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. 

What Are Our Treatment Options in Psychiatry?

choosing

I go through this almost every time I see a new patient.  I often hear that this is all they really wanted, “To know what my options are and that I’m not choosing something way out there.”

First off, most treatments for psychiatric brain illnesses are not done with intention to cure, but rather to restore health and increase quality of life.  Healthy is not the same as disease free.

This applies to all the treatments listed here.

1.  Hospitalization:

Inpatient – 24 hour locked unit, voluntary and involuntary, little psychotherapy, and daily physician care.

Partial Hospital – Day Hospital that runs during business hours such as 9AM-3PM, voluntary only, includes intensive psychotherapy, and weekly physician care.

2.  Counselling/Psychotherapy:

Talk therapy and exercises of various forms.  May be with physician or nonphysician.

3.  Stimulation Therapies, such as:

Deep Brain Stimulation (DBS) requires brain surgery to implant an electrical stimulation device in the specific brain area, controlled by a device implanted in the gut. Effective, but higher risk.  Least time consuming for maintenance care.

Transcranial Magnetic Stimulation (TMS) – The patient sits in a chair with a magnet at the head’s surface that uses magnetism to stimulate the brain for treatment, 1 hour a day, 5 days a week for various weeks, according to the patient’s need and funding.  Few side-effects.  Time consuming.  Not as effective as DBS or ECT but comparable to some medications.

Electroconvulsive Therapy – Uses electricity to stimulate the brain, inducing a short seizure for treatment.  Considered safe and of low risk.  Most effective.  Response is speedy.  Few, and mostly temporary side effects.  Does not enter into the body systems.  Less time consuming.

4.  Medications:

Chemicals for treatment in the form of pills, liquids, injections, patches, powders, vapors, gases – enter into the body systems causing physical side effects that, as with any treatment, must be weighed against the benefits.

Pills – generally taken daily, which is a challenge to treatment compliance, and activate internal conflict and personal stigmas.

Injections – generally done in a clinical setting, bimonthly or monthly.

5.  Aerobic exercise 50+ minutes, 5 days a week.

6.  Sleep hygiene.

7.  Diet

8.  Alternatives – such as over the counter herbals, naturalistic supplements, meditation, spiritual, acupuncture, acupressure, massage, or no treatment.

Questions:  What do you think of your options?  What do you choose?  And why?  Please tell us your story.

Did I miss anything?

Self-Care Tip:  Get informed about your treatment options.

Treatment Settings in Psychiatry

HEALTHCARE WITH GOVERNMENT OPTIONS PLAN: IS TH...

HEALTHCARE  (Photo credit: roberthuffstutter)

I thought I’d just talk briefly about some treatment settings in psychiatry.  It is confusing for anyone in the community, from nonpsychiatric physicians to architects, to know the differences between these.  Some of us have been through some of these programs but many many of us haven’t.

  • Inpatient, which is 24 hours a day and includes voluntary and involuntary admissions.  Here we have a skeletal number of group therapies and see the physician daily for psychopharmacology adjustments.
  • Partial Hospital Program, (PHP,) which is generally Monday – Friday, from 9am to 3pm, and always voluntary.  Here, we work in intensive psychotherapy most of the day, and psychopharmacological treatments with the physician at minimum once a week.
  • Outpatient, such as in a physician’s private office where psychotropic medication and psychotherapy are used.

It generally takes time to influence the way the genes express themselves in any therapy, whether it is talk therapy, medication or ECT, to name a few options.

This is skeletal.  Any comments or additions?

(Random) Self-Care Tip 🙂 – know your options

The Gift of Desperation

Life (23/365)

LIFE

Misty sounded relieved,

Yes.  That’s it.

She had just realized that life isn’t fair.  Sure.  She knew that before, but she just realized what she knew.  Don’t we all love that moment when our senses join up – sight, hearing, taste, touch, smell, emotion, intellect, spiritual and the rest.  That is a lot to coördinate after all and sometimes some of them don’t make the train.

Misty was a single mom of three.  Her ex-husband was what she called, “Disney-Dad,” and her kids relished their time with him.  Misty complained that she didn’t get to spend the special times with her kids.  She mainly took care of them, but missed out on irresponsible fun.  She was sure her kids wouldn’t look back and think of her like they would their father.  She was getting angrier about it all the time, ruminating about it and it was getting in the way of her ability to connect with others and feel pleasure.  There it was in front of her blocking her from seeing her kids even, let alone herself.

Then after weeks of this along with medication and talk therapy, she told me,

Yes.  That’s it.  Life is not fair.  There are many other things in my life that aren’t fair either and if I look for them, I could spend my whole day every day counting them off.  

It broke my heart a bit to hear her and see her there.  Humble like that; she would I think affect you the same way.  So real.

Yesterday, Carl D’Agostino replied to our post about growing our understanding of our choices beautifully.

…we wait until we are at our wit’s end before we seek assistance…. considering reaching out as personal failure or inadequacy re: our own self-esteem…. Foolishly we wait until our way just is not working anymore. That is why AA calls this a gift: the gift of desperation. …For many, the depths into which we have succumbed are now found not to be so deep at all and in fact, ladders are readily available if we use them in recovery. 

Ah Carl.  Say it again.

The gift of desperation.

Too good.  Don’t you think?

Questions:  Have you ever received the gift of desperation?  What did it bring you?  Where did it take you?  What did it do to you?  Do you still have it?  Please tell me your story.

Self-Care Tip – Celebrate your gift of desperation.

Presence Encourages Self-Care

The Forgetful Professor

Image via Wikipedia

I am writing a series of blog-posts outlining self-care in which we examine the tenets of self-care:

Self-Care Tip – Sit back and listen to the emotion to be present in your own life.

There are two terms we’ve used in psychotherapy since before Freud and Jung were around:

  • Transference – putting our feelings on the clinician.  For example, my clinician looks like my father.  I will transfer onto him my feelings about my father and subconsciously think he is like my father.
  • Countertransference is the opposite.  The clinician thrusts her own memories and associations on her patient.

These can be positive or negative.  Of course they do not stay in the clinic.  Transference and countertransference happen between all of us all the time.  Often it is healthy.  It helps us grow, model others, fantasize and move towards fantasies long enough to make them true.

Remember PattyAnne from yesterday?  …In PattyAnne’s and my case, PattyAnne could be said to have transferred her fear of being treated as a lesser person.  But what was my reaction and what is yours in similar situations?  What is our countertransference?

I have often been guilty of negative countertransference in situations like this.  I remember feeling dirtied by people’s prejudices and fears.  Almost like I needed to bathe afterwards.  The truth is, though, we don’t have to feel this way.

When people are afraid of us, we do not have to be afraid of them.  We do not have to anger, agitate, or feel “soiled.”   We can just be with them.  Let it be about them and not run away.  Be present.

Clinicians can be open to hearing this song.  When any patient starts in again, this time, sit back and listen to her fear rather than worry about what words carried it.  Patients will be better for it.  Maybe clinicians will be, too.  And that is key.  The gift we give first is to ourselves.  By just being with someone in her fear, we can just be with ourselves too, and vice versa.  Quite friendly to us both.

Presence encourages self-care.  It helps guard us against the temptation to see ourselves as victims.  When we do not realize that our emotions and behaviors come from us, were not imposed upon us from external sources or realize more specifically the transference or countertransference that we are responsible for – we can feel like victims.

Any time we do not own our emotions and behaviors, this is a quick path to losing our connection to our personal journey and become “absent” rather than present with ourselves.

Still, many wonder: at what point does “too much self-care” become part of the symptomatology?  This concern will resolve when we see how emotions are not moral implications.  “See” you tomorrow!

Questions:  How has feeling like a victim disconnected you from others and yourself?  How have you collected your absent self and come together again?  Please tell me your story.

 

Be Willing to Stick Your Toe In The Water of Self-Care – Just Start.

Three Capetian French scholars consulting an a...

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Self-Care Tip #204 – Be willing to stick your toe in the water of self-care – just start.

I’m not interested in medications.

I used to really wonder why anyone would come to me and say this.  Sometimes we would both realized that they didn’t know what a psychiatrist was.  My degrees seemed transparent as they hung so quietly on the wall.

My girlfriend, who’s an Ophthalmologist, loves it when her patients homogenize her work with what optometrists do.   And it wasn’t until I read Madeleine L’Engle did I understand more of the differences between astrology and astronomy by understanding their similarities first.

For the magi, astronomy and astrology were one science, and it is probably a very sad thing that they ever became separated. That is yet another schism which looks for healing…

Watch for the Light: Readings for Advent and Christmas.

In those cases when my patients don’t know who they came to see, I have tried to bridge the awkwardness with something to put them at ease.

Don’t run for the door.  There’s no cage.  See, the doors unlocked.  There’s no implication that you have to take medication just because you came to see a psychiatrist instead of a psychologist.

But I’m not interested in medication.

Then there are those who know who they came to see.  But they may not know the connection between behaviors, emotions and their brain health.  (Of course there are other reasons to see an MD I’m not covering here.)

I’m not interested in medication.

Who wouldn’t wonder?  Now I realize an MD is good for more than just prescribing, if she wants to be.  I know.  Wild and outrageous idea, right?  So before I educate anyone on my enormous fund of knowledge or my stealth abilities to diagnose and treat, I think about what it is that this someone thought they might get from coming to see me.

(Enters Fatima:)  Fatima came in this way.

I’m not interested in medication.

Fatima wasn’t feeling good.  Her emotions were corrupting her behaviors and quality of life and she was trying to help herself, stretching her toe into the pool of science, slowly.  She had never been a person to jump in and splash.

After speaking with Fatima for some time, we were able to come up with what she felt she needed help with, what she thought might be medical, what she might be willing to try – for now that meant engaging in psychotherapy, starting omega 3’s and vit D, working on her sleep hygiene, trying to get more aerobic exercise in (like a pill) and doing a mood chart.  We decided together that she would see how this goes for her over the next two to four months.  After that, if she wasn’t doing better or better enough, we’d consider a medical intervention.  We’ll see if she’s interested in medication.  Maybe not.  She can choose when she believes she’s making the right choice.

Questions:   What helped you take the plunge into medication therapy?  What held you back?  Or in someone you know?  Please tell me your story.

Rosa Parks Protesting From the Tower of Babel On The West Coast – We Have Choices in Self-Care

Photograph of Rosa Parks with Dr. Martin Luthe...

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Self-Care Tip #201 – Make a choice that takes care of your inner self and your quality of life.

Dear Sarah McGaugh alerted me yesterday to the #2 emailed article from the New York Time‘s besmirching the intentions of medication prescribing psychiatrists.  Funny thing is, it’s quoting psychiatrists bemoaning their own prescribing practices, victims to managed care and the force of the mighty money mongrel pharma agencies.  You who’ve been reading this blog already know my thoughts on that and might be able to take these boys aside for me and quietly help them learn about self-care.  Politely without whining you know.  You might not get in the New York Times doing it, nor photographed with a furrowed brow.  I’m sorry about that.  Self-care has never been glamorous.

I definitely know where these physicians are coming from when they complain about these qualities in their practices.  The good news is that they don’t have to practice that way if they don’t want to.  Yes they’ll earn less or they won’t.  I don’t know how it will pan out for them.  But they do have choices.  I know many physicians who feel the same way these men do and many others who enjoy working mainly with medication therapy.  It is their choice.

When I was studying on the East Coast, I saw more psychiatrists still using their “couch” skills in psychotherapy.  There were those that viewed West Coast practitioners as the Babelers who were responsible for the fall of the tower that would have should have led them to heaven.  They spoke of the culture of the West Coast psychiatrist.  They questioned periodicals authored by them and wondered if they ever read Kreplin.

Now WHO is this exactly who wrote this?  Never read something without first knowing who wrote it.  What authority do they have on this topic?

Not a bad thing to do as there are a lot of posers out and about, quill fast at work.

I remember my patient Dorinda, divorcing a meany who wouldn’t leave their home.  They had other places they could move out and into, smaller than the one they were in, but neither of them would go.  They both had their reasons.  In our popular New York Time’s article, the psychiatrist explains that he wouldn’t want a cut in pay and asks, “Who would?”  Dorinda and her meany husband would answer, “Not me.”  I would too and agree that probably, so would all of you.  But we do have choices.  I told Dorinda so much and quickly got on her “Meany-list.”  She was nice about it though.

My children learned about Rosa Parks in school a year ago.  They still bring her up at random times,

Mommy, she was a COURAGEOUS woman!  She changed how all the black people were treated.

My five-year old told me Rosa’s age when she started her

Redback and victim

Image via Wikipedia

 

work leading to desegregation and how long Rosa struggled before she and others were allowed to finally ride public transportation with whites.  She even described how these people protested; united together, refusing to ride public transportation at all until the law changed.  My kids have pretty great teachers at River Springs Charter School.

Maybe, if it’s alright with you, my daughters and their teachers could join you when you talk to these boys about self-care.

Questions:  How do you empower yourself when you feel caught in a web and victimized?  How have you seen others do it?  What do you think about this NYT article?  Please tell me your story.