what we have planned.

Before continuing, here is some of this and that to get to know me.

I was born and raised in Southern California. I am the oldest of three girls, and studying for a psychobiology major with a minor in nutritional sciences. Mental health advocacy is my passion, especially in multicultural communities where mental health and illnesses are stigmatized, and in Eating Disorders recovery.

I absolutely love going to Padres games. But even more so, I am obsessed with my new English Bulldog, Keilani. On the weekends, you can find me and Keilani at the beach or local coffee shop. 

Both Dr. Quijada and I have been working hard to create content for our subscribers. Our podcast will focus on self-care as practiced in daily life struggles and wins, eating disorder recovery, and mental health from a biological perspective.

We’re getting some final things settled and our first episode should be out very soon! Please suggest or ask anything. We would love to hear you.

To stay updated, follow us on Instagram @friendtoyourself  & don’t forget to share with your friends and family!

Blessings, 

Torie 

More on Dying

Tonight my husband cast this up on our monitor/TV. “This was my colleague.”

A couple who worked in palliative care used social media to share their experiences after one of them received a terminal diagnosis. It was later featured on The NewYorker.

https://www.newyorker.com/culture/the-new-yorker-documentary/what-is-it-like-to-be-dying

Watching with him the face of dying threw me back to watching my Dad. The way they both, Kathy Brandt and my dad, smiled up with tight faces, skin pulled over bones. So much love there. Dad would smile and I heard him say in it, “I love you Sana. Will you still love me while I die?” There is an insecurity I imagine in that process of saying goodbye.

Then when Kathy Brandt apologized to her audience for her condition. Her “weakness” was something to say sorry about. We also apologize for our weaknesses; for things we had nothing to do with other than that we are the carrier of some biology gone bad – major depressive disorder, cancer, alopecia… Name it. It will take you a while to cover all the things that we apologize for that describe our humanity more than they describe our fault.

Maybe we apologize rather, not in shame, but in empathy toward our listeners. There is a consideration of what our defect imposes on them. That could be. But I wonder what would happen if we didn’t apologize. Instead, allow the others to let our flawed selves just hang out there in the space between us, bringing them into a greater awareness of what we are going through. “Hello. There is no brush off here. Rather come be in my suffering and we will commune. You and me.”

There was no mention of God, what happens after death, or the meaning of life. I don’t know what they believed. They seemed like they just wanted to share the basic experience, the breathing, (…my dad rattled again in my mind when I heard that,) the changing face and body, the personality coming through, the relationships affected and so forth. This gives us space to be there with them, without doctrines setting up lines and corners we have to navigate. Not so bad. I appreciate them.

Speak: Let us know what you think of this documentary. Give us your adjectives. What notes does it hit for you; the resonance you hear and where you find your community. Speak!

Selfcare tip: Allow yourself not to apologize.

Our sinking boat and Care-Giving

On mental illness.

Generally we think about the individual/the patient. 

Generally we start with what they’re going through. 

  • We don’t generally… 
  • we don’t traditionally… 
  • we don’t naturally
  • I would say…

Our first instinct is not to think about the rest of those without. First, we think about those with mental illness. However considering statistics, the pool of persons who are not ill, is much larger to the pool of persons who are ill. 

It’s just how it goes to think of things this way. The person with the hurt comes first and last. Right?

Contrasting to this, healthy relationships ebb and flow. There is a dynamic. There is a back-and-forth. Sometimes it goes in one direction. Sometimes it goes in the other, depending on who needs what at the time. 

But when someone is ill, the needs tilt. They go more toward the person who is ill.

It’s like saying if you are in a boat on a lake you are likely trying to float. But the boat has a hole in the floor. Water is rushing in. In this boat with a hole on a lake, you with someone. There are two people. Bummer though. One of you has a broken arm. The other person has two healthy arms. Who ends up bailing more water? You guessed it. 

Even with the best intentions, the person with a broken arm is never going to be the same performer as the person with two healthy arms. 

Question. Is there culpability?

The person with two well arms is bailing water at breakneck speed. The person with only one fit arm is doing their best. Bummer though. In this story, they develop tendinitis. Bailing water slows down even more now that they have both a break in one arm and tendinitis in the other. The person with two well arms is still bailing frantically. The person with two healthy arms looks over and says…

What do they say?

Do they say, 

“Hey you! You are a dud partner. It’s your fault this boat won’t float.”?

Or, do they say,

“I am responsible if this boat sinks. I am responsible for your well-being because I have two healthy arms. It’s my job if we don’t float.”?

You see the gap. And both answers are wrong wrong wrong.

Unfortunately, most don’t say what is really going on. 

“No. There is no culpability. There is no fault. It just is what it is.”

Have you ever felt like it’s your fault? On either side of this equation. Caregiver or patient, there is blame we do to ourselves. Being joined, as a spouse, a parent, a child, a friend… with someone who is ill, even illnesses of the mind, puts you in a position of care-giving. 

What is it like to be a caregiver?

You may be saying, “Dr. Q. Are you a dummy?! It’s a tiring thankless job that I do because,” …there are so many reasons. Love. Finances. Religion. Guilt. So so many reasons we become, and stay, caregivers.

Dr. David Kessler, grief researcher, explains that in the grieving process we often fall out of intimacy with others because we are judging how the other person grieves. This took me by surprise. I didn’t realize that in our pain we judge. As pathological as it is, this is a process of self-preservation. Fists up, we are just trying to survive. 

“They are not grieving the right way.” 

“They are getting over it too soon.” 

“They are already forgetting.” …and so forth.

In a care-giving relationship, we get into the same trap. We judge ourselves and others in how we give and receive care. 

No one ever feels quite so lonely as when they are “right” and looking down at others. The other, even being one’s own tired crumbling self. Being at the “top” is a windy cold summit. The pedestal of “correctness” is paper mache. Care-giving easily encargos judgment, even judging yourself. And is isolating. I’ve never felt so alone as when standing in judgement.

Being a caregiver is, well, …giving!  There is a need.  We respond to the need.  We give.  There is also a taking from what is given. When we talk about this, some of us hear the tap, tap of a bookkeeper balancing ins-and-outs.  Tap, tap, take, take. “Keep it fair!” Or, “Keep it right!” There is judgment. Are you giving enough? Are you giving right?

How to pull away from the Judge Judy role:

Understand first that the illness is there just because it is. It’s no fault of anyone. No culpability. These illnesses are, at the most primitive perspective, because of our human condition. We suffer. It is what it is.

These illnesses come because we are human. It is what it is.

These come from biology we didn’t choose. It is what it is.

They come, perhaps, from bad choices, like illicit substance use, texting and driving, or ring boxing and collecting a series of traumatic brain injuries. Bad choices that, although have a degree of selfish beginnings, still come down to the human condition. They happen. Humans make bad choices. It is what it is.

My patient was struggling with her own sense of guilt. “I just feel responsible,” she said. “I’m his mother.” She couldn’t let him “hang in the wing, out to dry.” Rescue after rescue.

And that’s ok, right? It’s ok if that’s what you want to do. Rescue away, I say! But do you loath that about yourself?

While bailing water, take stock. It is your own choice. Think of your reasons why. Own them. Celebrate them rather than judge yourself. You are doing what you want to do. 

At FriendtoYourself, we say, “Everything starts and ends with me.” There is freedom in that. It is putting the judgment down and claiming your life. It is digging in your own dirt for your own worms and feasting. It is spending your energy where it will make a difference. With, “Me.” This is the only person I can account for. This is all I can have any control over, (as little as that is considering biology!) but it is what we have. 

And from this accountability, from this place of freedom, comes connection. Both to yourself and to others. The caregivers-martyr-death is lonely lonely, like a howl sounding that no one ever captures. A caregiver who repositions themself, adjusts and tweeks their lens, to say, “I choose…” 

What? What do you choose? Do you continue to give and bail water? Do you walk, or swim as it were? No judgment here. You are doing the best for others still when you do either of these. Sometimes you are still giving love when you swim away. Sometimes staying and bailing water is worse. It’s worse no matter what your choice is when you choose and perform from a place of judgment on yourself and on others. 

If this is off from your care-giving experience, forgive me and speak. Tell what you are going through. We need to hear.

Self-care tip: It is what it is. Find forgiveness for yourself in your human condition. 

Questions: What is your care-giving experience like? Do you judge? Do you feel lonely? What has helped you gain self care during it all?

Keep on!!!!

Anxiety and an Ultimatum

Photo by samer daboul on Pexels.com

“This isn’t working out for us. The way you…”.

Marcy said this was a repeated conversation between her and Eric. They had been dating for a couple of years. Although Eric was my new patient today, Marcy came with him to clinic to explain.

“He is so anxious and doesn’t get it.”

Apparently it had taken a, “do this or else,” push to get Eric into clinic as Marcy was about “to walk.” This is sometimes described as “rock, paper, scissors.”

I adjusted my posture. The tension in the room wrapped around me like numerous threads and I needed to gain some freedom of body and mind. “Do this or else” packages smell like stink to anyone in their space, but sometimes they are what gets people to “open a window” into what otherwise would continue to feel entrapment.

In her effort to balance this out, Marcy described all the great features in Eric’s persona. He was attentive and faithful. This meant a lot to her, who survived many dramatic abandonments. He was kind. And so forth. But…

Eric and Marcy went back and forth trying to explain to each other what they needed from the relationship and why they did what they did in it. Marcy needed Eric to make more decisions, to socialize, and, in general, proceed with less fear through life. Eric needed Marcy to take him as he was. He did not perceive that these behaviors were problematic. He did not connect that several of his previous relationships had ended for related reasons. He thought Marcy was being unreasonable, projecting her own personality onto his. They were different people after all.

This is what the anxiety-story sounds like. Over and over I hear it. It is familiar and common. Most of my patients think that they are unique in this condition, once they accept that it is a problem, that is. I tell them in a bit of a joke that it is, in fact, so very common, that it populates enough to develop into its own medical specialty.

I asked Eric a few basic questions:

  1. Do people think he is a “worry wart?”
  2. Is the worry distracting to him? Feel like “white noise” in his head? 
  3. Does the worry keep him from connecting with his own self, and others?
  4. Does it affect the way he makes decisions?
  5. Does it affect his quality of life? What he considers life worth living for?

I didn’t ask these question like this. They were more open ended, but this is some of what I was trying to glean. There were a few more questions that anyone can look up under the DSM-V and are certainly interesting to read about. In the end, Eric had to come to decide if the problems from his worry were greater than the problems he feared from medical treatment.

Eric explained that his dad would be very upset at him if he chose to medicate. No one “uses drugs” in his family, apparently. (And you know how I feel about calling medications drugs. It’s misdirecting.) I believe that I was supposed to smile at this reference to “the less extreme”, and through empathy, suggest a different nonpharmacologic (healthier) and less confrontational option – such as a weed that grows out of the ground, or cucumbers with cream cheese and dill, maybe.

It’s true that there are many other options to medications to treat emotional illnesses. However, we are talking about medical illnesses. In this case we refer to – anxiety is to the brain, much like diabetes is to the pancreas, cancer is to the replicating cell, or hypertension is to the diseased kidney. And like these other medical diseases, psychiatric illnesses are also potentially improved by other paradigms of treatment. But why in the world would we put science and medicine as an either or to these other options? Can’t someone eat a cucumber with cream cheese and dill, and also take a treatment that has been studied, that has separated from placebo in these studies, and that has gained indication for treatment through the Food and Drug Administration (FDA)? Forget the prejudice against pharmaceutical company profits and pick something extremely generic if you prefer. But please don’t exclude medical care. It reminds me of my aunty who thought to treat her colon cancer with clean eating, various body cleanses, and faith. And then some months later when the cancer had progressed and she was running out of life-time, she decided she wanted to treat medically after all. That’s a sad ending story that we are still grieving. 

Back to Eric and Marcy. He is still weighing his options. She is still complaining about his “limitations.” It’s a pretzel.

So I turn this over to you. How do you recommend we work through this? What could better dispel prejudice against treatment and bring people to a place of less suffering?

Please speak! Keep on!

Daughters

To all the daughters, of any age.

My girlness is triggered. Seeing my daughters grow in femininity is a live matchstick. Woosh! What is this edge and sadness and tears that surprise me; me, the well analyzed adult. Ha!

Where did these thoughts come from, like old dirty  socks from the backside of the dryer? 

My daughters explore their own free rights as well bodied young women. Then flashes explode in my mind, just as unsolicited as the original whistles and lewd comments were. “Hey! Chicky Chicky!” Kissing sounds smack in the air as the men encroach on my space.

My daughter wears a top just so, and suddenly I am 17 years old. My cousin smirks knowingly. “Are you going out to have some fun?” Later I understood he was convinced that because I looked the way I did, I was having sex with multiple partners. 

My daughters pick up on my inconsistencies when I warn them. My somewhat frantic words seem over the top and suppressive. They don’t hear my mom calling me an 8-year old hooker when I walk around the house in underwear. Apparently I was too old. The calendar page had turned and I didn’t notice. Time to wear full attire if my brothers and father were home. It was apparently also time to move my best friend out of my room. I was left alone, listening to the newly roommated brothers on the other side of our shared wall talking and laughing together into the night.

What is this arbitrary line I didn’t see? And how do I explain it and warn my daughters? I’d like to wrap them up in caution tape. “Please be careful my daughters. I love you. Please don’t get hurt.”

It felt like everything reinforced my own vulnerability to that line. “You are not safe,” the line read. “You are not equal.” And I can’t even tell you what it was like becoming a woman in medicine. As I walked along through life, the line progressed too, defining me. “You are just just a woman.”

I have worked so hard to smudge this line throughout my life. So hard. I thought it was as close to a nonissue as it could be while still having a vagina and breasts. This must be why it has been such a surprise when these visceral reactions to my daughters’ development jump up, like turning the crank on the jack in the box. Spring! Cue scary clown in my face. Probably my mother had her own jumping thoughts when she parented me just so. 

I’m sorry, Mom, for judging you. 

My daughters deserve to figure this out for themselves without my sleeping-thorns waking up all over them. They will do well. My fear will or will not continue to heal. But I pray that either way, I don’t use it against them. And I pray that my fear doesn’t ironically distance us from each other. 

If I were a wizard, I would twitch my nose, chant a marvelous Latin spell, and they would gain the ability to proceed with both the guilelessness and the smarts that would keep them from harm and still give them freedom. But the only magic I have is this clumsy love. 

The differences are real. The double standard is not arbitrary. I misspoke earlier.

Getting accepted to medical school with the many family and friends’ opinions dropping around me like stinky flower petals – “She’s her father’s daughter. That’s why.” A patient mid interview aggressively grabbing me. The failure of messy hair and weight gain. Being passed over for a directorship. 

And then there are all the wonderful realities of being girl…. Many. 

I will stand with you, daughters of mine. I will come when you call. I will shake my fist when you are shattered. I will work on my own self care. I will choose, and choose again, to not trip you. And when you mess up, I will still want you. Every time.

Self-care tip: Work on your own self-care in order to love your loved ones well. Keep on!

Questions: How have you found that the condition of your health – emotional, physical, spiritual – has given you more to give to the ones you love?

Hard life

To AnaSofia:

I feel ugly

I feel green

And while I work

I could eat a fly in between 


There are moments in my day

When all I do is think

And I think Of all the things I feel

And now I think I feel a horn on my head


Oh the weapons I possess!

Between my ugliness and horn

And survival skills – I guess

I am just mean


I mean no one will kiss something green

And warts are contagious to hand-holding romantics

And life is just hard

Life is hard when you’re a frog

walking the dog – and grief

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Sheez! Is everyone and their dog going through loss and grief or what?! 2020 has more memes then the president, or ex I guess? But it is TRUTH! 2020 brought so much pain and loss. From deaths, isolation, divorce, housing, jobs or the lack thereof, fires and natural disasters, and all the way to the “COVID 20# gain,” ie., loss of body figure, and more. (Those other people, not me.)

So speak. What have you been going through? Have you suffered through loss? Are you grieving?  Pause and think that maybe that emotion you’re consciously aware of may be coming from a place of grief.

There was a big crashing sound, then a thump. Like someone broke through a week floor board. Ron was in his living room waiting for his wife to come out of the bathroom. It has been a while he noticed when he heard it. An abrupt break in his quiet. Something had happened.

“Megan! Are you alright?”

Ron’s wife Megan was on the floor. Her skin was mottled. “How long had she been in there?” Megan’s pants were around her ankles. Ron ran to lift her up and there were smeared feces on her butt. “Megan. I’ll help you wipe. I got you, Honey.” But Megan didn’t answer or engage. She made no sounds. Ron wrestled the job done anyhow. Megan wouldn’t like this at all. She was cleaned and her pants were up before Ron called 911. Why did he do that, Ron wondered. Should he have called 911 first?

Ron was told that she must have died earlier, and as her body lost its tension, that’s when she fell to the floor, getting his attention. Megan was always complaining that Ron was distracted. She wanted more of his attention. “Hello!” she would say, snapping her fingers. But she said it with a bit of a smile, like she was still trying to be cute after 29 years of marriage.

Ron was devastated. “Megan was my everything; my best friend. I don’t have any other friends. I was always just with her.”

It had been three weeks since Megan died, and he was pale. He looked unhealthy overall. Like he was anemic and like a few other blood dyscrasias had him in their marks. He looked very different from how he had two months prior. Aged. “I don’t want to go on. I wish I’d just not wake up from sleep. I feel like I have nothing to live for.” We were doing telepsychiatry rather than in person, but he looked like he probably smelled too. I had known Ron to be fastidious in his toilette from our history together. I was alarmed.

Here was Ron, seriously suffering. I never want to tell anyone, “I know what you’re going through.” Because the suffering isn’t my suffering. It’s theirs. But for me, in my losses, I have come to a place of my own understanding and hope.

I haven’t had something that has taught me this much about God’s character in a long time than what I have had in losses over 2020. I wanted to give Ron some hope but I was clumsy. What do I say? We are all, even providers in mental health, baffled by death and those who survive. To survive the ones who die before us is a large span of hazy terrain.

When I think of grief, I think of the inverse times to make sense of it. Those kaboom great and wonderful cracks in space and time to try and bring balance in my heart. I’ve had those wondrous moments when God, when S/He, looked most directly at me. Like when each of my kids were born and that jug of oxytocin splashed over my brain. This morning walking by an enormous cactus flower, five bees taking pollen from her petals, He was there. A patient opened up, an honest pose, wanting to receive treatment, She was there. My acceptance phone call into a dreamed over residency program. 9/11. My husband in worship on an early day, door open to the cool and quiet, his profile. These times, I grew. God taught more effectively than a Harvard professor at her lectern.

But it’s been a long time since this much of learning has made its way into human-Me. Dad died and I just don’t feel like I’m completely at home any more. I will be waiting for him the rest of my life. With all his faults, and all his intense and prolonged suffering, yet he was valued. Placing Mom in an assisted living. Losing our childhood home. Death death. My girlfriend’s brother, then her father. My patients. Family. Death and loss. So much death.

I learned more thoroughly that God doesn’t feel completely at home either. Not without us. The sense of missing something. The feeling that the ground isn’t solid under foot. God is pacing the floor waiting for us. This is the big big message I’m getting from 2020.

In this year, I’ve collected a few resources for myself and others who are grieving.

Please message in any others that have brought value to you. We need them!

  1. Nora McInery: We don’t “move on” from grief. We move Forward with it
  2. GriefShare.org
  3. American VI: Ain’t No Grave, Johnny Cash
  4. David Kessler and Brene on Grief and Finding Meaning
  5. I will Follow You Into The Dark, Death Cab Cutie
  6. Grief Observed, by C.S. Lewis

What you got??? Add add more. Connecting through grief. Be a friend to yourself. Keep on folks! 🙂

Wanting, with a capital “W” …and God

A perfect world for me would include Wanting, with a capital “W”. We would want and have the energy and motivation all included, like a first class Qatar Airline’s ticket with real linen napkins for your glass of water with gas. We’d feel the desire to do things, and good things too. We wouldn’t crave that trash like cookies, ice cream, or chips until we couldn’t taste it any more. Nor would it drape us over couches all day watching tv or fill our heads with cotton-candy audiobooks.

A place of safety would have us full of urge and interest for growing our inside parts, the creative parts, the parts that parallel play with what is Love. We would Want, like a coil that unravels, like my puppy seeks my hand, like the people on Easy Street in a better place.

Wanting is a gift. It isn’t a right. People who have never lost it, they just have no idea about existing in the absence of it. But those poor souls who have lost it, who don’t Want, who have felt it leave them like a mist into the ether, that is hard.

I’d like to tell you a story to help you understand. And there are so many patients clamoring to speak, but my own voice for them is clipped by limited skill and talent. Their voices are most eloquent. For this, I refer you to the National Alliance on Mental Illness, (NAMI), who are people for people. An awesome resource.

However, in my own effort, know this: Wanting is a gift. I’ve seen what it looks like when it is gone, and it is vacuous, a void, a space where if not filled, devils come to occupy. The devils of our broken minds. Depression, that is dark. Down down, feeling like it will suck you into the earth and plants will grow out of your carbon compost.

Priscilla asked me why she felt this way. Why was the gift taken, without clear reason? That familiar phrase, “I don’t have a reason to feel this way. Everyone says I should feel good about my life. But I don’t. I don’t even care if I die. I don’t care about anything.” It’s a familiar phrase because many in Priscilla’s patient cohort say almost the same thing word for word.

I don’t proselytize in clinic but I am open to whatever religion people come in with and how they practice it in the world of mental health. For Priscilla, this was her conflicted outcry.

“I need help. I can’t go on like this. I’ve prayed for help. I’ve asked God to heal me. But I’m still so depressed. Please pray for me. Please help me.”

All the like minded believers are feeling super fine with her right now. “Yes. Pray about it. God can heal you.” And maybe some are thinking she must even be a little culpable. Even if at a dusty genetic level. Yet for whatever reason, God has gifted them with lovely Wanting. Not her though. Many here would think emotions and behaviors are spiritual issues, moral, and connected to salvation. I do. …As a psychiatrist, may I? But looking too close at that, at moralizing emotions and behaviors, is like poking the IRS, so all is quiet.

Her outcry, “Please help me!,” was a spiritual request synchronous with a physical and temporal one. “Please help me…” feel and behave well. It’s sounds of Naaman asking Elisha to remove his spots of leprosy. Or the crippled beggar, stretching his hand out to Peter. Or Esther fasting to beg for the lives of her people. “Please help me.” The spiritual is there with the body.

In my life, having practiced in medical research as well as clinical care for 18 years, and after a super super long many years of schooling, after having walked through church and daily Bible study, (and this is a run on sentence as that’s what this unfolding in my professional experience feels like sometimes), I am comfortable with asking God to help Priscilla, whilst helping her see and achieve how God, S/He, is going to do that for her through a medical approach.

But the absence of Wanting in her life, wanting to get up in the morning, wanting to read her Bible, wanting to take care of her kids, to shower, to have sex, when she doesn’t want this, it isn’t fair. It isn’t because she was bad, or is less than any of us, or doesn’t have the ear of God. I’m very comfortable saying that she has a treatable objectively identifiable medical illness. Thank God. God is all that is good, and kind, and God has mercy for us bleeders, the jacked up, the mean spirited and the ruined. God sees what is wrong with our bodies and minds, and God doesn’t resent us getting medical help. How absurd otherwise.

Self-Care Tip: Give yourself a break and ask for help. There is a better place. Keep on!

Questions: Have you ever experienced the absence of Wanting? Or seen it in someone else?

What did it look like? Please tell us your story. We need to hear.

Interim Post – floating home

Dad died and maybe it’s been about a month. I don’t remember the date. Now that I think about it, that seems like a failure. A “D” grade. How could I forget the death date? But I have been finding myself edging away from thinking about him and his death.

People talk to me about him and they say things like, “Isn’t it nice that he is resting now? He suffered for a long time.” And it is.

They say, “He really didn’t have much to live for any more. He couldn’t walk, talk, interact much.” And he didn’t.

Dad died about a month ago but Friday was the first time I said the words just so. My poor friend stuck her foot in it and I cringed for her. “How are your parents doing?!” she asked almost aglow. My parents brought that out in people. Good will and community. There was that moment when I wanted to protect her from Dad’s death and Mom’s isolation. But the knowledge grabbed me like a great wind and threw me up against it’s rocky finality. I looked her straight in the eye and responded, like I was gripping my seat in a Boeing 747 going down.

“Dad is dead.”

“He died about a month ago. And Mom is in an assisted living. She’s doing well, thanks.”

I hadn’t said those words out loud till then, to that unsuspecting kind face. Why hadn’t I? Dad is dead.

On Dad’s last night, Mom leaned over his face. (When Dad aged his bones seemed to protrude looking almost like a steering wheel, and the rest of his face sunk inward.) Mom pulled on his bones, trying to make eye contact. Dad had a hard time turning his head. She was crying. “You’ll always be my prince, Rob. You are a prince.” And Mom wasn’t glad for him to leave.

Even now, looking it up feels too tiring. Just when did Dad die? I don’t remember the date. Dad died about a month ago. And this month, has been full of work, and family, and wading through COVID-19. Dad’s ashes are sitting at the funeral home waiting to be buried whenever we are allowed to do it in person. People keep asking when the memorial is. And time is filling in the space between him and I. A foam. A retardant.

Telling my friend, saying the words, cleaned out some of the space. I had been, in general, fine over the past weeks; well cushioned and buoyed. Now, not as much. And I find that although it frightens me, and although thinking about Dad makes me feel unprotected and vulnerable to those somewhat odd congratulations on his death, contrasting with the apologies of others, although all this, the water I am in feels mostly like it is carrying me home.

This post is an interim post. I’ve not got selfcare tips to share. Just my journey. With you.

Keep on!

Your False Intuition

The curse of “intuition” in Data Science - Towards Data Science

You can’t listen to your intuition all the time. You have to have a healthy dollop of distrust for your own inner voice. The siren’s song of our inner self to isolate and “do it on your own”, however dulcet and powerful, are dooming.

When Marsha suffered a dramatic loss in the stock market, she became crippled by anxiety and irritability. It had the further outcome of estranging her from her spouse and friends. She spent all her clean, controlled, but lonely time, alone, like a many thorned beautiful rose in a glass vase.

Marsha and I tugged with this concept, like holding onto different ends of a rope. She did not want to go to therapy. She did not want to disrupt her flow.

Sometimes our lives are “in flow,” but it’s not a healthy flow. We are doing some healthy behaviors, such as exercising, getting our sleep, eating well. However despite this, our emotional disease progresses, unchecked by uncomfortable deliberate efforts. Sometimes we are medication adherent even, and yet our behaviors and emotions are not kind to ourselves. We remain in a condition of suffering, isolated; unable to connect to self and others.

During these times, we need to disrupt the flow. It is laminar, even lovely in its quiet arc, that dishonestly soothes. We need in this case, turbulence and a different direction.

If what you are doing isn’t working, add turbulence and do what is uncomfortable. In Marsha’s case, we both laid the rope down, (smile,) and she pursued a day hospital where she worked on changing her automatic thoughts toward those that were kind to herself. When something triggered her, how she responded, and before she even knew she was thinking about it, was healthier.

Question: Have you ever been misguided by your own thoughts? How do you safeguard against an intuition that may not be kind? Please speak and tell us your story?

Self Care Tip: Don’t let your own intuition be your only voice of reason. Be a friend to yourself.

NAMI – in case you want to join us…

Maintaining Your Mental Health During
COVID-19 Crisis
Due to COVID-19 Public Health protocols NAMI Temecula Valley will be hosting our Mental Health Forum online.
Wednesday May 20th 2020. 


 Our Guest Speaker:    Dr. Johnson-Quijada 

This is from the NAMI website:

Wed, May 20, 6pm – 8pm

Description: The forum begins with sharing, and resources. Following this, every month a pre-selected guest speaker will take the podium and share their expertise with you.
All questions and answers will follow the Mental Health Forum. The forum is held monthly on the third Wednesday and is open to individuals 18 yrs. and over.  DURING COVID-19 CRISIS JOIN US ONLINE.
JOIN ZOOM MEETING
https://us02web.zoom.us/j/89884260271?pwd=NllEOXkvRmlNdERWUXVtelRHTzhPUT09

Meeting ID: 898 8426 0271
Password: 417783
One tap mobile: +16699009128, 89884260271#, 1#, 417783# US

Dial by your location. +1 669 900 9128 US (San Jose)

Some notes: Share and care will begin at 6pm, and the presentation will begin at 7pm.

 Install and test Zoom ahead of time at the following link: https://support.zoom.us/hc/en-us/articles/201362193-Joining-a-Meeting

Dealing with it! Covid and Mental Health

Let me tell you a story.

Once there was a young man who couldn’t negotiate the world around him well. He ostracized his peers with his behaviors. He was easily offended. He didn’t enjoy much and people could sense that, like a divining stick whenever he was around. Do you recognize him? Have you heard this story before? 

Let me tell you another story of a middle-aged woman who lost her son suddenly to asthma. He was sleeping in his apartment in New York far from home. They spoke the night of his death on the phone, not knowing that it was their last conversation. This mother was awoken the following day by her son’s wife who screamed at her that her son was not breathing. This mother spent the next three years in seemingly mental silence. She felt like she turned off. She did not understand how this could have happened. She was not forgiving. She was called aloof by others. Other people did not remember her son like she did. Other people did not feel it inside of their bodies; feel it inside of their emotions; feel it inside of their spirit. Other people did not stop hearing God. Other people did not, as she did, and it left her very alone. Have you heard the story? Do you know her?

Once there was a teenager at work. Her boss pressured her to drink while on a break, and then keep drinking until she was drunk. He was her boss. She was afraid. Afraid of losing her job. Afraid of him. He forced himself on her and although intoxicated at the time, she did not blackout. She remembers over and over and over. She remembers, almost like rewatching a movie. Scenes from that day intrude during school. They intrude when she is with her parents. They intrude when she is trying to sleep. This teen avoids anything that reminds her of his stink. She avoids stores with bells that chime over the doors upon entry. She unfortunately hasn’t avoided alcohol though and that has been another form of misery to her. Do you know her? Maybe you have met.

There once was a boy who kept getting in trouble because he couldn’t focus. There once was an elderly man who only remembered his younger days and nothing new would stick. There once was a worry wort who couldn’t get out of her head. There once was… 

There once was you.  What is your story? And how do you deal?

We are currently in a quarantine. (There’s news! Smile.) And people want to know how to cope during this time of unanticipated stress.  

I’d like to ask you. How have you dealt with your emotional pain so far, apart from quarantine? All these stories could have potentially isolated us in our suffering. There’s nothing quite as potentially isolating as mental illness. It destroys our ability to see ourselves. We become disconnected from self and others. We lose empathy, trapped in our own suffering. We are called “selfish” because no one can give what they don’t have. We lose our ability to chose freely, because the mental illness chooses for us. But you know that you have come up with coping skills to deal. You have brought your suffering into the space of your healthy and become more whole doing it.

These are the same coping skills to fight the tendency toward emotional isolation in quarantine. 

Questions: What are your super-power coping skills you swear by? Please tell!

Self-Care tip: Fight the isolation from quarantine with the basics you already know, if you ask yourself. Keep on!

Mother’s Day – tied to a horse

Sometimes I don’t want to respond to the, “Happy Mother’s Day’s,” as I keep feeling all the many conflicting but authentic bits of motherhood under me, like thumping behind a free willed horse I’m tied to, who’s aiming through Nottingham’s Sherwood Forest. There’s so much pressure to be the cherubic woman on Mother’s Day. Really? Heals! Whilst roped behind a horses bum!

Look! There’s Marian! She’s sagging and her right boob is slung over her shoulder. Nifty!

“Way to go Marian! You look terrific!”

See. We all lie for love. 

Marian responded with a rude gesture but she was smiling. Oh, the inconsistencies women wrestle must be expressed!

There’s the number one: Being a mother is the best freaking thing of my life! I’m so glad I’m a mommy! And, thank you for making me breakfast. Yum!

Once a year.

Get away from my babies, world! You can never love them like me!

But numbers two through ninety-nine are always rudely jostling for position. Motherhood is like a stutter on repeat of, it’s really not about you!

Or wait, it is! If they fail, ie, turn into a collage of psycho-murderer blended with a throw-up fake and furry do-gooder, it’s all on me! Like getting ticketed when your kid shoplifts Snickers at Target. All time low. (I know you’re asking if that happened to me.)

One hundred stays quiet, squat and permanent: Those kids will leave you in the end. And then you are old.

But I think the reason we yell, “Happy Mother’s Day!,” to each other (and please don’t forget the apostrophe! There’s nothing that reminds us of what failures we are as mothers than bad grammer! Or is it gramm-ar?), is so that we remember, we have each other. We are really not alone.

Happy Mother’s Day, Peeps! You look great!

(Ow! Don’t throw things at me!)

And if you don’t get it, than you don’t get. Maybe read this again in ten years.

Self care tip: Stay connected. You are not alone.

Questions: Tell us about your Mother’s Day. Boys too! We want to hear you.