Wednesday, January 28, 2009

Voluntary Madness

I am putting this post down as a marker. Most of my readers will likely not guess quite what I am driving at, though I think they might find it interesting anyway. More information is going to come out over time on this book, and I just want my initial impression to be recorded.

Norah Vincent’s new book, Voluntary Madness: My Year Lost And Found In The Looney Bin recounts her experience being treated at three psychiatric hospitals. There is an excellent review in the NYTimes which also gives a decent summary of the book.

Norah is first treated at “Meriwhether” Hospital, likely a stand-in for Bellevue, for depression. I am already suspicious, in a way that only people who work in psychiatric emergency settings can be. The next two hospitals she signs herself into, and her experience of them, reinforce the suspicion.

I don’t doubt that she does indeed encounter “Teflon-slick professionals and brutish aides” at Meriwhether. I have seen both – heck, I have been both - and acknowledge that the failings of public psychiatric hospitals most commonly lie in these directions. It is hard to deal with violent people without looking – or becoming – brutish, and similarly difficult to deal with manipulative people without looking – or becoming – evasive. That certainly makes life harder for those remaining patients who are neither violent nor manipulative. They need to trust someone on the staff, but much of the staff looks untrustworthy. Meriwhether may be particularly bad as well. But Norah hasn’t walked a mile in those shoes. She can tell her side; her caregivers are prevented from responding because they keep her information confidential.

Tangent on medications. There are good reasons to attempt treatment for depression without resorting to medication, but these are more often an excuse. Because withdrawal from some medications is unpleasant is not sufficient logical reason to refuse all medications. Because medications can have side effects is only a legitimate reason to refuse them if you actually have those side effects. The fact that other people have them is irrelevant. Complaints about pharmaceutical companies and beliefs that doctors prescribe medications only because it is part of their blinkered world-view or that they’re getting a cut are likewise evasions. Doctors prescribe psychoactive medications because they often work, and work quickly. At $1000/day, quickly is important. When symptoms are severe, the efficacy of nuts and berries on mild-to-moderate symptoms does not factor into the immediate situation.

Second tangent on costs: Norah Vincent’s hospitalizations cost someone tens of thousands of dollars. If she was insured, then the cost was borne by ratepayers and the reduced care for others served by her insurer. That these considerations do not enter into Ms. Vincent’s planning her adventure is mildly diagnostic.

Back on track, or something like it: She insists on treatment without medication, then is resentful when she later becomes severely depressed. She wants certain types of therapy she thinks she will like better. These all involve paying attention to her. Is that harsh? Yes, and possibly unfair.

But I doubt it.

I would like to see the discharge diagnoses from those hospitals, especially the first one. I would like to see what her scores on the MMPI-2, or even better, the PAI, were. I am less enamored of projective tests, but the results of those would be interesting as well.

I am interested in this data because I suspect that a diagnosis of depression for this patient is uh, incomplete. Much of this pattern is familiar. Additionally, Norah Vincent’s previous book was Self-Made Man, an account of her 18 months posing as a man. While that would not ordinarily be pathological, in combination with the other information it is suggestive.

Update: I should ask Dr. Sanity for her opinion.


karrde said...

The attempt at diagnosis is interesting.

I read Self-Made Man, partly out of morbid curiousity.

My conclusion was that the book was interesting, but not good enough to justify the effort that she put into pretending to be a man so that she could write it.

The way in which she wrote did little to convince me that she was being fully truthful. I didn't suspect a direct lie about any particular; I did notice that she seemed not to care about the lies she perpretrated while pretending to be a man.

This led me to conclude that it is nearly impossible to tell how much of the book is truthful, and how much is not.

Beyond that, I did wonder at her sanity. But I am untrained in diagnosing such things.

terri said... her books are an outgrowth, or maybe acceptable way of acting out, her possibly real depression or disorders?

If she makes enough off of them she can repay her fraudulent medical bills. Although I can imagine her insurance company, assuming she has one, will probably drop her like a hot potato.

bs king said...

My initial impression is one of instinct. I worked in an ER with a Psych ER attached, and I remember how suspicious we were of people who came "desperate" for help, then immediately wanted to start calling the shots. I couldn't read the review (haven't signed up with the NYT) but from what you said, I just remember that you always knew there was something else going on when someone's ideas were a little to um, formed, about what was best for them, but they REALLY wanted to get healthy. Normally a pain pill prescription fit in somewhere. On the medical side these conversations would go like this "I've never had pain like this before in my life!!!" "Okay, we'll give you Motrin" "Oh no! Motrin doesn't work for me. I'll need at least a double dose of percocet. Or triple of vicodin. You know, if you have it."

Anyway, I often think people have no idea how good your "fraud alert" gets when you work in some of these places, and people are indeed treated accordingly. People with real problems tend to be pretty easy to work with.

Donna B. said...

bs king -- reading your comment and the blogs of ER docs and nurses for the past several years has led me to be very easy to work with. I'm so afraid of coming across as a drug-seeker that I am never honest about how I perceive pain.

Nah... I can handle. Tylenol and naproxen are fine...

Assistant Village Idiot said...

Donna B - the trick is to ask questions about them. Then they know you're not an, uh, expert.

Donna B. said...

Ah... ask questions. Thing is AVI, that I am sort of a lay "expert" on drugs after having cared for two terminal cancer patients at home and a head-injured child with paralysis and seizures.

Heck, I know more about the actions of my blood pressure medicine than the PA that prescribes it for me.

I'm the one that properly disposed of the fentanyl patches, ativan, methadone, and morphine that the hospice people left behind when my step-mom died.

Yet, my son and I have trouble getting klonopin to ease his muscle spasms and anxiety.

The fear of prescribing for non-terminal people with pain has some not so savory side effects.

Of course, my son asks for klonopin, not because he's addicted or drug-seeking, but because it really does ease his muscle spasms. Five doctors, and five co-pays before he got a prescription.

That's part of the problem I'm talking about.

As for my own pain (mostly arthritis related) I do understand that anti-inflammatory agents work best to alleviate it in the long run. I also understand that they are LONG acting, and that sometimes I want to go hiking with my granddaughter and would like some PAIN relief, not inflammatory relief to be able to do that.

To be completely honest, I have hoarded codeine prescribed by dentists and other doctors for documentable injuries that aren't nearly as painful as the arthritis can sometimes be.

Perhaps I am a drug-seeker. And I apologize for it, but I'm not a bad person.

Assistant Village Idiot said...

Well we believe you, but I don't think that's going to do you any good.

Carl said...

I also read Self-Made Man, which--as karrde says--details the extent to which she deceived dozens to pull-off the "experiment." Unlike karrde, I didn't think the book lied--indeed, Vincent essentially admitted that the falsehoods told in service of her "Ned" persona drove her to psychiatric hospitals.

As AVI says, this wasn't garden-variety depression. Rather, conceding she wasn't transsexual, Vincent swapped gender roles and "Gaslighted" herself. Her actions, and the book, were--in my uninformed opinion--crazy. How that altered her subjective view of treatment may be similarly outside rational analysis.

Donna B. said...

AVI -- thanks for believing me, if you do :-)

With my son, it's not a matter of never having tried anything else. The list of medications he's been prescribed is really really long.

Part of the problem is that he suffers from a closed head injury. He has many disabilities due to the diffuse injuries his brain suffered.

He is most often treated by doctors who are more familiar with schizophrenia, bipolar, depression, and drug addiction than are familiar with brain injury. He has been diagnosed with all of the above, depending on the specialty of the doctor. It's really frustrating.

Maybe he does have symptoms of all the above. However, most anti-psychotics make all his symptoms worse, especially his physical ones. Spasticity and muscle spasms are painful, and "ordinary" muscle relaxers (robaxin, for example) do nothing to prevent his spasms.

He has now found a neurologist and a psychiatrist who are (gasp!) working together to find the best cocktail for him. Neither are covered by his HMO, so it's not cheap, but he feels better now than he has in years. Half the drugs they are prescribing are not covered either.

As for myself, frankly, 90% of the time I do quite well on 2000 mg of Tylenol and 500 mg naproxen on a daily basis. If I've read the literature correctly, I can safely double those doses.

10% of the time, doubling those doses doesn't even touch the pain.

But, it's not worth the hassle to try to get stronger meds to use on an "as needed" basis because no one seems to believe anyone would use them "as needed" but would automatically become addicted.

I promise not to use your comments as a place to rant about this any more. I have my own blog, but I never feel inspired to write there!

Dr. Sanity said...

Hello, AVI

I haven't read either of her books, but radar is tingling, particularly when these books are written presumably to make the author money and fame. That alone would disqualify her as being an objective observer of the situations she purports to be studying. Beyond that I could not comment on anything except the medication issue. There is a controversy right now in Psychiatry about whether the DSM is far to inclusive and wide in its diagnostic captures and that for diagnoses like depression it far too often picks up people dealing with normal human sadness having to do with specific losses or traumatic events in their life. Some (like me) believe that by always going first for medication, we deprive individuals of the opportunity of growing and developing and learning how to deal with the realities and pain of the human condition. That said, it is clear from my clinical experience that for those with severe depression (what Freud called "melancholia" versus "mourning", i.e., dealing with loss) medications can be lifesaving. Determining which patients have that biological vulnerabililty that sends them into a profound melancholia when they are confronted with even a minor loss (or sometimes no loss at all) is sometimes difficult to sort out. The key, it seems to me, is to err on the side of compassion; but also on the side of short-term treatment and to ALWAYS offer the option of psychotherapy along with the medication. From your description, the book sounds fascinating; a sort of journalistist attempt to mimic a Munchausen's-type presentation. Thanks for inviting my comments!