About Face

FaceApp is the newest craze.

Make yourself younger.

Make yourself older.

See how ___________ (fill in the blank: much younger, much older, gorgeous, handsome, ugly, wrinkled, terrible!) you will look in five years, ten years, twenty years.

We are preoccupied with our looks, for good or ill. Selfies give us instant feedback. Tagged posts keep us honest. (I really do look like that?) We watch ourselves age, day by day, on social media.

Look, we are where we are. In life, in our careers, in school, in our family position, in our climb up the corporate ladder, in our steady, inevitable march toward the end of our lives.

The future will get here soon enough. Why push it, for goodness sake?

Do you want to enjoy the journey, feeling things, noticing things, accepting changes in your mind and body as you age? Do you really want to catapult yourself photographically or otherwise (Back to the Future movies notwithstanding) to age ninety, just to see how may wrinkles and chins you’ll have?

I am changing physically, and some of it I DO NOT LIKE. My stamina is not as good as it once was. I am not as physically strong. My body shape and composition are changing. My clothes don’t fit the same. None of these things keeps me from being as active as I can be mentally and physically. I try things. I push myself.

Try something. Turn your attention inward this week. Forget about your changing face, just for a week. Lines mean character. Gray means experience. Aches and pains mean you’re up and moving. “Only physically active people get these kinds of injuries,” I was once told in the ER after breaking my leg on sliding a bit too aggressively trying to stretch a single into a double.

LIVE YOUR LIFE. Don’t just document the hell out of it.

LIVE IT.

You will age, most assuredly, in good time, whether you use the newest app or not.

I can guarantee it.

 

A Day in the Life

“I’m going to cut off my head to stop the voices.
I have visions of shooting myself.
I have no income.
I’m tired of living the way I’m living.
I lost my job.
I’ve been using drugs for twenty years.
I pay for it by hustling, Doc.
Social Services took my kids last week.
I dropped out in the third grade.
Sometimes I take my kid’s Adderall.
I can’t take this any more.
My mother is in prison.
I shot myself in the face with a shotgun.
Do I look like I can afford an attorney?
On a scale of 0 to 10? How about minus five?
I will kill him. I WILL kill him. Do you understand me?
I flip out.
Maybe it’s the medicine.
Maybe I need more medicine.
I don’t need any medicine.
F—k you and your medicine.
I’m adopted. I don’t have any family history.
I don’t have any family.
You can’t help me, Doc.
Nobody can help me.”

The above short piece, entitled “A Day in the Life”, was first published several years ago after I had had a particularly hard day in the world of mental health. The comments you see there were things said to me by patients over a single twenty four hour period. One single day of stories about depression, betrayal, longing, sadness, grief, homicidal ideas, hopelessness, and resignation. Not long after the piece went up, I received a comment on Facebook from a friend.

“How do you do it?” he asked simply.

I saw a patient recently who was hurting and anxious and worried about her medical status, her mind, her ability to think and take care of herself and what would happen to her as she got older and more infirm. Her wandering narrative was punctuated by repeated questions.

“I bet I’m really bringing you down, aren’t I Doc?”

“Have you ever heard anything so sad, so awful, so terrible as my story?”

“I know you don’t care about any of this, but how do you listen to it?

“How do you do it?” she asked, echoing my friend from years ago.

I thought about that question a lot, in the context of all the misery and sadness and destructive behavior I had seen during that twenty-four hour period years ago, and in the more recent telling of my new patient’s story. I thought about what the minimum requirements for doing my job are, the ways that one can exceed those, and the ways that we must pace and protect ourselves so that we can do this job for a lifetime and help as many people as we are privileged to come in contact with.  It didn’t take me long to come up with the answer.

I had excellent mentors and excellent training.

Pharmacology professors like Richard Borison, who, notwithstanding his horrible judgment in matters financial that lead to his eventual imprisonment, had already forgotten more psychopharmacology thirty five years ago than I will ever learn in a lifetime. He had a way of making the difficult understandable, the complicated simple  and the insurmountable achievable.

Anatomy professors like Gene Colborn, who could find a muscle or a piece of cartilage or a tiny nerve in the human body by touch alone, who sat me down one day when I was struggling and overwhelmed in the early days of my first year of medical training. “ He looked right at me with clear, piercing eyes. “We don’t expect you to learn everything. Nobody can learn everything. The amount of information that we throw at you in the first year of medical school is just too much to handle. We expect you to learn how to manage everything. You can do this.” I often think about how he helped me believe in myself in a very dark time, and I use that feeling when listening and giving feedback to my own patients who might be in that same spot I was in all those years ago, not able to believe in themselves and their potential without someone helping them along.

Consultation-liaison psychiatrist Douglas Hobson who taught me about the esoteric, the strange, the interface between internal medicine and psychiatry and who introduced us to the Man Who Mistook His Wife For a Hat.

Stuart Finch, who ingrained in me the rule that a good child psychiatrist cannot and should not treat a child with severe emotional problems unless the family is all in and part of the treatment plan.

Larger than life people like my chairman Mansell Pattison, who loved life, lit up a room, ran a successful department of psychiatry out of his head, and died much too young in a tragic car accident. 

All of these and many more taught me the building blocks of my profession, drilled me on what was important,  taught by example, gave useful feedback, chastised when necessary and praised when deserved. They sent me out into the world of medicine in general and psychiatry in particular a well-trained clinician who was not afraid of hard work and who embraced lifelong learning. 

They also taught me to care. That is how I do it, even when it is so hard that I am tempted to give up. Because after all, if I didn’t care about my patients and their stories, I couldn’t do this every day.

Simple as that.

Who are your mentors? Who taught you about what is important? What lessons do you draw on every day when things get rough in your life?

Even more importantly, who is looking to you to be their mentor, their teacher, the one who pushes them to be their best, to go beyond their comfort zone.?

Demograffiti

Way back in the day, when I was going to medical school and my beloved Mac computer was but a gleam in its creator’s eye, we were taught to think about and to present medical cases in a very circumscribed and conventional way. After reviewing all of the pertinent medical records (which were all written down on paper and required transport from nursing station to workroom on small but sturdy wheeled carts, of course), we proceeded to the patient’s room (if hospitalized) or to the clinic exam room if outpatient and proceeded to take a history. Yes, my friends, we actually sat down, SAT DOWN, I tell you, and spent minutes if not an hour or two with the sick person at hand and actually talked to them, a la William Osler, giving them ample opportunity to tell us what was wrong with them, and then to gregariously yet sanctimoniously let them in on the secret, as if we had actually figured it out ourselves. (Most of the time, it is quite true, patients have a pretty good idea what is wrong with them and will tell us of we will only take the time to listen) Yes, the whole review and history taking process could be as long…as that last sentence was.

Now, after that was done, we of course did the requisite physical examination, which might include judicious use of a reflex hammer to the knee and a sticky wheel to test for sensation and a tongue blade applied at just the right angle to view whatever was lurking down the gullet. We came. We looked. We saw. We diagnosed.

Then we reported. To the chart. To our attending. To the nurses. To our less bright counterparts who were slow on the uptake and couldn’t tell the difference between a whiteout from pneumonia on chest X-ray and Aspen, Colorado in a February snowstorm. Our discourse almost always began as follows.

“This forty-two-year-old alcoholic white male presented to the emergency room with acute chest
pain of two hours duration accompanied by nausea, diaphoresis and pain radiating down his left arm.”

“This sixteen-year-old sexually active white female presents with new onset abdominal and pelvic pain and a moderate fever, with elevated white count and a left shift.”

“This fifty-year-old obese black female presents with abdominal pain, anorexia, listlessness and depression over the past three weeks.”

“This eighty-five-year-old male, a former aerospace engineer, presents with irritability, forgetfulness, wandering behavior, and inability to find words or name routine everyday objects.”

Now it is funny to me that in this day and age, when Google knows our whereabouts and Amazon can deliver things to us in two hours before we even knew we needed to order them, some folks take great exception to the routine practice of calling attention to one’s age, sex, race, color, creed, sexual proclivities or activity, body habitus, or other defining personal parameters and characteristics. Somehow, this is seen as invasion of a person’s privacy or is knowing too much about a person’s private information.

Really.

Well, when I was taught medicine, it was very important for me to know your sex, your age, whether or not you were HAVING sex, your weight, your alcohol and drug use habits (including the use of needles), your eating habits, your stress level, what kind of job you did, how much time off you took, your complete family history, and so forth. I needed to know those things, because in order to differentiate heartburn from heart attack, ectopic pregnancy from eructation, psychosis from neurosis and flatulence from petulance, I needed all the information I could gather, and then some. I might even have to speak with your spouse (with your permission, of course) or (God forbid) your mother to find out the things that you conveniently left out and did not want me to know.

Yes, today we who work in the healthcare industry are in the business of safeguarding privacy, and I am all for that. HIPAA (a 1996 Federal law called the Health Insurance Portability and Accountability Act that restricts access to your private health information) is king. However, I am not the enemy. Your other doctors are not the enemy. Your physician assistants, nurse practitioners, counselors, psychologists, nurses, phlebotomists, and lab techs are not the enemy. We are not Facebook. We are not Google. We are not Alexa. Okay, I think you get the point. We need to know these things because we know that dementia rarely strikes eight-year-old girls and sarcoidosis might be a little more common in a middle aged African American woman. An overweight man with chest pain who tries to keep his case of beer a day habit from me when I admit him to the hospital for depression will make treatment of his ensuing alcohol withdrawal that much more difficult as we work him up for his third heart attack.

In order to give you the excellent care that you deserve, we need to know everything that pertains to your health, including habits, mental health issues, and pattern of substance use. Please help us. Because you know, some of your demographics are written all over your history and physical and are easy for me to see. Other bits of vital information are hidden in your head. Unless you let them out, that is where they shall stay.

I’m a psychiatrist, but I’m not a mind reader.

CBD

One question I get asked a lot lately is this.

“Is it okay for me to use CBD oil?”

I thought it would be a good idea to address this general question in Mind Matters this week.

First of all, CBD oil and associated preparations are types of alternative medications, medicines that might not be mainstream or readily prescribed by doctors , but are nevertheless used by many people on their own. Alcohol and marijuana are two substances that are often used as “medicines” by those that think they function better with them than without them. Many people self-treat medical as well as psychological symptoms with nonstandard therapies.

Some of these agents, like CBD oil, do not currently have FDA approval for treatment of specific psychiatric illnesses. If you choose to use them, either alone or in combination with standard therapies, you must understand that there are several things to consider. First, they may have unexpected side effects. Secondly, they may interact with other foods or drugs that you already use. And lastly, they may or may not be legal for general public use. I will address some of these issues in the rest of this column.

According to WebMD, cannabidiol is found in the cannabis sativa or marijuana plant. There are eighty similar chemicals in these plants. THC is the major active ingredient, but cannabidiol makes up forty per cent of overall cannabis extracts. Cannabidiol may have antipsychotic properties, but we are not sure why. It might also actively block some of the effects of THC. There is really insufficient evidence for use of cannabidiol in bipolar disorder, dystonia, epilepsy, Parkinson’s Disease, schizophrenia, or social anxiety. Side effects due to cannabidiol use might include dry mouth, decreased blood pressure, light headedness and drowsiness. There is no good data on the use of cannabidiol in pregnancy or breast feeding, nor for many specific drug-drug interactions.

Some of these concerns were addressed in a recent interview on Medscape where Columbia University Chief Resident Angela Coombs, MD, interviewed Diana Martinez, MD, Professor of Psychiatry at Columbia and an addiction expert. Dr. Martinez stated that there is really very little known about how CBD affects humans and why. It may have some legitimate medicinal effects, but the jury is still out on some of these. She stated that if you buy CBD at stores, the advertised doses may not be realistic or true. Some websites of companies that manufacture CBD and have their products tested by legitimate outside companies will more likely list the actual amount of CBD available in their products. It might be very important to know about the presence or absence of contaminants as well. Some states like Colorado may do a better job at this point in testing products for factual labelling and overall safety.

CBD may be effective in treating seizures in some children with specific illnesses such as Dravet Syndrome or Lennox Gastaut Syndrome, obviously a very small group of people. If they do not respond to more traditional medication therapies, high doses of CBD in the neighborhood of 1000 mg might be effective.

The positive symptoms of schizophrenia (such as hallucinations) may be reduced with the use of CBD, but this is in the presence of traditional antipsychotics, not in place of them.

There is not much research to address the use of CBD oil in the treatment of anxiety or social anxiety. Dosing is largely unknown. 300-600 mg seems to be helpful for anxiety.

Dr. Martinez also addressed the drug-drug interactions that might occur when CBD is added to other, more traditional therapies. When the enzyme systems in the liver are affected by substances such as CBD, metabolism of other drugs might be sped up or slowed down, affecting the amount of those medications available in the bloodstream. This might lead to compromised treatment with seizure medications or antipsychotics. She also was not able to clearly answer the question about the legality of CBD at this time. Because of various bills, the DEA, the FDA and other regulators, there is not one specific answer as to the legality of buying, possessing and using these agents. Will it be regulated anytime soon? She was also not able to directly answer that question.

So, if you are thinking about using alternative therapies like cannabidiol, what are some of the things that you might need to consider?

1) It the substance an additive, food, plant, chemical, alcohol preparation or other kind of substance?

2) Is it approved by the US Food and Drug Administration?

3) Is it regulated by the FDA, DEA or other agencies?

4) Is it checked for safety by an independent lab or company for purity, quality, concentration, adulterants, etc?

5) Is it expensive or affordable?

6) Is it legal in your state or nationwide?

7) Does it interact with food, alcohol or other drugs? Are any of these interactions life threatening?

There is no hard and fast advice on the use of CBD oil yet, and much more research is needed.

And a Little Child Shall Lead Them

Funny how the world and its many events can stimulate our brains to recall things. As I write this column it is the seventy-fifth anniversary of D-Day, at that time the largest planned, multi-nation amphibious assault on an enemy defensive line in the history of warfare. I have also been reading about global warming, the flooding in the Midwest, political strife, and other natural and manmade disasters. This has been juxtaposed this past week with the wonderful visit of our two oldest grandchildren to our home, something that my wife and I anticipated with great joy and gratitude. The two opposite circumstances, and their associated emotions, brought to mind a story that I first told in 2005, as I was working as a Red Cross volunteer in Mississippi and Louisiana after Hurricane Katrina had slammed ashore and turned the world upside down for so many people on the Gulf coast. I thought I would share this story with you. It still makes me smile.

 

I had an encounter with a beautiful little girl in Mississippi, just days after the monster category 5 storm had entered her family’s life. It reminded me, harshly and painfully, of what present-day Red Cross workers and thousands of other volunteers are going through right now, trying to do what they can for and with people who continue to suffer in various scenarios in our country and around the world.

 

I met Erica at the First Baptist Church in McComb, Mississippi. We were deploying out of the Red Cross shelter there, and I would often see people in that setting at the church or in the gym where they were making their temporary homes until the aftermath of Katrina’s wrath could be sorted out. She was a frail seven-year-old with beautiful dark skin and large eyes. She had not been eating or drinking in the five days since Hurricane Katrina had demolished her family’s house. She now lived in a small trailer with her parents and younger sister. She had nightmares where her parents and teachers were brutally killed and maimed, and she had lost all interest in playing or singing. We sat crossed-legged on the floor of the education building hallway, busy volunteers bustling around us, a tired Red Cross worker and a little girl who had literally lost everything in her life but her family. I leaned against the wall, happy for a few minutes to sit down and rest. She sat with chin in hands, looking down at the polished floor of the church building. I had tried to engage her in conversation, to no avail. I thought I would try one more thing.

 

“Erica, what’s your favorite food in the whole world?” I asked.

 

She looked up slowly, her interest piqued. She sized me up with those big eyes as only a child can, and I saw a faint glimmer of a smile.

 

“Fortune cookies.”

 

“Fortune cookies?!” I said, truly surprised. I had expected the usual hamburgers, hotdogs or ice cream. “I’ve got your number,” I said instantly, my way to this child’s fragile and damaged psyche suddenly made clear to me. “Give me twenty minutes and I’ll be back.”

 

She looked at me quizzically, but a simple “Okay” came out.

 

I returned to a Chinese restaurant I had just found the day before. I had enjoyed a meal there that nourished my mind, heart, and stomach, and I had struck up a brief conversation with the staff while I was there. Wearing a Red Cross vest was almost always a stimulus for questions from those who lived in the local communities that we served. I sought out and spoke with the hostess, who listened to my story about the little girl whose life had been ravaged by this storm that came out of nowhere and changed everything forever. She stepped toward the back for a half minute, returned and immediately began filling a large shopping bag with handfuls of fortune cookies plus a few dinners for Erica and her family. As I pulled out my wallet to pay her, she pushed it away, tears streaming down her face. “Hurry back to little girl who will not eat,” she said, handing me the bag full of food. “Go. Go now!” I thanked her, many times over, for her family’s generosity and goodness that would mean so much to this little girl and her family.

 

I returned to the church education building hallway, finding Erica sitting exactly where I had left her, surrounded by boxes of peanut butter and tuna that reminded me of a protective wall.

 

The little girl and I sat cross-legged once again on the floor. She looked in the shopping bag that I set down between us, eyes growing big as saucers. There was no mistaking fortune cookies, with their brightly colored wrappers.

 

She looked up at me.

 

“Can you eat just one of these for me, right now?” I asked.

 

The faint smile returned.

 

“Yes.”

 

“Could I eat one with you?”

 

“Yes.”

 

Little hands plunged into the bag. Cellophane wrapping papers crinkled happily. We munched contentedly.

 

“Now, how many of these do you think you can eat?”

 

The little girl from New Orleans gave this some serious thought.

 

“ALL of them,” she said emphatically.

 

“No way! You haven’t eaten anything in five days,” I teased. “You’ll be sick!”

 

More serious thought, eyes narrowing.

 

“Well,” she said slowly, “maybe not TODAY!”

 

The smile broke through.

 

Disasters are overwhelming and ubiquitous. Our personal response, our personal ability to do anything helpful, sometimes seems tiny and insignificant. If we listen, look, and pay close attention, we can make contact with those who need us most and deal with one small crisis at a time. Much like Erica and her bag of fortune cookies, we may not be able to help thousands of people in one day. We can start with one fortune cookie and one little girl with dark skin and beautiful eyes and a smile as big as Louisiana.

 

Erica, wherever you are, you should now be a vibrant young woman. I hope you are doing well. I am so glad that I was able to share your favorite food with you that day, and I hope that your fortunes have made a giant turn for the better.

Janus Moments

Janus, according to ancient Roman mythology and religion, was a god with two faces. Purportedly, he could look toward the future as well as back to the past. When we think of him, we might think of someone who is “two-faced”, one who talks out of both sides of his mouth, one who cannot be trusted. We have many examples of people who behave in this way today. Just pick up a newspaper, sign on to your favorite news outlet, or turn on the television. Say one thing, act in the opposite way. Promise one thing, deliver another (or nothing at all). Smile at someone while stabbing them in the back. “Make something great again” by tearing it down. (that works well in medical school and boot camp, but other than that I’m not sure it’s a good way to run a railroad, if you get my drift)

Janus was a two faced god, for sure, but he was more than that. He was considered the god of beginnings, gates, transitions, time, duality, doorways, passages and endings. I am so sick of seeing and hearing and experiencing modern people and circumstances that do little more than belittle, tear down, marginalize and destroy government, institutions, morals and other people. Could we not look at Janus as a chance for looking back at history, learning from it, and then facing the future with a bright optimism that fuels positive change and enlightenment and respect for others? How many Janus moments could we find, if we could but look for them actively?

  1. New relationships. We meet people all the time, in the stores we frequent, at our places of worship, at work, at school, at play. New relationships are just that-new. They are opportunities to show compassion and friendship to others, while receiving the same from them and learning new things from them as well. While we have many fine older relationships that span years and even decades, new ones offer us the opportunity to  expand our worldview, our reach and our circle of influence for the better.
  2. Online encounters. We sign onto Facebook, Instagram, Twitter, Snapchat, WeChat, and dozens of other on-line clearing houses for ideas, self-expression and commentary. We pick and choose who to associate with there just as we do IRL (in real life). We look, listen and learn. We comment about the things that we feel most strongly about. It is a slippery slope, social media. Why? Anonymity is one big reason. You can say anything to anybody with impunity, to a point. You can cut someone down, cut them off, and cut them out of the herd. You can spew racist commentary, spout your political views and wish someone a happy fifth birthday, all on the same medium. Is this not the perfect place to model behavior, good behavior for others? Yet, we look backwards to arguments and wars and disagreements from the past, fanning the flames of hate and unrest that we thought had long since died down to a heap of cold ashes. We spew vitriol. We curse others. We demean others for their customs, their dress, their sexual orientation, their religious beliefs. It seems that social media is rarely the bringer of good tidings and happiness, as least on the whole. Where better to turn things around and use this Janus moment to look forward, literally turning our backs on hate and racism and homophobia and discrimination and fear?
  3. Death and loss. I was reading several articles this past week about D Day and its aftermath. On June 6, 1944, more than 160,000 allied troops made a spectacular beach assault on the German defenses on the coast of France. The attack involved incredible planning, unbelievable numbers of planes, trucks, amphibious assault vehicles, and of course the soldiers themselves. Nine thousand allied soldiers were killed or wounded that bloody day, but their sacrifices allowed one hundred thousand more troops to begin the march inland that eventually lead to Hitler’s downfall and the salvation of Europe and democracy in the free world. We mourned their sacrifices and their loss this past week, as we do and as we should every year, but is this also a Janus moment? I believe what I am thinking about this was best said by General George S. Patton. “It is foolish and wrong to mourn the men who died. Rather we should thank God that such men lived.”
  4. Aging: In another blog, I am writing out my feelings and coming to terms with Growing Older. Aging is that perfect mix of looking back and looking forward, never in equal parts. When we get up in the morning and have our increasing aches and pains and feel stiff and sore and tired, we look back at how young and spry we once were, and we grieve just a little. We have inevitably lost our physical youth. Ah, but what have we gained? As our physical bodies age and change, as they must, our minds are filled with memories and thoughts and ideas processed and lessons learned.  We have lived. No matter if our life spans ten years, fifty years or a hundred years, we have lived. That counts.
  5. Transitions. We all go through those times in life when things change. We graduate kindergarten and move to the first grade-real school! We finish high school and decide to go to college-or not. We get our first job and begin to pay our own way in the world. We pick a life partner. We have children. We lose a parent, We move to a new city. Transitions are those perfect Janus moments that let us say goodbye while looking ahead. We mourn the loss of certainty, yet we eagerly anticipate the joy of discovery. We are in one of those global times of transition in our country right now, on many levels. We are deciding who should be insured and have healthcare. We are deciding if women control their own bodies. We are deciding who can love who can marry. We are deciding how we fit into the world economy and the culture of man.

Like Janus, we look forward to these transitions as we walk through the gate of history. We anticipate the future. We want it to be bright for everyone.

Also like the god of doorways, passages and time, we look back at the past with some nostalgia, sense of sadness and loss. This is normal and should be embraced.

However, we turn our back on and ignore the lessons of the past, the signposts left by those who have gone before, at our peril.