Friday, September 07, 2007

Mental Health Comments

I'm mashing several posts together here.

I have on my caseload a gentleman in his 60’s with a history of very high competence in business who has been gradually losing short-term memory, causing him to become depressed/suicidal. There may also be some underlying narcissism, plus some evidence of a few manic episodes over the last four decades.

The complicating factor is that he has been to a specialised clinic for extensive testing. This mid-Atlantic clinic specialises in discovering subtle variations in ADD and selling books about that. Mirabile dictu, their tests five years ago showed that this gentleman had – gasp! – an unusual type of ADD. I very much want to write them a letter notifying them of our findings about his measurable memory impairment, asking them to update their records, and telling them to go f- themselves.

For added fun, the clinic was recommended to him by his brother, a PhD psychologist in Canada, who would like to move near here for a few months so that he and his brother can have some “really intensive” family therapy together about their childhood experiences. 50+ years ago.

I don’t know if folks saw the NYTimes science article linked, but Eli Lilly has an intriguing, very different antipsychotic in testing. On my team here, we start the trials of AC-104 this month. This yet unnamed drug is the clozapine metabolite I wrote about earlier this year.

Eugene Methvin, writing over at Tech Central Station, has an article about what we should do with mentally ill serial killers. I have mixed feelings about the article, but it is so very interesting that it is worth a read. The ideas are interesting, that is. Methvin’s writing, not so much.

Observing those who suffer from Borderline Personality Disorder is often frustrating for not only friends and family, but treating professionals as well. I certainly understand this, and have experienced my share of that frustration, but such people often exhibit in stark relief what is less perceptible in the personality foibles of the rest of us. I should note that all of us will display various behaviors which could be considered symptoms of a personality disorder if they were in excess. For example, everyone has situations in which they might be dependent – when we are in a serious medical situation perhaps, or in some emergency where another person who clearly knows what they are doing takes charge. Some of us are dependent in many situations – it is rather a first option coping mechanism for some, and we would identify that as a personality “problem.” The Dependent Personality not only leans or tends toward dependence, but has trouble taking any other role, no matter the situation.
We had two women with BPD come in this week who each showed a behavior in such an extreme that its meaning shone out clearly. The first listed what was going on in her life and showed such enormous emotional lability that it bled over into her understanding of events. She was talking about an argument with her mother which clearly made her unbearably angry and sad at the same time. She switched because of a chance association of her own to discussing the morning breakfast at the hospital. Because she was still riding the anger and sadness from thinking about her mother, she became upset that the nurses and dietician did not understand her special dietary needs and became near-hysterical describing her ill-treatment at our hands. She kept up the complaint throughout the day. Only – she had liked the breakfast when she had eaten it, even expressing same out loud at the time. The emotional overlay she added on later completely covered the real situation, and changed her perception of it. By this and a few similar examples, she showed clearly that her emotions are running the whole show. Her intellect lags behind in explanations, and is put into service only to make up reasons for the emotions to feel satisfied by. Never have I listened to someone for whom the powers of reason were so entirely an appendage. The intellect just sort of rolls on by itself automatically, making up explanations at the command of the emotions.

We all do this to a certain extent, quickly rationalizing the things our emotions direct us to. But the delay was so enormous in this woman that the process stood out in high relief. All of us allow our emotions to influence our intellect, but the intellect in its turn has some power to influence back. In this woman’s case, the intellect had no power of return influence.

The second woman was admitted for the 65th time – she has an equal number of admissions at two private hospitals as well, plus a wide assortment of other facilities in northern New England. She was sad – and thus suicidal, as she always is when sad – because the Labor Day holiday is always difficult for her. It is the anniversary of her cat’s death many years ago. This immediately arouses irritation in treating staff on an overfull unit. People want to yell “Your roommate has a five-year-old daughter dying at Boston Children’s Hospital. That’s a real tragedy. Get a grip.” (We don’t of course.) Our patient is also troubled because she visited a place she loved as a little girl that has changed, and a cousin who is only a few days younger attempted suicide (they have had no contact for years), and her bigger apartment isn’t as charming as the old one… Translation: I used to have a life. Now I don’t. I am fifty years old and I have nothing – no friends, no family, no job. She cannot say it quite like this, because it would lead so easily to the questions of what happened to all these things, and how did she lose them.

Yet there is a final difficulty with this. I knew here twenty-five years ago, before she had used up all her relatives, when she still worked full-time for months on end, when she had a boyfriend. She sounded exactly the same then, hearkening back to an earlier time of her life and what she had lost.

The cat is just an irritating detail in the story. It's her whole life that hurts. We all do exactly this in much milder form, where it's not so visible.

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