Get You Some of That – Medical Treatment for Medical Illness

…Continued from yesterday.

Cole_liveCole Swindell – Get Me Some Of That

Why do I feel so horrible when I start a treatment that is supposed to help?

Medication treatments for depression and anxiety, and some other brain illnesses, often worsen how you feel before you feel better. I can’t tell you how many patients have told me that if they had known this before, they never would have stopped their mediation(s).


Yesterday, our post discussed a Dr. Jones and Presley.

Presley fired Dr. Jones when after following her directive, he subsequently experienced an extreme panic attack. Dr. Jones may not have done anything wrong in her treatment recommendations. Presley was just an individual, as compared to a “number on the curve” of treatment responders. Escitalopram, the medication discussed as an example yesterday, (one medication option out of many), may have been dosed at an initial amount that Presley’s body couldn’t handle “straight out of the gait”, so to speak. But likely, if he had started at a lower dose, maybe ½ or even ¼ of the tablet, and then waited for his body to accommodate to the medication. Then Presley would have tolerated it. Presley would have tolerated slowly increasing the medication if approached, rather, piece-by-piece of a pill. I’ll even joke with patients,

I don’t care if you lick the pill. Just get on it.

When slowly titrating a medication, it allows the individual’s neurotransmitter receptors to down-regulate whilst the agent floods the receptors. If there is a neuron targeting another neuron, there’s a baseline balance in time. There is a baseline understanding between these neurons. An agreement, of sorts. “I’ll sit here and receive your messages,” (neurotransmitters, or chemical messengers such as serotonin, norepinephrine, and/or dopamine). “I’ll then carry those messages on your behalf to their intended recipients,” (such as the amygdala or hippocampus). But then this person artificially takes a higher quantity of these messengers, for example, by way of medications, and floods the system. The receivers, (or neuroreceptors), have to adjust to this to establish a new healthy baseline. 

In this initial time of treatment, when 1st introduced to the increased neurotransmitter-load, (ex: as released by a tablet of Escitalopram), there can be a negative response, such as panic and/or depression emotions. We call this, “initiation side effect’s.” Once the neuroreceptors get used to the new load, then the response improves. 

After accommodating to the new pharmacology, the brain is allowed to experience the blessing that comes from treatments, and heal.

Some individuals are outside of the curve and cannot tolerate the standard initial treatment dosage, like Presley was. Some are inside, and can without much difficulty. The point in treatment, though, is that the person just needs to get on it.

Get on treatment. However you do it. You have to make the treatment work for you, an individual, in your own way. The prescriptions are there to serve you. You aren’t there to serve the medications. I like to analogize Jesus’ statement,

The Sabbath is there for man, not man for the Sabbath.

Make it yours as an individual and reap the benefits; the blessings inherent there. (See Mark 2:27). 

If you don’t get on the treatment, you won’t get better. Anything less than this will be inadequate. It’s like drying water off your face with a hand towel while still walking in a rainstorm.

What is your agenda in treatment? List it. Write it out. Then, go get you some!

Outside a medical approach is like flicking water off in the context of a rainstorm. If your agenda is getting to your healthy self. Get out of the storm and get dry. Then go get it. 

You have a medical condition. Treat it with the assistance of a medical professional. 

I don’t go to a plumber to help with my electrical home repair. I don’t go to an accountant or a church counselor to treat a medical one. 

The plumber, the accountant, the church counselor are what they are. This is not minimizing their efficiency in their own fields of excellence. But why do we seek care in psychiatry from those who haven’t studied this? From those who are not experts in this? Maybe stigma keeps us away from psychiatric care. Maybe misinformation directs our search for mental health treatment elsewhere. 

Self-Care Tip: Get you some medical therapy for medical illness.

Question: What are further concerns you may have about taking medications? How would you prefer your medical providers to work with you? Please tell us your story. 

But I’m Not Someone Who Likes Taking Meds

pill

Presley couldn’t breath. A truck just drove through his thorax. A monster-hand was closing around his heart. He couldn’t swallow well. Was something stuck in there? Dizziness nearly dropped him, but instead of moving to sit down, like any other normal person would do, he bolted. A fire chased him. He had to escape or he would die. In the bathroom where he found himself, the mirror reflected a sweaty face and crazy eyes. Was he dying? Presley’s phone looked blurry as he dialed, 911.

Please help! I’m having a heart attack!

That was the first time this had happened. After the third visit to the emergency room over the past month, Presley was able to avoid calling 911, although still convinced he was going to die when the next episode hit. He agreed to seek counseling, where he was taught different skills to connect his mind and body, to slow his breathing down, to process, even when he was convinced he was dying.  For a time, Presley improved. It was like it never happened. He was almost able to convince himself that it wouldn’t happen again.

This turned over and over, feeling like he was going to die while losing his mind, re-engaging in counseling, thinking he was better, stopping counseling, and then another violent emotional event, thinking for sure, he would die.

It was after his second trip to the ER when he received the recommendation to schedule an evaluation with a psychiatrist. But he preferred to work through this in therapy. Presley didn’t like pills. He wasn’t someone who medicated. An olive-skinned athlete, he lived clean and didn’t believe there was much that healthy living couldn’t cure. And Presley did live clean. He ran fifty miles a week. He ate raw foods. He read his Bible.

After several months of this, his therapist, Dr. Wu, recommended he get a psychiatric evaluation. However, Dr. Wu agreed that he would continue to work with him, whatever Presley chose. (Was this the right thing for Dr Wu to do?) Presley chose, no. No psychiatrist. What would a psychiatrist do to him anyway?! He wasn’t crazy. (Except when he thought he was.)

Presley visited his primary medical physician, Dr. Belinda Jones. It had to be better than seeing a shrink!

Dr. Jones, I don’t want to take meds.

Dr. Jones, cleared him for any medical condition that might be contributing to his events. Only then was she able to convince him to try a “safe antidepressant”, escitalopram. After one pill, Presley had the worst event of his life. He’d never had any experience that was more terrifying. Presley didn’t go back to Dr. Jones, “of course.”

When these emotional tornadoes hit more frequently, he became paralyzed with fear that he would have them in public and be humiliated by them. Presley stopped going to work.  If it wasn’t for his rent, he’d never go back. But he had to. So finally Presley agreed to see a psychiatrist. …

To be continued

  • Sincerely, Dr. Q

Questions: What would you tell Presley? 

How would you like your physician and/or therapist to handle this, if it were you?

Why is Presley so opposed to taking medical therapies?

Please speak! We need to hear you.

Self care tip: Keep on! 🙂

Looking at your better future

smash

Dr. Kowalski walked into the hospital cafeteria and found me at our usual table, saying, “I hate it when I go to hug someone really sexy and my face smashes right into the mirror.” It wasn’t his joke but he always had something like this to toss at us other onlookers at the caf on our lunches.

He made me laugh and I felt like there weren’t enough of his type of friendship in my town. He was a peer in my community. He was a professional, a parent, a spouse. I enjoyed working with him and I respected so much about him.

Most of the time, with Dr. Kowalski, we talked about random stuff; hospital politics, his parents in England, God in his life, his kids’ latest antics, and the conversation rolled with content and interest. This day, after his short stent with humor, he skipped the food line, and just sat down to talk, starting in with a doozie.

My son is smoking a lot of marijuana.

Dr. Kowalski described the skeletal points of Frank’s, his son’s, journey with anxiety and then with marijuana. Now nineteen, Frank had anxiety his entire life. Paralyzing anxiety at times, and completely preoccupying at others with worries and inner tension.

Once when Frank was seven, “such a beautiful boy,” Dr. Kowalski told me, how Frank reacted when he was twenty minutes late picking Frank up from school. Most of the kids were gone already and Frank had to wait for Dr. Kowalski in the administration lobby next to the “mean secretary,” quietly in a big chair by himself, until Dr. Kowalski arrived. For three months after this, with his fluffy cheeks and round blue-blue eyes tilted up, Frank asked his dad over and over again, if he was going to pick him up from school that day. Would he pick him up and,

“Would he be on time?”

It was super hard for Dr. Kowalski to witness. Sometimes he would get impatient and snapped at Frank in response. Maybe raised his voice, or just ignored Frank’s questions. Dr. Kowalski felt a lot of guilt about this. He blamed himself in part for the persistence in Frank’s anxiety. If he had been more patient with him, if he hadn’t scared him with his voice, if he had gotten him into treatment… If he had been a better father, would Frank still have anxiety? Would Frank now be using three bowls of marijuana three days a week? Dr. Kowalski states that he would do anything to help Frank get better, and often does. Just about anything he can.

Whether Dr. Kowalski did or did not, Frank believed that anxiety led him to using marijuana.

Dr. Kowalski was the director of the adolescent psychiatry unit at our hospital. He knew that, although marijuana use often decreases the perception of anxiety at the moment, over all, in the way it affected gene expression, it exacerbated their anxiety. The disease exacerbated. So the user felt better at the moment, perhaps, but then the underlying anxiety process became worse and worse. Frank told me,

Using marijuana for anxiety is like a diabetic who takes insulin so he can eat a big cake.

But what could a father do for his son in this scenario? Being right, being correct about something, having knowledge apparently isn’t always how things, like convincing one’s son to stop using, are won. Dr. Kowalski did not know what to do.

Perhaps the guilt, perhaps the love, or for other reasons, Dr. Kowalski had spent the last several years of Frank’s marijuana-using and anxiety ridden life, trying to help Frank get into treatment. Treatment for anxiety.

When treating any biological psychiatric condition, something medical, we have to first look at anything we are doing to harm ourselves. Is there anything that is pushing us in the opposite direction of our efforts? Maybe we are drinking caffeine. That triggers anxiety. Or maybe we are using another substance that triggers, and/or worsens an underlying mental illness. With this in mind, Dr. Kowalski spent much of their discussions trying to engage Frank into preventative measures as part of his treatment recommendations. But what could a father do? Dr. Kowalski was not Frank’s treating psychiatrist. He was Frank’s dad.

Dr. Kowalski told me, with lines seemingly appearing out of no where on his usually bright and happy face, about his frustrations.

The amount of energy I am putting into helping him without results bothers me. And a lot of money to help him get better. I feel it is wasted until he puts in the effort to help himself.

I want to invest in my child! I do! But to help him get better. Not to just spin our wheels. He isn’t working to stop doing the things that actively work against this goal.

Feeling violated to a degree, used, Dr. Kowalski didn’t get it. He was giving his energy, his finances, his time, his emotion. He was giving every time Frank came to him or called in an anxiety crisis. Dr. Kowalski no longer wanted to do the “energy wastage.”

“It’ll be sad if Frank doesn’t get this idea,” Dr. Kowalski said. Frank may never choose to further work on his wellbeing, but the difference is that Dr. Kowalski decided he wouldn’t continue, with Frank, through talking therapies, and talking emotional rescue efforts, pretending they were working on something.

Dr. Kowalski wanted to tell his son,

I’m being taken advantage whether you realize you are taking advantage of me or not.

However, Dr. Kowalski was scared of stopping. He was scared of not staying on the phone for the long long conversations with Frank in crisis. He was scared of not continuing to pay for the talk therapy. He was scared of not continuing to give Frank his monthly living allowance while Frank was in college.

I asked Dr. Kowalski what the difference was between where Dr. Kowalski was now and wherever he thought it would be for him when he wasn’t being “taken advantage of?” If Frank wasn’t going to put in whatever effort Dr. Kowalski thought Frank should be doing to get better, where would that put them? Dr. Kowalski feared that this bond, yes maybe a bond somewhat founded on illness but still a bond between him and his son, would fail.

Their relationship, true, has strengthened, like an Indian trail that is treaded down daily on the forest floor from their repeatedly hashing out the anxiety. If that changed, Dr. Kowalski feared that maybe Frank would not see much reason to call Dr. Kowalski. Maybe what Frank valued in his dad was just that.

Dr. Kowalski told me that he believed there was, in reality, a sustainable bond between them. But Frank? He didn’t know what Frank would believe.

Dr. Kowalski and I rolled this story around in the air between us. After a stretch of disclosing his sincere grief, real fears, and underbelly of sorts, Dr. Kowalski decided, rather than starting with what he would stop giving and doing for Frank, he’d like to ask Frank,

What do you think your life would look like if you didn’t have this anxiety? Who would you be? Who would we be?

Dr. Kowalski said, “I’d love to find out.”

Self-care tip: Start with open-ended questions with yourself and look ahead.

Question: What is keeping you where you are and where would you be if it weren’t?

The Path of More Resistance, and Brain Health

 

The bar hummed with the energy of human emotion.  It was one of the few places Alfred could still smoke in public. He remembered the first time he was directed to a smoking area in the airport that looked like an enclosure for zoo animals, with glass walls, and positioned in the line of traffic. What in the world?! So Alfred felt unjudged at the bar, and also pumped up.

Alfred got energy from being with people – gravitated to them like a little brother follows his big sister around. If it was the bar, or the smoke break, Alfred got energy if he wasn’t alone. He absorbed every moment, marinated in it no matter how brief. The “moment” was his forever, for however long that moment would last. He was inside the color, flavor, aroma, texture, and song. He noticed. And, Alfred grazed. Amongst ideas, people, choices, and of most anything that came into his field of vision, he chewed it up in that space of time, and then moved on without guilt. Generally people didn’t hold grudges when he moved on. Alfred was just so nice!

When Alfred was in sync with his energy, senses, feelings, and perceptions, and his wife was in sync with her own, she looked at him like he was someone she was interested in. He could make her laugh and play, whereas she was never normally someone who was playful. This was nectar to Alfred’s pollinator.

Out of sync, however, Alfred’s wife called him names when they argued. He was “flakey,” or “narrow-minded.”  And Alfred, awkward with conflict, developed the habit of escaping during those times. He did not like conflict.

Alfred began to drink a lot more alcohol. After work instead of going straight home, he’d “catch a few beers with the guys”. When entertaining clients he started joining them when he offered alcoholic beverages to his clients, imbibing during work hours. His work performance started to smell sour like his alcohol.

You can see where this is going for Alfred. When he came into my office, he reported his inability to enjoy anything, increasing hopelessness, and now when he left the bar in the evening, his mood regularly plummets, a false weight in the scale of life.

Alfred looked at me with a degree of distrust, expecting judgment. But of course, he was also coming to me for judgment – an evaluation and diagnosis, and then to present a plan for treatment.

The treatment plan was short this day. Go to alcohol rehabilitation. Telling Alfred that there was nothing else we could do for him until he engaged in a rehab, was nerve-racking for me. (I never know how a patient will respond after similar directives like this. Sometimes they are not kind. Especially when talking about their substances or addictions, of any sort.)

Alfred stood up, a bit like a mechanical man, thanked me for his contact referrals, and left. I thought that was the last time I’d get to see him. It’s impossible not to hope for the best.

The deal with brain illness is that the treatments I am able to offer in an outpatient setting are ineffective in this context. Other stuff going into the body hits those brain receptors, turning genes on and off, like Wile E. Coyote in the back country. It would be enabling the mal-behavior if I diverted our focus onto anything else. Even so, like so many in the company of users, it is wilting not being able to offer more.

About two months later, I was completely surprised when Alfred came back sober! He told me he did just what we talked about, and rehabilitated. More surprising though, was his statement,

Thank you for refusing to treat me. You saved my life.

Alfred was still married, and yes, the marriage was still volatile. But he wasn’t plugging his ears and disconnecting from his wife with alcohol. It was a start. And Alfred still had restarts available to him.

We did end up starting psychotropic medication and psychotherapy, with which Alfred continued to heal.

I am humbled by Alfred’s courage to pursue rehab, the path of more resistance, and recognize that I should never underestimate the same courage in others when they present similarly.

Self-care tip:  Taking the path of more resistance may bring just what we are hoping for.

Question: What have you done courageously? Where has it taken you? Please tell your story!

The Sins of the Fathers, and Mental Health

 

“We know the Bible speaks of sins of the fathers passing to the 3rd and 4th generations while God imbues his kindness and mercy far beyond that to those who love him and keep his commandments.”

Rosa had no experience in the world of mental health, or so she thought. She had spent her formative years studying the world through the perspective of her church and interpretations of the Bible. As you know, there is a lot in both with a lot to say about emotions and behaviors. However Rosa was taught and modelled that these were moral issues and not biological. An either or, verses, part of the same thing. Could we call it sequent variants, maybe something like genetic alleles? Or maybe something better to describe this is out there, rather than an either or.

Rosa Leticia Montoya, at this point in her development, with her own overwhelming emotions and her husband’s plummet into dark moods, felt forced into considering mental health. She did not want to go there, but here in the space of losing control, not trusting herself or Carl any more, and before she was willing to say she didn’t trust God, she was doing what was a last resort. Considering that she was going crazy was the only thing this chaos could mean.

Before she completely surrendered to the idea that biology was behind this sinister change, she had to ask, “Is this because of our parents?” She had spent her life trying to untwist the bad choices her parents had made and the consequences those choices had on her life. Drugs, alcohol, and cheating were what she had grown up with. Quietly. Hiding it in the church. Rosa there, praying a lot to live well and be forgiven. Praying that bad thoughts would go away. Praying to depend on God and not on herself, as seen through her perseverating worries ever since she was a child. Worried and worried. Not speaking of the wrong Bible-breaking life her parents wore like underwear beneath nice tailored clothes. Would she ever be forgiven? Would she ever stop sinning?

So she asked me, “What do you think?”

That’s a lot to work with as a psychiatrist. So I did what most of us do. Ran to the shelter of medicine. Whew! But there is the added benefit that God created medicine, psychiatry, and all that there is in my tool bag worth working with.

Even so, there was only so long that I could avoid the topic of God and His punishments, per her perspective. It came up every visit.

If you believe in God, at some point within your discovery of mental health, this question will come up. Rosa is not alone. Are the emotions and behaviors gone amok, such as seen in anxiety disorders and depression, secondary to moral weakness? Living with “too little” dependence on God’s power? Is it this? Or is it an “either or”, with our biology? …a matter of cellular grey matter composed of DNA-expressing pathology? And is this something evil woven into my DNA because of what parents did? Well, I’ve spent 30-some years in school and now 15+ years in practice in this space and am still trying to understand.

I’m wondering if you would help me articulate this. It’s fundamental for us in self-care. It’s not possible to be very friendly to ourselves with the dissonance.

So in our self-care question today, please answer us. What is the relationship between “the sins of the fathers” and biology? Please speak!

Self-care Tip: Pursue kindness in your belief systems toward yourself.

Thank you for speaking with us! Keep on!

Portrait of an Old Woman

Portrait of an Old Woman

It is New Year. Another year.

Another year older. I hate getting older.

I joke about it – about forgetting a name here and searching for a word there, about new wrinkles, about an age spot, about the difficulty of getting rid of a flab around the stomach. But it bothers me. It feels as if somehow every day I am getting closer to being a smaller, weaker me with less ‘me’ in it.

Couple of days ago, I stumbled onto a new app on the phone that ages your picture for you. Supposedly, this will make you friendlier towards your future self, so you will take care of it better. Well, ‘it’ being me, really. Obviously. I knew that.

I found a picture of me on the phone I thought looked like ‘me’. The ‘me’ I know. The ‘me’ I like. I hit the “aging” button on the app…

****************************

I had come to visit Mrs Beren.

Her face looked small and fragile against the white hospital sheets. Old. Quite a bit older than her fifty-nine years, in fact. With so many chronic diseases, it was no wonder.

She had put on lipstick, I saw. Not a bright garish red I would have expected from someone who was vain enough to bother with makeup while being in the intensive care unit. No, it was a tasteful light pink that did not clash too strongly with her tired and pale face, wrung out from endless nights on a hospital mattress.

She was a strong woman, I knew. Not her body – that was weak – but her mind. I had always been fascinated by it for the years I had known her.

Strictly speaking, I didn’t have a reason to be here, monitoring her progress with the disease that had landed her in the hospital, for the umpteenth time. She had everything wrong with her. She could no longer walk due to neurological damage and depended on her husband to lift her from the chair to bed at night, and back to the chair in the morning. Her kidneys had failed her and her husband brought her to dialysis three times a week. Just this year, she had been in the hospital with pneumonia, urinary tract infection and now again with fever and sepsis that the doctors had not found a reason for yet.

Mrs Beren was not my patient.

Her husband was.

I had no reason to be here.

But her husband had asked me. I had run into him unexpectedly in the hospital hallway, looking out of place and out of sorts. I had been surprised to see him – he was one of my healthier patients, with a minor heart problem, who I saw for routine visits only once a year. He always came with his wife who drove herself into the room in a motorized red wheelchair. I had been confused by it at first – why bother coming to her husband’s appointments when clearly she was so much sicker than he? But after a few visits, I realized that this was their life. The edges of individual lives had blurred. It was a unit, with her being the guiding force. It had always been the two of them, all their lives since they were teenagers. When I asked questions from Mr Beren, the wife answered half of the time. They joked about how the new reliance on a wheelchair for transport no longer allowed them to enjoy traveling that they had been fond of in the earlier days of marriage. When I asked for a report on his exercising, it was the wife who proudly told me how she pushes him to go for a walk each evening – with her driving her motorized wheelchair, right next to him. They told me about the adjustments of their house they had to make, about the new car they had to buy. The life in their little unit had changed to accommodate her increasing disability but at the core they were still the same people.

I had not asked for their life story. It had just naturally flown out of them, piece by piece, over the years’ worth of visits.

So here I was, staring at Mrs Beren’s pink lipstick.

“I ran into Roy in the hallway”, I started. “He told me you could use a visit.”

“Good old Roy”. She looked up, pensive. “How did he seem?”

Confused by the question, I hesitated slightly. “He seemed … well. Worried, of course. About you. I know you have not had it easy lately.”

“No.” I could see she was testing the words before speaking. “I don’t think it will get any better, frankly. And I am pretty tired of being sick. I just don’t know what will happen to Roy when I’m gone. He is not strong.”

Implications were heavy between us. Not strong like her, getting herself to all her husband’s appointments in a wheelchair. Not strong like her, worried about her husband while lying deathly ill in the intensive care. Not strong like her, making herself pretty with lipstick on what she thought may be the last days of her life.

***********************

After I first hit the “aging” button, I slammed the phone down. The woman who had looked back at me from the picture was old. Heavily wrinkled, with saggy skin and grey hair.

Also, unmistakably me. It was chilling. Unnerving. A little nauseating.

I picked up the phone again and tried to look past the wrinkles. The confident pose I had liked on the initial picture was still there. The sparkle of enjoyment in the eyes was still there. The smile of general happiness with life was still there. It was me. Old – yes, but still ‘me’.

It made me feel better. The woman on the picture wasn’t smaller or lesser. Just different.

I don’t have a choice in getting older. But as a colleague and friend likes to point out frequently, the alternative is far worse. So, I can choose how I get older. I can choose to be the “me” I like even when old. I can choose to be strong even when sick.

I can choose to put on the lipstick.

 

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Portrait of an Old Woman, by Guido Reno

My Inner Demons and I are on the Same Side – Living in the Now

“I stop fighting my inner demons. We’re on the same side now. T-shirt”

― Darynda JonesSecond Grave on the Left

 

Monday came. I was not ready to tackle the day. I lay in bed a few minutes longer while I started to dread and plan for the day’s appointments, calculating drive times, meals, and accommodate everyone else’s schedules before I had even thought to blink open my eyes.

It dawned on me at some point that I was living out a day that hadn’t even begun yet.

The anxiety of the impending tasks, or the overwhelm that comes with trying to handle everything before it arrives, you know this too? The exhaustion that eventually overtakes us makes us ridiculously absolutely not excited about our lives.

Living in the future instead of now is like sprinting ahead of our own feet, if only we could! The only task we have to do is to actually wake up.

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