Concise Documentation of the Assessment and Plan

I asked Cedric Skillon, MD to write this post to elaborate on his method of documenting elements of the treatment plan. Dr. Skillon and I work in the same system of care. Over the years I have been impressed with the high quality of his work and a lot of that is captured in how the treatment plan is documented. I think his documentation is concise and yet it covers a lot of ground in terms of the clinical discussion with the patient and his thought process. What follows a discussion of his approach and a good example.  The remainder of this post was written by Dr. Skillon.   Fell free to add comments on what you find useful as concise documentation.

George Dawson, MD, DFAPA


Assessment and Recommendation/Plan

Throughout my medical education I was reminded over and over again to document everything that occurred during an appointment; because if it was not documented, it did not happen. But just as important, during my psychiatry residency training at Western Psychiatric Institute and Clinic, Dr. Petronilla Vaulx-Smith expressed upon me the fact that with every medical note that I write, any physician should be able to read my note, understand my logic, and be able to pick up taking care of that client from the last note that I wrote. Over the years my notes have evolved to include the following.

Assessment: In this section of the note I have 1-2 sentences to highlight sign/symptom changes that I have documented in greater detail in the History of Present Illness section of my note.

Recommendations/Plan: In this section I document medication and therapies prescribed, as well as the target symptoms for the medication or therapies that I am recommending. I also educate the patient about potential side effects and medication interactions with the prescribed medications. I then numerically list each step of the plan for that appointment, including medications prescribed and discontinued. With each prescription I state how long the prescription will last and if there was a refill included. I list continued therapies, including community support such as attending AA meetings.

Below is a fictitious example of an Assessment and Recommendation/Plan.

Assessment: Patient reports worsening depressive and anxiety symptoms. Patient has maintained his sobriety.


Recommendation/Plan: Plan to discontinue Wellbutrin XL. Plan to continue with current dose of Prozac. Plan to start Effexor XR in combination therapy with Prozac to treat depressive and anxiety symptoms. The patient will continue with individual psychotherapy and continue attending AA meetings. I educated patient about the risk of serotonin syndrome with the combination of Effexor XR and Prozac. I educated the patient about the symptoms of serotonin syndrome.


1. Patient was educated about the above assessment and plan.

2. Patient was educated about the side effects and potential benefits of each prescribed medication.

3. Patient gave verbal informed consent for the prescribed medications.

4. Discontinue Wellbutrin XL

5. Start Effexor XR 75mg take one pill daily. I gave patient a written prescription for a 30 day supply and no refills.

6. Continue with current dose of Prozac. On 12/20/16, I gave patient a written prescription for a 30 day supply and 5 refills)

7. Patient will continue with individual psychotherapy.

8. Patient will continue attending AA meetings.

9. Patient will schedule a follow up appointment to see Dr. Skillon in 2 weeks.

10. Patient agrees to call readily with questions, side effects, or clinical worsening. Patient agrees to call Dr. Skillon, or go to the closest emergency room if he has onset of suicidal ideation or homicidal ideation.

11. Treatment plan was discussed at length including alternative medications and importance of compliance.

Cedric Skillon, MD




Attributions:

Graphic at the top is from Shutterstock per their licensing agreement - "Medical files on a shelf" by Val Lawless.

Can A Philosophy For Living Prevent Addiction?

A couple of years ago, I responded to a New York Times editorial by a philosopher.  It was focused on the release of the DSM-5 and like most pieces in the press, it was highly critical of psychiatry.  The philosopher's argument was basically that the DSM-5 had an implicit agenda.  That agenda was that it was a blueprint for living.  As an acute care psychiatrist for most of my life, that analysis was more than off the mark - it struck me as absurd.  The only advice about living that I gave people was lowest common denominator advice:

1.  Get a stable place to live where you feel safe and you can unwind each day.

2.  Get adequate sleep.

3.  Eat nutritious food.

4.  Get some exercise.

5.  Stop drinking.

6.  Stop using street drugs.

7.  Try to stop smoking.


This is advice where the patient has been unable to secure any of these elements, is also often physically ill, and we could offer active help.  None of that advice is contained in the DSM-5, but when you are treating people with severe psychiatric disorders it is useful and potentially life saving advice.  You can read about the "blueprint for living" argument and several additional arguments in the comments at this link.  One of my main points is that psychiatry and medicine in general are focused on extremes and not normative human conditions.  Medicine generally tries to draw a line (however imprecise) between the pathological and non-pathological.  The only real life lessons there are is how to avoid some pathological states.

The other part of my career in the outpatient setting is trying to convince people to stop using drugs and alcohol at various stages of addiction.  The pathway to addiction and the pathway to recovery back out again are complex.  Not everybody makes it.  The argument for recovery has always been quite basic.  Stop using or end up "crazy, in jail, or dead."  Far too many people are exposed.  As a reductionist, I teach that there is a certain portion of the population that is at high risk for addiction due to neurobiological factors.   There is also a portion of the population at low risk because of dissimilar factors.  With the current push toward universal cannabis legalization, widespread availability of opioids, and the idealization of hallucinogens and psychedelics larger and larger numbers of people at put at risk, just based on their biology.  The backdrop here of cycling between permissiveness and prohibition at the cultural level was noted by Musto a few decades ago.  The problem is that American society deals with that conflict by political arguments.  Those arguments are focused on liberalized drug use or prohibition without any common sense in between.  In the United States that no man's land points directly to a lack of a philosophy for living.

What do I mean by a philosophy for living?  To me it means a way of living that is based on reasoned principles rather than popular culture.  A way of living based on contemplation rather than impulse.  A way of living based on conscious decisions long before the time when the decisions are no longer conscious or reasoned.

The best example I can think of is from the field of addiction.  There is always a lot of confusion over the issue of decision making in psychiatry and addiction.  Patients without addictions are often told that they have choices.  That is a gross oversimplification when it comes to how people with mental illness make decisions.  The same thing is true of addiction.  The main difference is that a moralistic approach to addiction is still acceptable at many levels of society.  That is - if you correct your moral problem -  the addiction will be solved.  That is presently a lot harder to do with severe mental illness in most settings short of a not-guilty-by-reason-of-insanity defense.  Even in the case of severe mental illness that clearly caused the crime, the the NGRI defense is usually not exculpatory.

Given those scenarios a philosophy for living can be considered a preventive measure rather than a primary cure.  As such it is outside the scope of psychiatry.  There have been a few psychiatrists who were philosophers, but the vast majority were not.  Over the years, I have found a first rate philosopher who I have followed on his blogs and in several of his books.  Massimo Pigliucci has written and edited several excellent books including Denying Evolution and Philosophy of Pseudoscience.  He also stopped writing what I consider to have been and outstanding blog about philosophy called Rationally Speaking that is still available to read.

For the purpose of this post he also writes the blog How To Be A Stoic. Most people have a truncated view of Stoicism.  It is really not like the stereotypical Norwegian bachelor farmers of the upper Midwest.  It is not the image that many of us got studying ancient governments and cultures.  It turns out that Stoicism is a philosophical approach to life.  That makes it unique in the field of philosophy, since most philosophies are not about how to live your life.  He recently offered to field some questions and answer them according to his interpretation of Stoicism.

It is against that backdrop that I sent Massimo the following question:


"I am currently an addiction psychiatrist and that means 100% of the people I see have one or more serious addictions.  While I operate from the neurobiological perspective with regard to addiction - phenotypic plasticity is operative.  I would estimate that 40% of the population is at risk for addiction if exposed to a matching intoxicant.  Availability of drugs as seen in the current opioid epidemic is always a significant factor.  

It is hard to ignore the cultural biases that lead to this exposure.  It seems to be part of the American culture that people expose themselves to drugs and alcohol at an early age.  In Middle School and High School as well as college there is peer pressure.  People who abstain from intoxicants are viewed as being square or possibly closet prohibitionists.  The former President of Mexico Vincente Fox suggested the entire reason for the War on Drugs was "America's insatiable appetite for drugs.."  I think that he was right.

I think that an important public health strategy would be to intervene at the "philosophy for living stage" that currently seems based on hedonism before the significant neurobiological effects from the intoxicants takes over. 

Is there any advice that Stoics may have to offer in this situation?  I guess I see the problem as a lack of a reasonable plan for living at the bare minimum when it comes to excessive drug and alcohol consumption.  

There is not much of a window between that and a full blown addiction."

And this is what he said.  Please read his well thought out post that contains some additional references.  His  discussion of the ancient version of the Serenity Prayer was very interesting.

Can Stoicism as a philosophy for living prevent addiction and a lot of other decisions that Americans make that are not in their best interest?  I agree with Massimo and think there are paths in addition to Stoicism.  The point of this post today is here is one example of what might be possible.  Here is an alternative to moral development that does not quite go the way it is taught in psychiatric texts.  Here is an alternative that offers more than a relatively bankrupt culture that emphasizes money, violence and hedonism.  Here is an alternative to prohibition.  After all if you are contemplative and are assessing your life on a daily basis relative to specific virtues - you will not need external controls.

Having a philosophy of life seems much better than not having one.


George Dawson, MD, DFAPA


Supplementary:  I wrote all of this post except for the book titles and the conclusory paragraph before reading Massimo's reply.  I did not want to be biased by his reply and try to seem more knowledgeable about Stoicism than I am.  A philosophy for living is definitely outside the expertise of most psychiatrists.


Attributions:

Photo at the top is  Agora of Smyrna, built during the Hellenistic era at the base of Pagos Hill and totally rebuilt under Marcus Aurelius after the destructive 178 AD earthquake, Izmir, Turkey from Wikimedia Commons By Carole Raddato from FRANKFURT, Germany [CC BY-SA 2.0 (htta significant hsitroical basis of Stop://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons.

Marcus Aurelius was a Roman emperor and also a practitioner of Stoicism.  His surviving writings provides a modern day resource of Stoicism.  From the number of quotations I think it is safe to say that modern day Stoics consider him to be a Stoic philosopher as well as practitioner.

JWH Compounds Make the NEJM

JWH-018

AMB-FUBINACA

Synthetic cannabinoids have been a problem for over a decade.  There have been sensational news reports that typically occur as a result of aggressive and disorganized behavior when users are acutely intoxicated.  When these compounds initially started to appear on the scene, regulators were far behind the curve.  Some of the first forms were sold in head shops, wrapped in paper and labelled "Not For Human Consumption."  They went by names like K2, Spice, and Plant Food.  They are typically applied to shredded plant material so that they can be smoked.   The chemical structures of these compounds do not resemble typical cannabinoids and the synthesis is relatively straightforward.  That has facilitated black market production.  Apart from easy availability the other draw was that users could take these compounds and not have to worry about standard drug testing protocols in the work place.  The word on the street was that the synthetics were undetectable by typical urine toxicology and that was accurate.  Apart from isolated aggressive incidents there were also deaths associated with their use.  There were some epidemics that clustered in communities and eventually (like most drug epidemics) the sale of the compounds was prohibited and some head shop operators were prosecuted.

From the standpoint of addiction practice, many of these compounds create a dangerous situation for the patient and a dilemma for treatment facilities.  They are highly addictive to some people and unless there is some familiarity with the concept of delirium producing drugs causing addiction, it may not be clear why anyone would continue to use them.  Many people are amnestic for what occurred when they were under the influence.  In some cases they develop life threatening conditions as a result of use and crave the drug when they are being acutely treated for the medical complications.  Another abused drug with this kind of dissociative profile is dextromethorphan.  When used in high doses it leads to delirium and hallucinations and can be highly addictive.


The JWH designation represents the organic chemist John W. Huffman who synthesized the series of compounds as cannabinoid receptor agonists.  The goal of the research was to produce pharmacological probes to study cannabinoid receptors.  He is a coauthor on 30 papers in Medline.  There are several articles in the popular press including several that include his opinion about his original research being used to produce compounds for sale as street intoxicants.     JWH compounds have been in the medical literature since about 2005.  PubChem contains structural information on 281 JWH compounds, 367 protein targets, and 706 bioassays.  PubChem also allows the user to generate 2D and 3D structural similarity comparisons and bioactivity analyses - for example activity at the CB-1 and CB-2 receptor.  As the JWH compounds and other synthetics have evolved they follow a familiar pattern of the development of classes of addictive compounds - subsequent syntheses have increasing activity at the target receptor.

There are other classes of synthetic cannabinoids in addition to the JWH compounds including UR-144, AKB4, AB-CHMINACA, AB-FUBINAC and others.  There are also a number of psychedelic phenethylamines 2C-B, 2C-I, 3C-E, 3C-I, and 2C-P that are often sold as equivalent drugs.  There are obviously no guarantees that purchases from non-medical sources results in the desired chemical or effect.  There is a also a class of synthetic cathinines referred to as Bath Salts, that are structurally similar to amphetamines and are often sold as mephedrone, MDPV, or methylone.  The total number of synthetics and the requirement of relatively sophisticated analysis for detection (gas or liquid chromatography-mass spectrometry) frequently leaves the acute care or addiction physician depending on history alone about what was ingested.

The New England Journal of Medicine has a general review of the issue in the January 19, 2017 edition (1).  Full text of the article is available online.  The article details the current number of new psychoactive compounds as 540 with 177 identified synthetic cannabinoids in 2014.  They have an illustrated timeline of the evolution of these compounds from 2010 to 2016.  The most interesting aspect of the timeline is the evolution of a 50 fold increase in drug potency from JWH-018 in about 2010 to AMB-FUBINACA in 2016.

They also provide an analysis of a mini epidemic of AMB-FUBINACA use in Brooklyn that occurred in 2016.  Of the 33 people exposed - 18 required transport to medical facilities.  An index case is described with features of a blank stare and unresponsiveness 13/15 on the Glasgow Coma Scale.  He had episodic groaning and slowed movement of his extremities.  The term "zombielike" was used as a descriptor but in psychiatry that term is used so frequently by patients and untrained observers that it lacks meaning. The patient was sweating and had normal vital signs with the exception of tachypnea with a respiratory rate of 21.  Screening labs, toxicology, and ECG were all normal.  He recovered in about 9 hours and was discharged.  The authors recovered the original herbal product labelled "AK-47 24 Karat Gold"  and sent that as well as biological samples (blood and urine) from 8 other users for analysis.

The samples were analyzed with liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF/MS).  AMB-FUBINACA was confirmed as the compound in the original packet of material.  The de-esterified product rather than the parent compound was confirmed in the blood and urine of the patients with serum concentrations from 66 to 636 ng/ml.  

In the discussion the authors point out the potency increase with these synthetic compounds.  They illustrate the attractiveness to drug dealers and users - about $3800 of AMB-FUBINACA can produce about a half million dollars worth of product containing about 64 mg of the original compound sprayed over shredded plant material.  That is strong incentive for getting this drug out on the street.  They also discuss the role of inter-agency collaboration in identifying novel intoxicants during similar mini-epidemics.  In this case the entire timeline from case to molecular identification was 17 days.  In many toxicology cases that I have been involved with, it often takes that long to learn that the lab you are using is not able do the necessary analysis.

Treating patients addicted to these compounds will be a challenge in the foreseeable future.  People who changed to synthetics just to escape drug testing in the workplace have ended up addicted to these compounds.  The psychoactive side effects of the compounds frequently results in a downward spiral of job loss, loss of relationships, and social isolation that goes along with the preoccupation of using the drug.  Explaining to the patient and their family that this is a potentially life-threatening addiction is not necessarily a deterrent to further use and fatal outcomes are possible.  Understanding the motivation for using a drug that has never been tested in humans, can result in the loss of days or an entire weekend, and can result in toxidromes that directly or indirectly lead to fatal outcome may be another sign that this is a neurobiologically mediated process that bypasses rational thought.

Prevention would seem like it is the best approach but American society remains fascinated by intoxicants and Americans have plenty of money to spend on these drugs.  Like most political arguments the common sense approach of a better plan for living is lost between the poles of liberalized drug use and prohibition.  I hope that the people at highest risk for using these drugs can learn to avoid them without exposure.          


George Dawson, MD, DFAPA




References:


1. Adams AJ, Banister SD, Irizarry L, Trecki J, Schwartz M, Gerona R. "Zombie"Outbreak Caused by the Synthetic Cannabinoid AMB-FUBINACA in New York. N Engl J Med. 2017 Jan 19;376(3):235-242. doi: 10.1056/NEJMoa1610300. PubMed PMID:27973993. (free full text online).


Attribution:

Molecular structures at the  top of this post are generated from NLM PubChem interface and are public domain.


Additional Analyses Available from PubChem:

I ran two analyses for 281 and 279 JWH compounds.  Additional information is available if you run the analysis for yourself.

Supplementary:

I encountered some stories on the Internet about the chemists who originally synthesized these compounds in the course of their professional careers.  Some of them have felt badly about the morbidity and mortality associated with their use as street drugs.  Others have pointed out that they were not intended for human use and not tested in humans and therefore nobody should be using them.  Keeping in mind the profit motive suggested by the NEJM article and the incentives for gaming the system by finding compounds that are not on the Schedule of Controlled Substances, I don't think that there should be any question that the sellers and buyers of these drugs are responsible for the outcomes.

Emery Dreifuss Muscular Dystrophy and Lipodystrophy

Public radio is a consistent source of content about medical problems that contain lessons for everyone.  I happened to hear one last weekend.  The program was This American Life and the story was called Do These Genes Make Me Look Fatless.   The story starts out with writer David Epstein describing the public reaction to his latest book The Sports Gene.  As part of the correspondence a 39 year old woman named Jill Viles sent him an illustrated letter and it contained the heading "Olympic Medalist and Muscular Dystrophy Patient with the Same Mutation."  The side by side photos of Jill Viles and Olympic sprinter  Priscilla Lopes-Schliep are side by side on the web page and I encourage anyone reading this to take a look at the comparisons and try to figure our how Ms.  Viles came to this conclusion.  Epstein was interested and replied getting a detailed scientific brief in return.  He got a second opinion from a geneticist that he consulted in the making of his book who concluded that Ms. Viles was probably wrong about the genetics.

From there the story goes into the incredible history of Jill Viles and how she started to research her illness.  After normal early developmental milestones she started tripping and falling at the age of 4.  She was taken to the Mayo Clinic and Jill, her brother and father were all tested and showed evidence of muscle damage.  They concluded that although it looked like muscular dystrophy, girls never got it and therefore she did not have muscular dystrophy.  Over the next 8 years her arms and legs got extremely thin,  she had a burning sensation in the legs, and all of the subcutaneous fat in her extremities disappeared leaving very prominent veins.  Within a few weeks she started to fall again and was no longer able to ride a bike or roller skate.  She regained her ability to walk and then began a very unusual research program to see if she could find out what was wrong.

She started by looking at tales of the supernatural - like poltergeists.  She reasoned that the people in these books she was reading could not explain what was happening to them and she might find an answer.  Then she went to college and started to study medicine on her own.  Her project involved reading textbooks and journal articles on muscle diseases trying to find one that matched her own experience.  She was reading an article on  Emery-Dreifuss  muscular dystrophy when she noticed the description "Popeye arms" and had an immediate association to the appearance of her father's arm.  As she read the description she noticed that she had features of the illness.  She took a number of the books home on break and her father discovered that he had both the muscular and cardiac symptoms with bradycardia into the 30 beat per minute range.  His doctors told him the symptoms were from exposure to a virus.  He was re-evaluated and a pacemaker was placed.

Jill went to a neurology clinic for confirmation of the diagnosis, but the neurologist there just make a diagnosis of Muscular Dystrophy.  She got angry and would change the diagnosis by writing in the chart.  The rationale was that women do not get Emery Dreifuss Muscular Dystophy (EDMD).  She eventually located a group of researchers in Italy specializing in the disorder and sent them blood samples of her entire family.  Four years later she had confirmation that she had the gene - a single base pain mutation on the Lamin gene.  According to the Universal Mutation Database the LMNA gene has 464 known mutations and 283 variants.  Some of the diseases are more well known than others.

At this point before I get into some additional details of the illness, this is clearly an inspirational story.  Jill is clearly a very bright person.  Transitioning from an explanatory paradigm that went from the supernatural to cutting edge DNA and genetic research within a few years while dealing with a significant chronic medical problem for  which there was no clear diagnosis or treatment is astonishing.  It is a testament to her intelligence, character, and mental flexibility.  In the process she her research also made a significant difference in her father's life and the life of Olympic sprinter Lopes-Schliep.  Hearing her speak about these details in the audio file is necessary to bring some of these details to life.

Jill got a job in a lab at Johns Hopkins combing the research for any reference to the lamin gene.  In the process she came across another photo that reminded her of her own appearance.  In this case the prominent feature was a loss of subcutaneous fat called partial lipodystrophy.  She maintained that she also had this rare disorder and was met again with denials - in this case based on the likelihood of having two rare genetically determined illnesses.  This time she believed the deniers.  She also started to get increasingly anxious in reading about  EDMD and the short life expectancy.  She stopped the research completely and started teaching at a local community college.  She got married and gave birth to a son who does not have EDMD.  She had more severe weakness after the pregnancy.  Jill's father died suddenly at age 63.  In the gathering at the familiy home her sister showed her pictures of Priscilla Lopes-Schliep.  She noticed the characteristic pattern of veins and muscle fibers.  Twelve years after she stopped researching EDMD she started to research lipodystrophy.  Eventually Jill arranged a meeting and they both  submitted samples to a world expert on the condition - Dr. Abhimanyu Garg.  He confirmed they both had the same rare type of hereditary lipdystrophy.  It turns out that the partial lypodystrophy mutation and the EDMD mutation are both on the lamin A/C gene LMNA.

Jill also reached out to Etienne Lefai a researcher studying SREBP-1, transcription factors that control muscle mass through protein synthesis.  Overexpression of these same factors can lead to muscle atrophy.  Dr. Lefai credits Jill with changing the path of his research when she reached out to him.  He described her a awesome and the only example of someone outside of the research community coming in and altering his basic path of research.    

I agree completely with Dr. Lefai.  Part of the story here is how much credence you give the theories that your patients have.  For a psychiatrist it is somewhat easier.  Good psychotherapy depends on finding out underlying theories, testing them and suggesting alternate theories at times.  It can be a trying process.  Sometimes your patient really is being followed by the FBI and figuring that out is a major decision in the diagnosis and treatment plan.  I have gone to some elaborate lengths to create an experiment and conferenced in some experts from other fields like electrical engineering to test a person's theory about how the  world  works.  In the addiction field it is very common to encounter people who have never had a chemistry course in their life and now consider themselves to be experts in pharmacology and organic chemistry.  I listen to all of these theories and carefully weigh them and consider their overall meaning.  It was interesting to read why the experts rejected Jill's correct theories and how they gradually came to accept them.          

Another reason for this post is that is also allows me to highlight what I consider to be the best resource on the Internet for musculoskeletal diseases and that is the Washington University Neuromuscular Disease Center. It is essentially a free online text in neuromuscular diseases ranging from the clinical presentation to pathology to molecular biology.  It is an immediate resource for any physician treating someone with a neuromuscular disease.  In the case of Emery Dreifuss MD, there is a comprehensive page with the genetics listed right at the top.  The National Organization of Rare Diseases has a web page on congenital lipodystrophies.

I often think about what research was like when I was in medical school.  My wife and I would head to the Medical Library and I would run around pulling bound journals while she copied the articles that I needed.  That was a lot of heavy lifting that is no longer necessary thanks to the modern flow of information.

I thought about that when the story described Jill lugging heavy books home in a backpack.  That was definitely another measure of her determination.


George Dawson, MD, DFAPA




References:

1: Dessalle K, Euthine V, Chanon S, Delarichaudy J, Fujii I, Rome S, Vidal H,Nemoz G, Simon C, Lefai E. SREBP-1 transcription factors regulate skeletal muscle cell size by controlling protein synthesis through myogenic regulatory factors. PLoS One. 2012;7(11):e50878. doi: 10.1371/journal.pone.0050878. PubMed PMID:23226416.

2: Gnocchi VF, Scharner J, Huang Z, Brady K, Lee JS, White RB, Morgan JE, Sun YB, Ellis JA, Zammit PS. Uncoordinated transcription and compromised muscle function in the lmna-null mouse model of Emery- Emery-Dreyfuss muscular dystrophy. PLoS One. 2011 Feb 22;6(2):e16651. doi: 10.1371/journal.pone.0016651. PubMed PMID: 21364987.

3: Scharner J, Brown CA, Bower M, Iannaccone ST, Khatri IA, Escolar D, Gordon E, Felice K, Crowe CA, Grosmann C, Meriggioli MN, Asamoah A, Gordon O, Gnocchi VF, Ellis JA, Mendell JR, Zammit PS. Novel LMNA mutations in patients with Emery-Dreifuss muscular dystrophy and functional characterization of four LMNA mutations. Hum Mutat. 2011 Feb;32(2):152-67. doi: 10.1002/humu.21361. PubMed PMID: 20848652. 

4: Scharner J, Gnocchi VF, Ellis JA, Zammit PS. Genotype-phenotype correlations in laminopathies: how does fate translate? Biochem Soc Trans. 2010 Feb;38(Pt 1):257-62. doi: 10.1042/BST0380257. Review. PubMed PMID: 20074070.


Attribution:

Figure at the top is from National Library of Medicine Genetics Home Reference page on the LMNA gene.  It is the cytogenetic location of the LMNA gene.  It was generated with the NCBI Genome Decoration Page.  The copyright is Health and Human Services and I assume this is public domain.

https://www.thisamericanlife.org/radio-archives/episode/577/transcript

http://www.emerydreifussmd.org/genetics.html

Racing Thoughts?

From the DSM-5 under criteria B.4. for a manic episode: "Flight of ideas or subjective experience that thoughts are racing." (p.124). In a previous post I discussed how easy it was to make a reliable diagnosis of bipolar disorder because the patient needs to describe a clear cut episode of mania. The main problem becomes determining whether they are actually describing a manic episode or not. There are a significant number of confounding factors in that determination. The best way to illustrate what I am talking about is to focus on how the term racing thoughts is used in psychiatric evaluations by patients rather than psychiatrists. DSM technology gives surprisingly little guidance on what a racing thought is. In clinical practice that is very problematic, especially if psychiatrists are depending on the observations of untrained observers. People who appear to be hyperactive or agitated and hypertalkative are frequently described as having racing thoughts. In many cases when asked directly they will reply: "My thoughts are always fast." or "This is normal for me." or "What do you mean by racing thoughts?  I don't know what that means."  At the observer level, many observers have reported to me: "The patient states he is having racing thoughts" as though that is diagnostic.  It may be - but it also might not be.

One of the commonest scenarios for racing thoughts doesn't involve mania at all.  It involves anxiety and insomnia.  Initial insomnia is a case in point as in: "I try to fall asleep but as soon as my head hits the pillow my thoughts are racing and I am thinking about a million things. After a while I look at the clock and it is 2AM." In the sleep literature the experience of racing thoughts here is associated with the phenomenon of hyperarousal and it is the commonest form of initial insomnia.  In other words, when I go to bed to sleep at night - I have really trained myself to think about all of my problems for several hours before I fall asleep.  It is not about sleep at all. Subjectively a person may thinking about every hypothetical in order to prevent mistakes - a common cognitive error of the anxious.  Many people experience this high arousal and excessive worry state as racing thoughts, but the main difference is probably in the time domain. The insomniac experiences a compression of time.  The worry is continuous and at least initially there is some surprise that hours have passed and there is no onset of sleep.  When the insomniac wakes up in the morning the racing thoughts are probably not there. With an episode of mania the racing thoughts are usually phasic change until the manic episode resolves or a different cognitive process occurs like increasing incoherence and distractability.

One of the best modern sources of information on psychiatric phenomenology remains Andrew Sims' Symptoms in the Mind. His discussion of racing thoughts is more comprehensive than most and far superior to anything that you will find in the DSM.  I am sure that the DSM authors will point out that this is why psychiatric training is necessary to use the book and that the book is not a substitute for training in phenomenology. Without that training racing thoughts on the part of the patient or the observer is often anyone's best guess. The best example I can think of was a patient who was being presented to me as "histrionic and overly dramatic" who was in fact manic. It is difficult if not impossible to sustain a dramatic presentation of mania, racing thoughts and pressured speech for any length of time.

The Sims discussion of racing thoughts occurs in his chapter: Disorder of the Thinking Process. In it he uses what he refers to as Jaspers model of thought association.  As illustrated in the tables, people tend to proceed from one constellation of thought to another unless they have specific disorders of thinking.  Sims diagrams out the thought disorders using a very nice graphic to illustrate these clusters and how a person moves from one cluster to another.  I have included a couple of examples in the tables here and how the thoughts proceed as indicated by the red arrow.  As I thought about it there are some differences with anxiety and mania.  The anxious person will be operating form clusters of questions and doubt.  That leads to more and more branch points or worry.  The manic person on the other hand especially if they have grandiose and expansive mania is not operating from excessive worry or doubt but declarative statements consistent with their confidence level.  As I thought about both people trying to sleep, the anxious person would be laying in bed the entire time, probably with their eyes closed going through these constellations of thought.  One of the commonest sleep complaints they describe is: "I can't shut my mind off - it is racing."  

The manic person for the same time frame would undoubtedly be up and engaged in some activity late into the night - if not for the entire night while experiencing a rapid progression of thoughts.  They will often describe their thoughts as going too fast to describe and certainly too fast to speak, even though many can speak at a very fast rate.  A secondary phenomenon that I typically ask about is excessive thoughts with no progression or what Sims calls "crowding of thought."  His specific description is that thoughts are being passively concentrated and compressed in the head: "the associations are experienced as being excessive in amount, too fast, inexplicable and outside of the person's control."  Sims sees this as occurring in schizophrenia, but I have definitely asked that question to manic patients and had them agree that was happening to them.  Jaspers also describes flight of ideas as a massive flow of content without an increase in the speed of thinking. 

The interesting aspect of focusing in only on the conscious experience of racing thoughts is that there is not necessarily an associated pressured speech.  Andreasen defined 18 different thought disorders in her early work and one of them was pressured speech.  She defined pressured speech as a rate of at least 150 words per minute. (3).

From a clinical standpoint a number of syndromes present with self descriptions of racing thoughts including anxious and agitated depressions, some forms of attention deficit~hyperactivity disorder, various intoxication states.  Racing thoughts is often the first phenomenon described by people who are under a lot acute stress and in some cases physical illness.  Many people become delirious for one reason or another and describe what amounts to a state very similar to pre-sleep reverie as racing thoughts.  The recent literature on racing thoughts supports the observations in this post and suggests that thought overactivation that includes both racing thoughts and overcrowding is a common phenomenon in mood disorders including unipolar states.  It also highlights an inherent limitation of the DSM - despite an abundance of descriptors it is inherently weak on phenomenology and this needs a lot of work with trainees who may be too focused on the DSM as a system for indexing rather than a comprehensive diagnostic system.  The criteria of racing thoughts certainly seems to lack specificity at several levels and clinicians encounter a broad spectrum of people who describe racing thoughts and do not have mania.  

Rather than a central feature of the diagnostic process, I would speculate that most experienced clinicians find that racing thoughts are an elaboration down the mental checklist after they have a detailed history of mood, activity level, and sleep changes.  At that level most of these clinicians are matching patterns of hundreds or thousands of people treated rather than specific written criteria.


George Dawson, MD, DFAPA



References:

1:  Andrew Sims. Symptoms in the Mind. Third Edition.   Elsevier Limited, Philadelphia, USA, 2003: p. 149-155.

2:  Karl Jaspers. General Psychopathology. Volume I.  John Hopkins University Press.  Baltimore, Maryland, 1997. p. 210-213.

3:  Andreasen NC. Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of their reliability. Arch Gen Psychiatry. 1979 Nov;36(12):1315-21. PubMed PMID: 496551.

Abortion, Women's Mental Health, and Politics...

Let me preface this post by saying that I am not a member of a political party and I do not endorse any political views about abortion.  The only interest that I have in abortion is what women tell me about it in the context of a psychiatric evaluation and treatment.  I also do not want to see women's mental health become a surrogate end point for the political debate on abortion.  In the state where I practice the Minnesota Department of Health mails a report on the number of abortions in the state with a number of warnings about the legal requirements of reporting abortions (p 51-57 of this report) despite that fact that 99+% of all physicians and 100% of psychiatrists do not perform abortions.  I bristle when I get that politically motivated report each year.

I am writing this post to examine whether or not any objective research on the mental health effects of abortion can be done.  This examination was precipitated by a post on a forum of the Time story "Abortion Doesn’t Negatively Affect Women’s Mental Health: Study".  Whenever I see an article like that I think of two things - the life experiences that women have told me over the years and where abortion fits in.   I also try to think about how I would do a study of this issue.  What would constitute mental health?  Most large studies don't depend on interviews anymore and that typically means a checklist or some sort of psychometric instrument.  There are typically cutoff scores and comparisons of cutoff scores between the research subjects and a control group.  Correlations are made with come psychiatric diagnosis or psychological construct to determine mental health.  With that kind of technology the underlying assumption is that these are good measures of mental health and that it covers all of the possibilities.  Human consciousness covers a lot of ground and there are generally subtle problems that don't get covered by these gross measures.

The study in question (1) is based on telephone interviews semiannually over a period of 5 years of a cohort of women selected for having an abortion, having a first trimester abortion, being turned away from access to an abortion and giving birth and being turned away from access to abortion and not giving birth.  In their results section, the authors plot the results of 11 interviews, but they point out that the subjects participated in an average of 8 over the 5 year period.  The women who received an abortion presented within 2 weeks of the clinics gestational limit for abortions (N=452).  Women with pregnancies up to 3 weeks past the gestational limit were turned away.  The turnaway group either gave birth (N=161) or had an abortion or miscarried (N=70) as possible outcomes.  Based on those outcomes they were identified as the turnaway-birth and turnaway-no-birth groups.   The first trimester group (N=273) was included to study whether or not the psychological outcomes differed if a woman had an abortion early or late during the pregnancy.

The test metrics were all Likert scales.  The depression and anxiety ratings came from the Brief Symptom Inventory (BSI) a 53 item rating scale of various psychological symptoms.  There are grouped ratings for 9 different symptom constellations including anxiety and depression.  All subjects are asked to rate their level of distress due to a symptom on a severity score ranging from 0 (not at all) to 4 (extremely).  For anxiety and depression their are 6 items each and subjects were identified as a "case" of anxiety or depression if their aggregate score were 9 of the total possible score of 24.  

Life satisfaction was determined by one item from the Satisfaction with Life Scale: "I am satisfied with my life."  One item was also included for self esteem.  Both were rated on a 5 - point scale from 1 (not at all) to 5 (extremely high life satisfaction/self esteem).

Using these variables, the trends were best illustrated in graphics of depressive cases versus time and depressive symptoms versus time (figure 1 above) and similar graphics for anxiety, self esteem, and life satisfaction.  The general trend was for less anxiety and depression slightly higher self esteem and life satisfaction over the 5 year course of the study.  I think analysis of the latter two elements was limited by the the single items 5 point scale and a regression toward the midpoint of the rating.  There is the usual extensive statistical analysis of what I would see as fairly limited data.  The turnaway groups and the near limit group generally had more depressive and anxiety symptoms and cases and lower self esteem and life satisfaction that the first trimester abortion group.  Their statistical analysis is consistent with those observations.

The authors conclude:  "Our findings add to the body of evidence rejecting the notion that abortion increases women’s risk of experiencing adverse psychological outcomes. Women who had an abortion demonstrated more positive outcomes initially compared with women who were denied an abortion."  In their secondary analysis they show that a history of previous mental health problems or psychological trauma correlated with adverse outcomes and may have worse outcomes if they are denied an abortion.  They discuss the importance of individualized care and recognizing the response to an abortion or in this case denial of abortion.  One trend that I did not see any specific comments on was the turnaway-no-birth group and the fact that it seemed to have the best outcome at 5 years in terms of depressive symptoms/syndromes and higher self esteem and life satisfaction.  In their overall conclusion the authors believe that their study shows that there is no necessity for laws warning women about the adverse psychological consequences of abortion and that being denied an abortion is potentially more detrimental.  

In their own discussion of the limitations of the study, loss of subjects over time was significant - 43% over 5 years.  They discuss the methods they used to limit bias due to loss (potentially of subjects with mental illnesses).  They discuss their alteration of the BSI and point out that it is really a screening instrument so that the identified cases in their study would require additional screening for an actual diagnosis of an anxiety disorder or depressive disorder.  

I had several thoughts when I read this study.  Women don't generally come in to psychiatrists and say they are depressed or anxious as the result of an abortion or a denied abortion.  That might be different in psychiatric clinics that specialize in women's health issues.  They often don't discuss the issue at all in the initial diagnostic evaluation.  They disclose these details along with other sensitive issues after a relationship has been established with a psychiatrist.  In that context there can be discussions about thoughts, images,  and feeling states related to abortion into other forms of psychopathology.  An example would be intense guilt, rumination, and self criticism about the abortion during an episode of depression.  When any person gets depressed it is a common experience to scan past personal history for stressful events from the past that lead to the same emotion.  There can be daydreams and fantasies of what the child would have been like.  There can be brief episodes of depression or anxiety related to self criticism, doubt, shame, or interpersonal conflict about having had an abortion.  Many of these thoughts can occur at a future date when the history of an abortion can take on new meaning such as a new committed relationship.   Any life event that impacts person's conscious state and causes them distress is significant to me, whether it is picked up by rating scales or not.  I would see these reactions as being part of normal emotional life rather than anything pathological.

Equating the mental health of women to a DSM diagnosis  or psychometric construct is a mistake.  The DSM is a product of looking at the 5% of people who are outliers and trying to characterize their problems with with categories or continua.  That approach removes human consciousness from the equation and that should no longer be acceptable to psychiatry or anyone interested in the conscious life of real people.  An event with as much potential meaning as abortion can never be adequately characterized as a psychiatric diagnosis or a psychometric scale.  The reactions are too diverse and nuanced.  Suggesting that abortions or the lack of abortions does or does not affect women is more of a political statement than a statement that takes into account the most important aspect of the human psyche - the unique conscious state of every person.  That conscious state is unique because what happens over the course of your lifetime matters and some events matter more than others.

My conclusion from practice is that abortion is one of many events that has the potential to significantly impact the conscious state of a woman.  That should be the consideration in the case of contraception, pregnancy prevention, and abortion and not whether or not it causes mental illness or symptoms.  A woman's unique conscious state should also be considered in the case of unplanned pregnancies and why that decision is much more complex than a list of social variables or whether or not contraception is used.  A more appropriate focus on conscious state rather than mental illness or symptoms would yield a more realistic idea about the effect of life events like abortion.  That result will be anything but simple and that is why simplistic political solutions or response to those solutions do not apply here.

I have a secondary conclusion about the place of politics in both the research and clinical care of women.  It has no place at  all.

It is as obvious as an annual vaguely threatening letter about abortion reporting to a psychiatrist from the state government.  When politicians practice medicine nothing good happens, but this letter goes way beyond that.


George Dawson, MD, DFAPA


References:

1:  Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women's Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. 2016 Dec 14. doi: 10.1001/jamapsychiatry.2016.3478. [Epub ahead of print] PubMed PMID: 27973641.

Attributions:

1:  Graphic at the top is from Reference 1 with permission from the American Medical Association - Order Number 4024950066424

2:  Thanks  to Pearson Assessments for sending me a sample copy of the Brief Symptom Inventory.  www.pearsonassessments.com

Do Businessmen Dream Of Medicine Without Doctors?

You bet they do.

My first exposure to the business-driven dystopian future of medicine occurred in Fort Lauderdale in 1994.  I was the Public Affairs rep for the Minnesota Psychiatric Society.  The APA decided that it would be a good idea to bring all of the Public Affairs and Legislative reps of the local district branches (DBs) to Florida for a conference.  On the surface it was supposed to be focused on getting solutions into the hands of the DBs.  In retrospect it was a shocking introduction to how the managed care industry would lay waste to the field of medicine in the decades that followed.

The keynote speakers for that conference were Governor Arne Carlson from Minnesota and a business consultant.  Minnesota has always been a hotbed of managed care activity and for the past three decades any physician practicing here has been a witness to what can happen when government and business bureaucrats practice medicine.  The end result of rationing psychiatric services over that period of time has been a system of care that is so fragmented and that provides such poor service to patients and family members that the current Governor Mark Dayton recently called for massive reform.  The result of that Task Force is quite unremarkable but that is another story.  In 1994 Governor Carlson was there to brag about MinnesotaCare, a government insurance scheme for the working poor and the Health Care Provider Tax on all health care providers in the state to finance it.  He was describing them as major breakthroughs but over the years they have proven to be very suboptimal programs.  The Provider Tax in many years acts as another revenue source for the State and that revenue is not directed at anything to do with health care.  I have never witnessed any of my working poor patients get on MinnesotaCare.  It appears to be rationed as tightly as a managed care option.  Some members of the audience were less than receptive to these ideas and the Governor did what he could to put them in their place.  The precedent of never telling a politician that they are wrong about their supposed health care reform was easily established.

The consultant provided an even clearer picture of the business agenda. He bombastically presented the first wave of fake news that helped establish managed care.  That fake news was - "Nobody needs specialists anymore.  There are too many of them and they are too high priced.  We are going to buy them out and put them out of business.  The only doctors we need are primary care doctors."  He focused on orthopedic surgery as a case in point, but he pointed out that the same was true of any medical specialty.  It was an implicit threat to all of the psychiatrists in the audience. Of course his statement was pure fabrication.  There is no way a businessman is going to spend a dime to buy practices when he can just manipulate them out of business.  It was the beginning of the full court press to manipulate physicians into doing whatever the business types wanted them to do.  In the following 2 decades - physicians and patients were manipulated into using primary care physician offices for a gatekeeping function for everything while simultaneously reducing reimbursement to those physicians to the point that they needed to see 30 to 40 patients a day to keep the doors open.

I was working for an altruistic multispeciality clinic at the time.  I say altruistic because one of our goals was to see all people presenting to our hospital or clinic irrespective of their ability to pay.  We had to work harder as a result, but were generally quite content.  The physicians were high quality and we were all collegial.  I never trusted any group of physicians more.  The work environment resembled the training environments that I had worked in - county hospitals and VA hospitals and clinics.  Billing, coding, and reimbursement were far removed from the work.  We had billing and coding specialists who came by, read our notes, and submitted the billing documents - totally unseen by us. All we had to do was focus on the practice of medicine.  Anyone working in those days would tell you that was more than enough.

But there was fear in the air.  Over the next several years the physicians in my group were talking about how the local managed care companies were going to put us out of business.  Since were were the largest provider of medical and psychiatric services in the east Metro area and had the market cornered on poor reimbursement,  I dismissed it as hysteria.  Over the next several years we were acquired by one of the three managed care companies that provide the bulk of medical services in Minnesota.  In the process our self funded malpractice fund disappeared.  The provision of care also started to change.  There was no longer an acute care Neurology service.  Stroke care was going to be provided by "an internist with an interest in strokes."  The internal medicine consulting service became the hospitalist service and primary care physicians no longer saw their patients in the hospital.  The decisions were not discussed.  There was no consensus.  Department heads were let go.  Physicians were just told what to do.  At some point my request to talk with the wizards behind the screen was met with a simple answer.  There was now a "firewall" between physicians and the administrators and there was no way that I would ever question their decisions or talk directly with them.  

The administrators began to proliferate.  An endless series of administrative ideas began to be put on the physicians.  Physician were no longer practicing medicine all day long.  Suddenly there were plenty of feel good meetings for administrators.  And so it went.    Outright bombastic contempt for physicians was no longer necessary.  The administrators had won.  Additional mechanisms were put in place to suppress any dissent.

The contempt is still palpable in some of those dissent suppressing situations.  These days - all it takes is a complaint against a physician to activate what is typically an airtight mechanism to scapegoat them within the organization.  It doesn't matter if the complaint is real or not.  In many organizations, a physician's annual evaluation actively solicits anonymous complaints about them.  It is part of a general effort by administrators to illustrate that physicians are really deficient human beings, only able to function in the context of a beneficent organization and supervision by a business person.  Some organizations have a "three strikes and you are out policy" and they don't want to debate the merit of any complaints.  They just list it as a strike.

This is how being a physician devolved from being a fairly autonomous profession to one that is clearly under the boot of the managed care industry and the government and everything that entails.  It was largely an exercise in fake news and rhetoric on the part of the business community and a complete lack of response from physicians or their professional organizations.  That practice is alive and well today.  There is no science involved in business management and no standards.  That alone would create some suspicion about how medicine is currently managed - but there are very few critics.  Physicians as a group have never been able to grasp one of management's unscientific techniques referred to as pushback.  Instead of standing there like deer in the headlights pushback against all of the fake news generated by these managers.

If that ever caught on with my colleagues - we would all start pushing now and keep it up for the next 30 years to just break even.


George Dawson, MD, DFAPA




Supplementary 1:  Businessmen here is used as a generic form of businessman or businesswomen.  There are clearly plenty of female managers who also do not know what they are doing.

Supplementary 2:  A few words about pushback.  According to William Safire writing in the New York Times - pushback the noun began to surface in business journals near the end of the 20th century.  In my experience it started to show up in medical meetings about a decade later.  The current Merriam Webster definition is "resistance or opposition in response to a policy or regulation especially by those affected".  That does not really capture the business application of this term.  In a business meeting for example, the strategy might be to exert some kind of pressure on a group or subgroup of people affected by the business and see if there is any pushback.  In some cases, no pushback is expected because the employees are fairly expendable.  I heard a business story about retail stores that use a clopening strategy where the same employee closes the store one night and has to open it in the morning.  That is very inconvenient if you are that employee and trying to coordinate daycare for children or a second job, but pushback is not really anticipated.  In the case of professionals who are required in certain positions pushback might be anticipated with certain mandates.  I have been in meetings where the question was asked: "Has there been any pushback from the doctors or nurses on that?"  If there is none, the leverage is typically increased until there is.  In the case of physicians it rarely (if ever) happens.  There have been numerous explanations for the lack of assertiveness on the part of physicians.  The general explanation is that it is unseemly behavior that is inconsistent with the professional image of the physician.  I think the real mistake is that physicians assume that the business manager class has the same degree of professionalism and values when they clearly do not.  Any physician being pushed around or bullied by business managers knows exactly what I am talking about.  They do not think or act like physicians.  It is time to stop acting like they do.

Ref:

William Safire.  Pushback.  New York Times.  January 14, 2007.    


Supplementary 3:  From Orwell's 1984 as O'Brien interrogates Winston Smith and plants the idea that the only way man can assert power over another is by making him suffer and goes on to detail how that is done.  He concludes:  ".....Always, at every moment, there will be the thrill of victory, the sensation of trampling on an enemy who is helpless.  If you want a picture of the future, imagine a boot stamping on a human face--for ever."

That is exactly where the business world and the government want the medical profession.

Ref:

George Orwell. Nineteen Eighty-Four. A novel. London: Secker & Warburg (1949).

Attribution:  Image from this post is downloaded from Shutterstock  per their standard licensing agreement.  Image number 59502138 by Stokkete (photographer).