He was in his fifties and he wanted the same medications he had, except for one thing. He just could not manage to have sex with his live-in girlfriend. He never had. I was filling in at a clinic where I knew this was the only time I would see him.
There are a couple of strategies with prescription medications that sometimes work. A partial agonish to reverse a receptor; adding another antidepressant. I reluctantly told him about them, since a complex mental illness was being otherwise quite well managed. I mean, this man’s diagnosis was “schizo- affective disorder.” He had been really psychotic, hearing bad things and thinking they were real and running naked in the streets. As much as I think an interest in sex is healthy and part of normal living, I certainly did not want to risk having all of these horrible things happen to him again. Luckily, he told me the last thing in the world he wanted to think about was another drug. Even a little bit of another drug.
There are herbal solutions that actually work. I was thinking about some oriental herbs, which I certainly did not think were that expensive. But he assured me he had no disposable income at all. Maybe true, maybe not, but I always wonder at least a little bit when people tell me that they want something very badly, but then do not seem to find any money for it. I mean, he was a heavy smoker (over a pack a day) and I was certain insurance did not pay for that. I tried to approach this subject, and he became so angry at me I would have dived under the desk for protection if it had been physically possible. Read more on Men Just Want To Talk About Sex…
Filed under relationships by on Jun 16th, 2010. Comment. 
People who have panic disorder go to doctors to take care of it. I have had maybe hundreds of patients, more than I can count over my years of practice, who have come to me with this. Most of them do well. Usually the panic disorder runs its course.
That is not to say that panic disorder is not terrifying. Often people believe that their first panic attack is a heart attack. Often they have come to me already addicted to benzodiazepines by emergency room physicians who (understandably) worry a lot more about the immediate comfort of the patient than about the long term situation. Here is the official government take on panic disorder. Yes, find a psychiatrist you can trust. Yes, they recommend family and support groups. Good stuff, but free and easy to recommend. Yes, there is some exciting new research but as long as insurance companies and HMOs determine how people get treated, it is unlikely that research will be quickly translated into treatment.
Most people who go with the mainstream treatment do pretty well. Here is another description of mainstream treatment, a little more complete. Read more on A Real Doctor — Like House MD…
Filed under medicine, prescription drugs, Stimulants, Substance Abuse by on Jun 17th, 2010. Comment.
A nurse told me, “she called the clinic and she was ranting. She must have been drunk.” I did not think she was. She was a born-again Christian who did a lot of Bible-thumping, not that Bible-thumping by itself actually prevents anyone from drinking. She was in her fifties, trying to go back to school to get a college diploma she had missed earlier in life, with marriage and children. Something spiritual and faith based. I didn’t care what she wanted to learn about, for I truly respect people who are trying to accomplish things. I just didn’t think she would want to be seen buying a bottle of anything, for she was so sensitive about a public image that did not mean very much to anybody else. I think she was sensitive about it because she lived alone and her church was her surrogate family and they lived near her. All her life was in walking distance. Somehow I just did not see her as a drinker.
“I think she did something she usually does not do when she calls us. I think she just took everything her pain doctor prescribed for her.”
I had seen this woman in the office a few days before. She told me she had not yet taken any of her pain medications that day. She was awake and alert and pleasant, really pleasant. She told me she did not sleep and so she needed some sleeping pills. She had been in the hospital for something unrelated, some kind of a minor surgical procedure. Somehow, a nurse I work with had done the research and talked to someone who had taken care of her in the hospital. She slept. Lots. Late. Missing breakfast and eating it when it was cold. She had been on a relatively low dose of pain medications for her chronic pain problem. As far as I could figure, and I had taken care of her for a while, her pain was what you call “benign” pain. I mean, and she had told me the truth on this one, she had osteo-arthritic pain.. So how did she end up on so much pain medicine, and asking me for sleep medicine which she had not received, since in the hospital she had been taking the same thing I had prescribed. Read more on It Was All Prescribed…
Filed under prescription drugs by on Jun 24th, 2010. Comment.
She was nearly thirty, dark haired and round-faced and ambitious, and wanted to be a drug and alcohol counselor, maybe. Maybe not. She had only three months of sobriety from alcohol; probably wanted to be one of those people in power. So many programs dry people out and let them “stay on” a bit. So many people use their own exaggerated stories to “help” other people stay sober. A closet industry of subjective touchy feely, trampling, as many do on my long years of difficult, mind boggling training with cheap feel-good.
Her drug and alcohol counselor had told her that she would feel rotten for a while, so she had accepted that. But she felt obligated to tell me that she had felt rotten, so I let her talk and tried to listen.
People coming off alcohol may take as much as a year to get their sleep cycle back (alcohol represses Rapid Eye Movement sleep) and to stop feeling a little bit nervous. But this was not that. Read more on Serotonin Syndrome: Less Is More…
Filed under prescription drugs, Substance Abuse by on Jun 24th, 2010. Comment.
He was 23 years old with a rich ethnic heritage and identity that he said gave him strength. He looked like any one of hundreds, maybe thousands, of “youths” you could find on the streets. A couple of tattoos. The kind I would see when I was driving with my husband and think sometimes “wow, it was so much easier in the days of Marlon Brando movies.” I would have preferred a handsome renegade in a leather jacket to this obese, angry, unkempt person who clearly did not want to talk to anybody, including me. He was not my patient. A frustrated therapist asked me to see him because no medications had worked on him. She had expected me to come up with a miracle drug we could get samples.
He told me the same thing, over and over again, that he was doomed, that nobody could help him, that I was a nice lady, nicer than most, but I was wasting my time just like the rest of them.
He heard voices, always angry and deprecating voices, telling him he was going to die, that he was no good and deserved to be killed. Many times, in his life, he had attempted to prove the voices correct. Read more on The Devil’s Role In Mental Illness…
Filed under depression by on Jun 25th, 2010. Comment.
I was looking at Paul Fink’s column in the April 2010 Clinical Psychiatry News, one of those newspaper format “journals” that we like to call “throwaway journals” because subscriptions are free and they summarize other journals, as they usually end up in the trash. He writes for other psychiatrists. It is possible to identify with him if you do this for a living and are sentient enough to know what is going on around you.
I always liked this guy. Older people have a lot to say when they have practiced long enough to see trends go up and down and know their fate.
If I remember correctly, he is the one who said a while ago something to the effect that psychiatry is like prostitution in that the amateurs think they know as much as the professionals. Nobody has better nailed the central difficulty of this job. Read more on Purpose and Aging…
Filed under Aging by on Jun 29th, 2010. Comment.
The first time I found out about neuropathic pain, it was not even mine.
I was living in Amiens, above a cafe, and had adopted the boss, the patronne, as a surrogate mother. I came home late from a laboratory class one night and I tried to figure out what I was looking at with a dim light only on in back. I found this 80 year old woman in the back room with her blouse undone and an older man apparently angry at her pointing his finger. I ran in and asked him to identify himself, as I was concerned for Madame, and there was apparently some difficulty. He was nearly as old as she and they were both laughing heartily indeed. That is how I met this noble “docteur du quartier” (neighborhood doctor) who was performing what he described as an “honest and beneficial auscultation” and prescribing for her chest cold.
His whole practice was cafe backrooms. His patients the cafe patrons, who often had no cars, or no place else to go for medical care. He practiced a simple medicine, and as I advanced in school and he knew what I was learning he told me all that was too technical for him, and he would leave that to the young ones, especially the girls like me, because girls pay a lot of attention to detail and remember everything. And girls are nice and take good care of patients because they care a lot and try very, very hard. He told me not to tell anybody he said that. I never told anybody he said that until just now. Read more on Neuropathic Pain and Benfotiamine…
Filed under Alternative Medicine by on Jun 30th, 2010. 1 Comment.