“The devil is talking to me.”Briefly on God and Psychiatry

“The devil is talking to me.”

Her lips shaped words but her voice was like a robot. 

My gorgeous tall black thin framed model-bodied patient looked at me with a face that barely moved. Almost flat. Her eyes rarely blinked, with orbs that seemed to jump out at me when she spoke. 

This is Talia, a 3.8 GPA college grad last year who just started her first job in marketing. She has been a Jehovas Witness for about ten years and is passionate about her God and religion. She has been attending church related meetings lately about 6-7 days a week and loves to read her Bible for hours. However, over the past six months when she reads the devil and his minions cuss loudly in a cacoffany of foul persecutory language. She is afraid all the time and has high inner tension. 

Talia cannot sleep any longer for more than a few hours at a time. She has been losing weight. She has lost her job, and is panicking, terrified to read her Bible or go to church. 

Her family says she is talking to herself, and has “crazy eyes”.  They do not know what to think. Maybe she is possessed as well as crazy. Maybe both. 

Is Talia possessed by the devil? Is Talia crazy?

I was in Los Angeles this summer with my kids, walking on Hollywood Blvd. We passed several people who were responding to internal stimuli. One extremely saddening lady was slumped against a shadowed corner sitting in her own piss leaking down the street, her shirt half open, as she spoke to various targets. My kids were afraid. We were all, frankly, sad. My kids did wonder, too, were these people possessed by the devil?

Have you ever wondered if the devil was talking to you? Or working on you? 

The question is, if you want to ask this, rather ask, “What does this say about the character of God?” Included in all the biology explanations and psychosocial intersections, we bring the magical and spiritual. If you ask about the devil, ask rather about God. What does this say about God?

Talia had been adhering to her treatments and now celebrates that she is able to read her Bible again, go to her religions meetings, and has even driven around a parking lot once with a family member in the seat beside her. She is sleeping through the night, able to enjoy life, the simple and large things like the touch of shower water or taking a walk. 

When Talia hears voices, she no longer believes the voices come from the devil but rather demonstrate that she has missed something bad inside of herself that she hasn’t yet surrendered. I asked her, “What does that tell you about God? The character of God.”

We are so quick to assign nonbiological causality to emotions, thoughts and behaviors. It turns out that when the brain gets sick, emotions, thoughts, and behaviors generally go the direction of bad, rather than “good.” Naturally we ascribe moral value to what we are culturally primed to believe has moral value – emotions, thoughts, and behaviors. The question becomes, “What does it say about who God is when we do this?”

I like to think about the character of God. It is a picker upper. When I get enmeshed in some line of thought that demonstrates a poor reflection on Gods character, I figure at some point that I’m not seeing things clearly. It’s always a relief. I don’t know it all. If it says horrible things about God’s character, than I must have some misinformation or misinterpretation. 

Others may say rather, I am misreading Gods character as good. That’s not a perspective that is friendly to me in the end. One of the reasons I reject it. 

Self care tip: Ask yourself, “What does this say about God’s character?”

Questions: Have you ever wondered if the devil was talking to you? Or working on you? 

Do you ascribe moral value to emotions, thoughts, and behaviors?

What does it say about who God is?

It’s not my fault

It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

Introducing our new co-author at Friend to Yourself

Finally!

I’ve been hoping, asking, looking, waving awkwardly in the hospital hallways, trying to find someone who would join me in this great blogging experience with you on self-care. And, finally.

Please join me in welcoming Dr. Helme Silvet! You will love getting to know her, and she will love, as I do, sharing space with you. Keep on.


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Helme Silvet, MD, MPH, FACC
Loma Linda University School of Medicine
Chief of Cardiology, Jerry L. Pettis VA Loma Linda Healthcare System

Hello!

 

My Blog Journey

Sana (or Dr Q) and I have known each other for two decades or so (and yes, we have lived that long). We have spent hours talking about what makes us excited to be physicians, what gets us up in the morning, and what makes us upset. Finally, we decided that it was time to share some of these thoughts together. Taking care of self is a principle that we both try to teach our patients, but also practice ourselves in order to be effective parts of our families, communities, and humanity. The goal of this blog is to attempt both from the, perhaps, somewhat unique perspective of biology, and medicine as the starting point to self-care.

My Professional Journey

My medical experience started in the “old country” behind the Iron Wall – I grew up in Estonia and graduated from medical school there. After the Soviet Union opened its borders, I made my way to the U.S. and finished an internal medicine residency at Loma Linda University and cardiology fellowship at Brigham and Women’s Hospital/Lown Cardiovascular Center. Starting in 2003, I have worked at the VA system as a cardiologist. Along the way, I also graduated with an MPH degree from Harvard School of Public Health. I am passionate about making people get better – this includes preventing, treating and managing heart disease as a cardiologist – but also helping my patients make sense of their life journey. One cannot treat and prevent disease without caring for the whole person.

My Life Journey

Between my two sisters and myself, we have lived in 5 different countries – this has made for interesting holidays! Seeing different parts of the world up close has given me plenty of experience, but has also come with a certain sense of displacement. It has been a continuous struggle in my life to figure out where I fit in the wide world in general, and in my little microcosm of a world in particular. In this context, it has been fascinating to learn different things from different cultures, and observe how people with different life experiences can effectively communicate with each other. And I noticed that somewhere along the way, my quest for truth and knowledge is giving way to a quest of understanding and compassion.

Disclaimer

The thoughts on this blog are my own and do not represent entities I belong to in a professional capacity. The stories that I tell are true in principle but the details may have been changed to protect people’s privacy. The blog is not meant to offer professional advice or treatment advice for specific medical conditions; the goal is to share ideas, general principles and stories of a personal journey.

 

Desperation – When to Speak

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I’m about to park in LA for the LAX protest against the immigration ban.

Last night my husband and I debated whether to come or not and were both disappointed to realize that we both wanted to be here. I mean, it’s Sunday and we don’t get a lot of down space. We have our kids who, thank goodness, still want more time with us. We have projects and exercise and self care that is on our agenda. We are moving away from a “zero percent progress” every day toward something better, right?

Apparently, I’m a moderate. I haven’t felt the pain. I don’t have the fire. But not very long ago was the Jim Crow era, where our parents came from.  When there’s something I’m passionate about, I have to get my feet moving or I’ll miss it.

But this immigration ban is bad. This is just xenophobia and racism.  It is personal. I think of my Lebanese cousins who have been in the war and immigrated to our country with their hairy arms and scars. I think of Mom. I think of my in-laws who arrived in New York from the Philippines with $5.00 in their pocket.

What have immigrants done for America? Well. Look around. What have you done? This is who we are.


In a protest, community is strong. Unity is strong. Today, there was some prodemocracy stuff, but there was also a lot of anti-Trump-eting and name calling.

The protest felt a little like people were peaceful. They were upset. There was a lot of Trump-fest going on. But it wasn’t just that. There was a little anger with a little despair. Those guys were suffering, but it could lead somewhere.

When we start protesting a person, it becomes a zero-sum. We lose the opportunity. We didn’t waste all of the opportunity today. It was mostly a foreboding of what could happen.

When Martin Luther King marched at the Lincoln Memorial, it was very organized. They had basically shut down the city bus transport by not using them and choosing instead to walk seven miles to work, or set up car-pools, an early Uber system. They were unified in their despair. MLK had been put in jail many times for his fire. He was not moderate. When he spoke, he spoke about justice and equality, and didn’t give stage to McCarthyism. He mentioned him, but that was it. If Trump were president at the time, he would have gotten the same mention in his speeches and letters.

MLK said in his letter from Birmingham Jail, that moderates are just as evil because they are not going against what’s wrong. And that’s what’s wrong with all these things is because we are moderate.

So one of the reasons we go to these things is so that we don’t allow things to passively happen.

“Shallow understanding from people of goodwill is more frustrating than absolute misunderstanding from people of ill will. Lukewarm acceptance is much more bewildering than outright rejection.”

We have a general idea that this isn’t right. But we don’t have that despair. We are privileged. But we have a sense that this is wrong. So that’s why I move. To help me understand.

Maybe we, in this generation, have not suffered enough to stay focussed on the principles being violated here. We are America. We believe in humanity. We do not discriminate against another race. We do not believe our race is better than theirs.

The world is small. A refugee physically, manually by another human’s own hands, who is being pushed away back into the ocean from a Greek beach because the Greeks cannot feed their own countryman, affects all of us. Starvation changes one’s belief systems, I am told. These people are not moderate. They are being violated. I don’t want to be a part of who violates them. It doesn’t need to be said that I wouldn’t want to be them.

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Why do we march? To get our feet moving. We want to learn more. We march to help us understand.

 

Self Care Tip: Find your fire, take a stand.

Questions: What’s your story about immigration? How is this personal to you? Keep on

 

This is What America Can Give You

I told my patient today,

“You’re smart, you’re beautiful, you’re young, you’re healthy. This is what you have. Go and do it. Fight hard. You can only control yourself. Don’t wait for someone else to fight for you. This is what America can give you. The opportunity to fight hard for yourself.”

Keep on.

Electroconvulsive Therapy: Addressing the Stigma

http://www.medpagetoday.com/resource-center/Advances-in-Major-Depressive-Disorder/ECT/a/61938?eun=g8732591d0r&xid=nl_mpt_special_reports_2017-01-16

Bad Sleep is Not Sexy

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I tell my patients some rough version of this:

My agenda is that you get sleep.
My agenda is not that you take your sleep meds the way I prescribe them.
Just don’t take them at a higher dose than prescribed.

When prescribed medication, sometimes my patients tell me they think, from me or from other physicians, that they need to do it exactly as prescribed. And that may be true. With most. But there are some medications, which must be specifically described by one’s prescribing provider, that may be used in the way that the patient determines is most useful. The patient needs to look, to think, to speculate, to reflect. Adjust the medication dosages, and try again.

Going forward, before I tell you how you should sleep and what to take for it, think about how your sleep is.  What are the difficulties you have with sleep?
Falling asleep?
Staying asleep?
Early morning awakenings?
Is your sleep refreshing?

Renaldo, (“Please call me Ren”), can’t fall asleep. He lays there for hours, before he finally falls asleep in the early morning hours.

In Spanish we call the early morning hours “la madrugada”. I’ve always enjoyed that word.

It’s been happening on and off for Ren over the past year, but is worsening lately. He is now afraid to go to sleep. Afraid to looking into the dark night while in the company of his thoughts. He has a feeling of dread as his evening comes around. He finds himself avoiding going to bed.

When dealing with insomnia, first we look at these personal observations. They are called “symptoms,” when they are involved in a pathology, a medical illness.

Then we look at why. Why?

To answer this we consider what regulates sleep in our body and outside of our body. These pathologies we suffer come from what is in our body and as they intersect with what stressors come to them from outside of our body.

There are so many medical illnesses that produce insomnia.
Inversely, there are so many medical illnesses that come from poor sleep.
There are also many behaviors and outside-of-our-body stimuli that affect sleep.
Hmm.  Well it’s not either/or. It is likely a tangle of these roots that make this ugly plant grow.

Where to start?

We have covered sleep hygiene a couple times. Have we made the changes in our home and personal sleep culture to groom our sleep accordingly?

Say we have. We don’t read in bed. We don’t have a TV in our room. We don’t use the bedroom except for sleep and for sex. Hey! Sleeping well is sexy! Ahem….          ….We keep the lights low. We try to go to and out of bed around the same times every day. And so forth.

If these were not attended to, a disease process may develop. It is during sleep that our body heals. None of our body rhythms heal during the day. All the neurotransmitters, chemical messengers, hormones, all of these replenish and regulate into a healthy rhythm during sleep. Also, all of our memories consolidate during sleep. That dumbing in parenting syndrome, which I’ve respectfully labelled “DIPS”, may come more from the broken nights, than by the busy busy kids.

Okay. Say we are practicing good sleep hygiene, yet continue to have poor sleep.

There is a reciprocity between symptoms and disease etiologies. In other words, a broken sleep cycle may trigger certain genes to express themselves, and vua-la! Ren is suffering from an anxiety disorder.

Or, Ren’s anxiety genes become triggered for another reason, maybe simply his age, maybe he has low testosterone, maybe he has a thyroid disease, or he snores, and his circadian rhythm, (ie, sleep cycle,) disrupts. Vua-la! Ren is suffering from a sleep disorder.

It’s like the wheels of my mom-van. I bumped the curb the other day and pinched my tire. I disregarded it, …and the orange hazard like on my dashboard. Don’t judge me.

My steering seemed to wobble over the next hour. I pulled over and sure enough. A flat. I wisely (grimace) decided I could just drive it to the repair shop, rather than get a tow. By the time I got there, my wheel was bent and my van alignment was off. There’s a reciprocity to the wellbeing along with the demise of my van’s health.

In my book, Sleep Well, I cover some of these anxiety illnesses. I don’t cover affective illnesses such as depression, or hormone imbalances, or so many other physical pathologies that are involved in generating poor sleep. They are also reciprocally important to emotional health and a quality of life.

I told Ren,

So what do you think is going on with your sleep?…

Questions:
What are your sleep symptoms?
Do they come from a pathology?
Are they triggering other pathologies?

Self-Care Tip: Sleep Well. Be a friend to yourself.