Thursday, February 19, 2009

Treating Marilyn

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...


Louise Woo, coordinator CABF-LA Area Support Group said...

Unfortunately for most psychiatrists, the first time they meet their patients is when a person is nearing rock bottom. Given that first impressions DO matter, who do they see in front of them? A person who is ill, barely functioning, and possibly a danger to self or others.

Now, since Marilyn was a public personality, they might have had some idea WHO they were trying to restore. But what do they know of the rest of us? Nothing.

I say this not to absolve doctors of their responsibility to understand their patients, but to remind patients that you are generally NOT your best advocate when you are very ill.

As the mother of two teenage sons with congenital mood disorders, I have long had the responsibility of helping our doctors understand who these people are when they are well. Consequently, over years, they have seen my sons recover and now "get" where the baseline is.

Doctors know what your normal heart rate or blood pressure should be, but there is no quantitative way to measure your emotional state.

Given this, I encourage people to swallow their pride and bring along a loved one to your doctor's visits -- especially when interviewing a new practitioner. Having a friend, relative or significant other explain WHO you are when you are well will help your doctor immensely. This will help speed your recovery -- or help you decide you need a better doctor if this one seems clueless.

Just as we need our loved ones' help if we've been brought to the ER in a car wreck, we also need their help if we've had a brain wreck. Make arrangements in advance who you'll call in an emergency. The people who love you will thank you!

John McManamy said...

Hey, Louise. Absolutely agree. I first presented with severe depression and absolutely could not recall the good times, so my pdoc was not about to mistake me for the type who danced on tables.

Naturally, he diagnosed me with depression. The antidepressant flipped me into mania, which ironically may have saved my life.

But I'm not letting the pdoc off the hook. To him, a depression was a depression. Through careful probing (and listening), a clinician can tease out different types of depression.

I specifically recall telling the pdoc I felt highly agitated. That should have set off an alarm bell right there. I was a prime candidate for a mixed state, which meant bipolar had to be a consideration.

I also told him about my history of depressions. This would have put my depression in the "recurrent" rather than "chronic" category. Again, a candidate for bipolar.

At the very least, he should have thought twice before prescribing an antidepressant.

But yes - having family or friends in the consultation is not only advisable, it is imperative. Frederick Goodwin MD insists on this.

David Miklowitz MD has pioneered family therapy for bipolar, and his studies demonstrate without doubt the value of family involvement.

Typically, we present when we are depressed. Had someone who knows me been in the room with me, that person might have said, "Tell the doctor how you stay up all night on projects," or "tell the doctor how you're one of the few straight white males in the world who can actually dance."

In my Princeton talk, I actually raised this issue, but time was running out and I didn't give it the attention it deserved.

Sitting in the back row was the douche bag pdoc who had treated my former wife. With my wife's permission, I accompanied her to an appointment. The idiot wouldn't allow me to speak and didn't solicit any info from me.

I strongly suggested to my then wife to switch pdocs, but she had confidence in him and it would have been highly inappropriate of me to pressure her. In hindsight, I should have been highly inappropriate.

Since he was my then wife's pdoc, I used him as my temporary meds check guy when I moved to the Princeton area until I could find a competent pdoc. But a meds check guy was all I needed, so I wound up keeping him.

Anyway, there he was at my talk. When I wrapped up, he left the room without acknowledging me. Fucking asshole. I know he didn't give a crap about my wife. It was all about his authority as a pdoc.

So, yes, family members, friends - insist, absolutely insist - on being present during appointments (not the whole time, the patient needs to air things in private). If the pdoc goes into asshole mode, make a scene, then insist that your loved one fire the idiot.

Mental illness is a FAMILY illness, not just an individual illness. Family members are a pdoc's best source of information. They are the best hope of a patient's recovery.

On top of that, family members need to know what is going on from the pdoc. It's the only way to forge a working clinical alliance.

Thanks for bringing up the topic, Louise. Good subject to write a guest blog about - hint, hint. :)

Louise Woo, coordinator CABF-LA Area Support Group said...

Thanks John! I'll get around to it in due time.

In the meantime, here's a great piece on Marilyn from the legendary Liz Smith (reprinted from 2008):

Cristina Romero-Sierra said...

Ahhh... Another refreshing gray area of thinking. :)

I have found a lot of health within my bipolar spectrum. It's encouraging to be picking through the rubble and finding treasures. It was such a tall order from my first psychiatrists to try to get rid of ALL of my bipolar. It is akin to throwing the baby out with the bath water.

John McManamy said...

Hey, Louise. Great Marilyn article. I've always admired Marilyn in all her complex strengths and vulnerabilities. I'll definitely have to update my old Marlyn article on my website.

John McManamy said...

Hey, Cristina. We "grays" have all the fun. :) We definitely need to resist psychiatry amputating the personality out of us. It's a very tricky balancing act, but balance we must. Too often I see the extremes between over-medication and noncompliance. Like you said, no black and white. We're into gray.