Tuesday, May 19, 2009

Tooting from San Francisco - III: A Major Sea Change

I’m actually thinking with a clear brain. So THAT’S what it’s like. Trouble is I need to be winding down for sleep. To recap my day:

Tuesday 6:00 AM. I’m up way too early and can’t get back to sleep. I’m headed into my third day of the American Psychiatric Association’s annual meeting in San Francisco with precious little sleep in my bank account.

8:45 AM. I’m seated for my first talk of the day. “Have you heard the news?” I ask the psychiatrist next to me. I hand him a print-out. The heading reads:

“Breaking News: Psychiatry Comes Up with New Diagnosis of Asshole.”

The piece is a hard copy of a blog piece I wrote a couple of weeks back. We’re about to hear a talk by Robert Cloninger on “Developing a Positive Psychiatry of the Person,” and it’s nice to know I’m doing my bit.

“Treating symptoms is not enough,” Dr Cloninger opens. It’s all about well-being. Dr Cloninger has been a major paradigm-shifter in mapping out the fine points of personality and their interacting dynamics. Personality, he explains, is non-linear, involving the way we learn and adapt, plus the internal and external forces that pull on the self.

We are shaped by our genes and environment, but our self-awareness (a uniquely human trait) allows us to modify these influences and move forward with our lives.

Personal change, he said, can happen very rapidly, if you can get the person to recognize their strengths and weaknesses.

11:00 AM: I’m struggling to stay awake. Marc Schuckit of UCSD is about to talk on the fine points of the genetic and environmental influences involving alcoholism, and my cortex is running on empty.

I’m at the talk by virtue of Kenneth Kendler’s presentation the day before. Dr Kendler used alcoholism as an example of gene-environment interaction, and I figure this is a way of getting deeper into the topic.

I’m not disappointed. Dr Shuckit’s research into the area began some 30 years ago when he started asking a few simple questions. There are many causes of alcoholism, involving many genes and environmental influences, but Dr Shuckit noticed that when those with alcoholism described their early drinking experiences, they tended to remark about how they could drink everyone under the table.

The technical term is “level of response” (LR). These individuals need to have a lot more drinks to feel the same effect as their peers, and kids drink for effect. Once you get into the pattern of heavy drinking, Dr Shuckit said, then the environment kicks in: You hang out with heavy drinkers; they expect you to engage in heavy drinking.

Dr Shuckit has tracked more than 400 offspring of alcoholics and control subjects for 25 years, and found that LR is a reliable predictor of alcoholism. He is also getting a reading on the genes involved.

So, say you know that your 12-year-old has a genetic predisposition to LR, is there anything you can do about his environment to protect him? Different peers? Different expectations?

12:30 PM: I meet up with a good online buddy, Gina Pera, who has a great ADHD blog. Nearby, we grab some gyros and take them outside. Gina’s been a great moral and intellectual support to me, and I could literally sit out in the sun all day with her, but an afternoon of dark rooms beckons ...

2:05 PM: I walk in late to a very large packed room where an expert panel is discussing borderline personality disorder. What is wrong with this picture?

A mere three years before, at a featured lecture at the APA in Toronto, one of the pre-eminent leaders in the field, Joel Paris, spoke to mostly empty chairs. Earlier, at a bipolar session, one leading expert had been dissing the borderline diagnosis.

In three years, something has dramatically shifted in psychiatry. Earlier - at a session at the same time as Robert Cloninger’s - leading borderline expert John Gunderson had spoken to a packed house. Add to that the packed house from Dr Cloninger’s presentation.

At a brief pause in the proceedings, I ask the psychiatrist next to me what is going on, and he confirms my impressions. In essence, the bloom has gone off biological psychiatry, which translates into sending patients out the door with just a prescription. We’re seeing the pendulum swing back toward an earlier era when psychiatrists used to spend time working with their patients to find solutions to their personal problems.

It is reasonable to infer from this that the profession is becoming receptive to the goal of recovery.

It’s as if at some point in time in the last three years psychiatrists had suddenly woken up. I have no idea how this will play out in the real world, where psychiatric practice is dictated by the insurance industry and where old habits die hard. But I can assure you, this is a major story, perhaps the biggest event in my 10 years of reporting on mental illness, and one readily quantifiable - just count the people in the room.

4:00 PM: I am literally sleep-walking through the afternoon poster session. This is usually a great learning opportunity for me, my chance for one-on-one face time with the experts. But my brain isn’t tracking. I’m not engaged. No sense hanging around ...

5:00 PM: I’m back in my room at my fleabag hotel. Sleep, glorious sleep. One minute later it’s 8:00 PM. I get up and splash water on my face, taking an inventory of my brain.

My sleep is not messed up, I decide. I’ll be out like a light before midnight. Moreover, I’m taking tomorrow morning off. Late sleep. A little sight-seeing. Time to wind down ...

4 comments:

Stephen Blau said...

Re: BPD: "I have no idea how this will play out in the real world, where psychiatric practice is dictated by the insurance industry and where old habits die hard."Our habits are probably similar, but keep an ear out on Canadian pdocs' take on this. We're much less beholden to industry.

John McManamy said...

Thanks for the suggestion, Steve. At the Cloninger talk, I swear I was the only American in my section of the room. I walked into the borderline talk too late to get a read on the people in the room, but the person to my right was from the UK, and the people to my left were from another part of the world.

This is going to be an exceptionally interesting development. We may see US psychiatry remaining stuck while the rest of the world moves in a new direction.

Clearly, sending a patient out the door with just a prescription is not treatment. But that will continue to pass for treatment as long as no changes to health care happen.

Thus - to get psychiatry to pay attention to our needs, first we have to reform health care in the US top to bottom.

Gina Pera said...

Hi John,

Great wrap-up, especially given the sleep debt. I so enjoyed meeting and talking with you. Your book has been a great introduction to the issues surrounding bi-polar disorder. Your blog, too!

You definitely have the historical perspective that I lack regarding the APA conference, so regarding this:

"I ask the psychiatrist next to me what is going on, and he confirms my impressions. In essence, the bloom has gone off biological psychiatry, which translates into sending patients out the door with just a prescription. We’re seeing the pendulum swing back toward an earlier era when psychiatrists used to spend time working with their patients to find solutions to their personal problems."

---
This sends a shock to despair to my heart. In that same presentation, I could listen to only so much talk of personality disorder, especially borderline personality disorder (which seems to be the "theme" of this conference) without wondering who would connect the dots.

For the speakers to keep repeating terms such as impulsivity, poor regulation, emotional lability, and more that completely demand screening for ADHD, yet the speakers never mentioning the term, well, it left me entirely disheartened.

And yes, I understand that these behaviors cut across many DSM diagnoses, but anyone who knows ADHD knows how often it is misdiagnosed as one or more of the personality disorders. Or, at least the underlying ADHD component of these personality disorders is entirely missed. No wonder most of these have such poor prognoses.

I wish the psychiatric field would stop lurching from one extreme to the other -- biological to psychodynamic and back again -- and learn to integrate. Of course, you're not going to treat (especially late-diagnosis) ADHD by simply writing a prescription (especially if you don't learn how to titrate and assess for comorbidities). And any psychiatrist who attended one too many pharma luncheons and concluded that would be the case is a fool. To jump to the other extreme, by eliminating the neurogenetic underpinnings almost entirely or treating them as a curious aside, is equally foolish.

To me, it was disgraceful that the only ADHD-related topic at the APA was the pharma-sponsored program (which I heard from others aas excellent). Maybe there were others, but I couldn't find them in the program.

(Which reminds me...I've never seen such a poorly designed conference program. No empathy for the end user at all, and frankly, that's how I feel about a lot of psychiatrists who refuse to integrate the biological -- no empathy for the patient.)

As for possibly seeing more foreigners in that audience, John, I'm afraid we might start moving in the same direction as the rest of the world, meaning backwards.

Gina

John McManamy said...

Hey, Gina. I see your point. I'm hoping the way the pendulum is moving is that pdocs don't just send patients out the door with a prescription (keeping in mind the very low adherence rates). That we need a lot more face time with our pdocs to pick up not just personality issues that keep us stuck short of recovery, but to get the diagnosis right, as well as dialing in the diagnosis.

This is why I appreciate sharing ideas with you. From where you are, you can see over hills and divides that I cannot.

I didn't realize the ADHD session was the only one on the program. The APA needs to do a lot better than that.