Depression by e-mail and debilitating body odors

Science lite From the Boston Globe.

Screening college students for depression with an e-mailed questionnaire may be a promising way to track levels of mental health on campus. But connecting students with help looks more challenging, according to new research that also found depression rates higher among college students than in the general population. Irene Shyu and a team from Massachusetts General Hospital distributed a depression questionnaire at four unidentified colleges in Massachusetts, Pennsylvania, and California, using e-mail lists provided by student groups. A total of 631 students agreed to take the survey for a chance to win a $200 gift card.

There’s a sucker born every minute. The survey found that the rate of major depression in those surveyed was higher than the rate in the general public (about four percentage points higher.)

She’s at it again

For some people, worrying about bad breath or body odor can be so extreme they become housebound or suicidal, a Brown University researcher reported this week. Even though others can’t detect any smell, the preoccupation persisted among the 20 people whose cases Dr. Katharine A. Phillips described at a meeting of the American Psychiatric Association in New Orleans.

“Patients suffer tremendously as a result of this false belief and they appear to be very impaired,’’ she said.

I think I see where Dr. Phillips is heading. I’ve cut and pasted her previous infomercial from the New York Times on the subject of debilitating underbites.

The good news is that there are treatments that can help. The scientific research that’s been done indicates that serotonin reuptake inhibitor medications (for example, escitalopram, fluoxetine or fluvoxamine) and cognitive behavioral therapy are helpful for a majority of people with B.D.D. More research is needed on these treatments and on other types of therapy, but this is good news for people who suffer from this distressing, impairing and sometimes disabling disorder.

Oh I wish I were picketing down at the American Psychiatric Association Convention in New Orleans. That would be time well spent.

Ramped up

In his latest book, Anatomy of an Epidemic, Robert Whitaker looks at the Open Dialogue program in Western Lapland (Finland) and can’t quite put his finger on why these group meetings generally in the person’s home are so effective. (The number of new cases annually in this region show an astonishing 90% drop from the 1980s.)

Without knowing this program either, but having spent two years in another program in Europe which thought it was cutting edge, I will offer some thoughts. First of all, the initial Open Dialogue meeting takes place usually in the person’s home within twenty-four hours of reported psychotic behavior. If the psychotic person jumps up and leaves the room, he is encouraged to listen in to the conversation even if not physically present in the room. (The open door policy.) Medication is not usually discussed in the first few meetings and often is not recommended at all.

Whitaker claims that the Open Dialogue concept of psychosis doesn’t fit into either the biological or psychological category. It is familiar to me because it is very much like the Family Constellation Therapy that Bert Hellinger and others espouse. “Psychosis does not live in the head. It lives in the in-between of family members, and the in-between of people,” Salo explained. “It is in the relationship and the one who is psychotic makes the bad situation visible. He or she ‘wears the symptoms’ and has the burden to carry them.”

As a parent, would this concept of the origin of psychosis make me feel better or worse about the situation compared to the group meetings that I went to with the family in the psychiatrist’s offices? There, psychosis was considered something foreign to everybody, family and patient included. It was something that just “happened,” like becoming diabetic or discovering that your house was burgled. Medications were part of the deal, and were insisted on. I’ll put my money on better outcomes in Lapland.

The program we were involved with made me feel anxious. I am sure that the families are anxious in Lapland, too, but it seems like the situation is diffused rather quickly within the privacy of the home. We suffered through the horror of thinking that my son’s brain was inexplicably damaged, we were led to believe that the doctors held the key and that there was nothing that we could have done to prevent this or to get over this. (There’s no cure, right?) We were also encouraged to attend meetings with other parents who, naturally, were worried about their children – and it showed. It was a climate of fear. Then the side effects of the drugs quickly became apparent – leading to more fear and a sense of doom.

The “problem” had been escalated by dragging it under a bigger spotlight instead of containing it and working through it where it arose – in the home. A massive case of over-reaction to a problem of living.

Times and thinking change (again)

Today’s meeting with all three psychiatrists was to confirm Dr. Stern as the sole psychiatrist from here forward. We agreed that Dr. Stern could handle both the medication and the psychotherapy. Chris ended up with an extra psychiatrist after he left the hospital last May so that Dr. Stern could concentrate on the psychotherapy without having to always be checking on the med situation. The second psychiatrist has been bringing her boss to these meetings.

We discussed taking Chris off one of the two medications and all psychiatrists agreed that one medication was better than two. I was wondering if I heard this right. Up until now, the psychiatrists here have been saying that two are better than one, and suddenly, now they agree that one is just as good as two. This is what I have been saying for the past five years, and what psychiatrists in North America have been starting to say. This is encouraging, indeed.

Ian seems to be convinced that Chris will not relapse as long as he’s on the drugs, but Dr. Stern was of the opinion that Chris’s recent relapse may not have been related to going off the drugs. She felt that the relapse may have been more linked to the stress of our wanting him to go back to university away from home. I was delighted to hear her say this, that getting off meds doesn’t always imply relapse. More to the point, she can see a time when Chris may no longer be on any medication.

We agreed that should Chris ever relapse, we would intervene early, and involve a short term therapy program where medications wouldn’t necessarily be used.

Progress has been made.

From Slate Magazine

The Three Christs of Ypsilanti
In one sense, Rokeach’s book reflects a remarkably humane approach for its era. We are asked to see ourselves in the psychiatric patients, at a time when such people were regularly locked away and treated as incomprehensible objects of pity rather than individuals worthy of empathy. Rokeach’s constant attempts to explain the delusions as understandable reactions to life events require us to accept that the Christs have not “lost contact” with reality, even if their interpretations are more than a little uncommon.

A cookbook for memories of sexual abuse
In the summer of 1990, Elizabeth Loftus got a phone call from an attorney in San Francisco. A man named George Franklin had been charged with murdering a child, based on the recollection of his daughter, Eileen. Loftus, a psychologist, had testified in dozens of cases about the fallibility of eyewitness memory. But this case was different. The murder had happened 21 years earlier. Eileen’s purported memory, however, was less than a year old. According to the prosecution, she had repressed it.

Truth or Consequences? Exploiting psychology in law and advertising
But Loftus was more than a trainee. She was a trainer. She had learned how to make people remember and believe things, and this knowledge was as useful to advertisers as it was to lawyers. Her only qualm about manipulation was that people might be harmed. And advertising didn’t strike her as terribly harmful. Most advertisers, she and her colleagues noted, were “unlikely to try to plant a negative memory, as has been the issue with false memories of childhood abuse.”

The idiocracy of social specialization

Either because of greed, or an overspecialized view of the world, people allow that lens to color whatever impinges on their senses, to force answers to fit that view, rather that seek solutions without preconceived notions, or from other perspectives. That’s why a multidisciplinary approach to problem solving is catching on. (The First Domino)

My father was a radar technician during World War II who spent time in the jungles of Burma with the Royal Air Force. We heard few stories from the war, but one thing he did share was that when the radar didn’t work, he was expected to fix it himself in the jungle using whatever ingenuity he could muster. The Americans, on the other hand, would fix the equipment back at the base and parachute in the new radar equipment. My father admired the American approach. On the other hand, what would happen if one day the drop-off failed to happen? Nevertheless, when it comes to products, specialization seems to make sense.

There are plusses and minuses to everything. In my lifetime I have witnessed a steady increase in social segregation which is touted as “specialization.” It strikes me that it long ago reached the level of idiocy. Lateral, all-encompassing solutions seem rare these days. The elementary school system is a prime example of the trend to social isolation. In the eighties and nineties most of the kids in my sons’ classes wore some kind of label. There were “the gifted” and “special needs”. There was French immersion (segregating the ambitious middle class from the supposedly “less intelligent” children, poor children, immigrant children and the handicapped), there were these really specific learning difficulties that all seemed to relate to auditory and visual processing skills. We didn’t think to call it stigma, we called it “progress”.

The kids that were specialized were stigmatized by those who weren’t members of that particular group and vice versa. While nobody “seemed” harmed by this, it got the momentum going for seeing the world through a prism. And so we end up with doctors diagnosing “Body Dysmorphic Disorder” with a straight face.

It is hard to pinpoint where this school yard segregation all leads to because the graduates are dispersed across the population, but it is a disaster, I am convinced, when it comes to segregating mental health. The difference is that with a mental health label you get a drug and you further self-stigmatize by joining with groups of people with whom you share a “problem.” Buy a tee-shirt and proudly proclaim you’re bipolar or the sister of a bipolar (Glenn Close). How exactly is this going to decrease stigma? It totally takes the spotlight off the need for the medical profession to clean up its act by encouraging everybody to be abnormal and to roll in it. I have long maintained that there would be no stigma if people were encouraged to get well. Where’s the money in that?

I hope, as The First Domino suggests, that a multidisciplinary approach is catching on. I think Chris’s psychiatrist, Dr. Stern, gets it. She is now proposing some alternative healers herself.

Not everybody’s good looking

I don’t know whether to laugh or cry. Jeff’s underbite is now an abbreviation: B.D.D. Jeff needs an orthodontist, not a pychiatrist. (Note that Dr. Phillips thinks her judgement about Jeff is better than Jeff’s judgement about Jeff.)

Obsessing About an Underbite

Katharine A. Phillips, M.D. Can concern about an ordinary body flaw like misaligned teeth be a sign of a serious psychiatric disorder? That’s the question explored by Dr. Katharine A. Phillips, a professor of psychiatry at Brown Medical School. Dr. Phillips recently joined the Consults blog to answer readers’ questions about body dysmorphic disorder, a troublesome condition in which people become so obsessed with perceived body defects that they refuse to leave the house or socialize.

Q.I have underbite. I do not have the insurance to correct it and it is a battle to walk out the door every day. I feel like people can see it from two blocks away. It has had a massively negative impact on my life and I feel like I don’t even want to try to achieve anything anymore, because why bother? I will still look like this. I’m not even looking for an answer here, I just wanted to get this off my chest. I wouldn’t wish this upon my worst enemy.

Jeff, Iowa

A.Dr. Phillips responds:

Jeff, you highlight some important points about body dysmorphic disorder, or B.D.D., although without meeting with you I can’t be sure that you have the condition. People with B.D.D. are preoccupied with slight or nonexistent defects or flaws in their appearance, and the preoccupation causes significant distress and can interfere with school, work, relationships or socializing.

Just as you feel that people can see your underbite from two blocks away, many people with B.D.D. have the distressing experience of thinking that other people take special notice of them in a negative way because of how they look — for example, by staring at them, laughing at them or making fun of them. This is an emotionally painful experience that can cause people with B.D.D. to isolate themselves from other people. It can be a clue that a person has body dysmorphic disorder.

You imply that you would like to get surgery — indeed, a majority of people with B.D.D. get cosmetic surgery or dermatologic treatments for their bodily concerns. This is problematic, because research studies indicate that cosmetic treatments usually don’t improve B.D.D. –- and can even make it worse. And people with B.D.D. tend to be dissatisfied with the results of such treatment. In contrast, people who don’t have B.D.D. are typically satisfied with the results of cosmetic treatment.

It makes sense that cosmetic treatment wouldn’t help B.D.D., because the problem in those with the condition isn’t with actual appearance -– rather, it’s a problem of distorted body image. Changing a surface physical feature doesn’t fix the person’s tendency to worry, obsess and over-focus on minor details and imperfections and to see themselves in a distorted way, differently from how other people see them.

Your comments also convey the huge impact that B.D.D. often has on people’s lives. As he says, just walking out the door every day can be a battle. Level of functioning and quality of life vary for people with B.D.D. but on average are very poor.

The good news is that there are treatments that can help. The scientific research that’s been done indicates that serotonin reuptake inhibitor medications (for example, escitalopram, fluoxetine or fluvoxamine) and cognitive behavioral therapy are helpful for a majority of people with B.D.D. More research is needed on these treatments and on other types of therapy, but this is good news for people who suffer from this distressing, impairing and sometimes disabling disorder.

To learn more about B.D.D., see Personal Health columnist Jane Brody’s story “When Your Looks Take Over Your Life.” And please join the discussion below.

Robert Whitaker and alternative mental health

Robert Whitaker’s new book, Anatomy of an Epidemic is not intended to be about alternative health care, although he does write about the Open Dialogue program in Western Lapland and cites studies on exercise for depression. His Mad in America blog also references these two areas.  Whitaker’s book is a stunning public policy critique, a self-help book only in the sense that it may galvanize people who are on way too many psychiatric drugs to taper or get off them completely.

Many people who read Whitaker’s book may be left with the impression that outside of what’s happening in Lapland and doing laps for depression, that’s about it for alternative help.

Fear not. Most people who recover do it their way. They do whatever it takes. My blog lists the best that my own research has uncovered. Vitamins and mineral supplements in high doses act like drugs – with side benefits, not side effects. Then there are various kinds of psychotherapies – one reader insists that cathartic psychotherapies are the best (and I agree). There is cognitive behavioral therapy that many people say has benefited them. Then there is energy medicine in its many forms. I am a particular fan of the Assemblage Point Shift. It’s cheap, non-invasive, shamanic in origin, fun to participate in, and it corrects your energy imbalance in ways that you can see almost instantly. Sound therapy – totally new and exciting. The particular kind of sound therapy that Chris undergoes is very similar to taking LSD under controlled conditions. The medical profession is only beginning to look into LSD as a useful treatment for mental illnesses. You can control your consciousness now by undergoing sound therapy without having to get the blessing of the medical community.

No doubt Robert Whitaker will be writing another book on mental health in America. It would be simply fabulous if his next book is on the subject of how the mental health “industry” has discouraged recovery for those in need by demonizing alternative mental health treatments, practitioners, and out-of-the-box thinkers who challenge the status quo.

WHO said it

From: Pharmacological treatment of mental disorders in primary health care
© World Health Organization 2009

Basic principles of prescribing

1.16 In general, polypharmacy should be avoided. The term polypharmacy defines the concurrent use of two or more medicines belonging to the same pharmacological class (for example two or more antipsychotics or two or more antidepressants).

Perceptual illusions

Please read Ron Unger’s latest post Anatomy of a Delusion, based on his reading of Robert Whitaker’s Anatomy of an Epidemic. He writes:

What I am struck by is the similarity between the dynamics around the delusions of those who get psychiatric labels, and the delusions of the mental health system itself.

His post then lists some really good delusions of the mental health system which are also uncannily similar to the delusions of mental health clients. This is Ron Unger writing at his usual best. Here’s number 4 on his list of delusions invested in by the client, which is darn similar to the delusion of the mental health system vis a vis medication, when you think about it.

Even starting to question the delusion is scary & upsets psychological equilibrium, as even considering that one might have been so wrong about something creates a sense of “losing one’s grip on reality.” This loss of equilibrium when one starts to question the delusion is taken as evidence that it should not be questioned.

Whitaker in his book, writes about the young woman/old hag optical illusion. This is the drawing that most of us are familar with that shows a young woman, if you look at the drawing one way, and an old hag if you focus on it another way. Whitaker is writing about it more in terms of a perceptual illusion in which the public prefers to believe that psychiatric drugs produce outcomes like the beautiful young woman, but he writes that a closer look will reveal what the public doesn’t see – long term use of psychiatric drugs reveals the old hag, an different picture.

The young woman/old hag drawing is also useful in explaining how illusions/delusions can quickly turn to disillusion when it comes to psychiatric medication. Seeing the beautiful young woman is the illusion that I invested in the first couple of years of Chris’s “illness.” Gradually, disillusionment set in and and I finally was able to see the old hag. Both are there, if you look for them, but once you have seen the hidden perception, it is hard to regain the original image. Now, trying to recapture the beautiful young woman image is almost impossible for me. I know she’s supposed to be there, but I don’t see her.

Mommy Dearest

It’s Mother’s Day in France. Since I missed getting this out earlier, here are some selections from the New Yorker Book of Mom Cartoons.

Little girl dining out with her parents. “You order for me, Mommy. You know what I like.”

Little boy walking with his father: “Dad, if Mom ever gets another boyfriend, I hope he’s just like you.”

Mother and female friend sitting on couch with little boy spray painting “I need love” on the wall behind them. “Oh, he’s just trying to get my attention.”

Father and son about to cross in the middle of a busy street: “Tell your Mom we crossed at the corner.”

Gift card categories to choose from for Mother’s Day: Earth; Career; Loving, Biological; Surrogate; Unwed; Unfit

Hollywood producer type welcoming his ancient mother into his office: “Mom, baby!”

Woman at cocktail party: “I don’t have to choose between baby and a career. I’m a surrogate mother.”