Been Shrunk?

kw: book reviews, nonfiction, science, medicine, psychology, psychiatry, psychiatrists

I am pretty sure the number of psychiatrists I have engaged approaches ten. Only two were "normal", whatever that might mean. I have also had talk therapy with several other psychologists, and I remember only one who was someone I'd be willing to befriend.

Over the years I did, finally, come to understand that a psychologist or therapist is empowered only to offer talk therapy, while a psychiatrist, who may also conduct talk therapy, is an MD who can prescribe medication if needed, or prescribe visits to a therapist. I was rather slow on the uptake. I thought of them all under the derogatory heading "head shrinkers."

Up front disclaimer: I am considered "crazy" by many, and looked at askance by many more. The label I've earned is Bipolar 2: I am a middle-of-the-road mood cycler. Bipolar 1 is the more extreme version and shades into what I call Bipolar Zero: someone with maniacal energy for a few weeks at a time, followed by months of melancholy and reclusiveness, culminating in deep depression and perhaps a suicide attempt (or several); only to pop back into mania almost overnight. That is one pattern of the classic Manic-Depressive syndrome. My "mania" is called "hypomania", meaning sorta-kinda-manic, and my depressive periods are more a kind of introversion and withdrawal. I also cycle rapidly, with several cycles yearly rather than one or at most two, the more usual pattern. I suspected this about myself beginning about age 30, but it was more of an "I wonder" sort of idea for a long time.

At about age 55 I saw a psychiatrist and it was confirmed. This was the wise and lovely Dr. Valentine (I don't mind using her name; I'll defer for the others). She confirmed that I was Bipolar 2, and discussed several courses of action with me. I had gone to her when a short stint using Zoloft had the unexpected (to me) result of triggering full-blown mania. My GP, who had suggested trying Zoloft because I felt very depressed (more than my usual month-or-two-of moodiness), saw that I was manic when I saw him after taking Zoloft for two weeks. I was interrupting him—heck, I was interrupting myself!—and making all sorts of grandiose statements. At my most effusive, I had not been so grandiose before. Dr. Valentine prescribed a mild mood stabilizer. I don't remember which one (this was almost 20 years ago).

The drug eventually had side effects I didn't want to cope with, including the need for a daily nap. However, when I called for an appointment I found Dr. Valentine had moved her practice to another state. The mental health appointments were being paid for through a program at DuPont called Employee Assistance Program (EAP), which contracted work through ComPsych. I had to go through them to find an in-network doctor. No doctor I saw after this came even close to the combination of caring and expertise. Though they were competent, they were all rather off-center, and some were downright looney. I realized that ComPsych draws mostly from the bottom of the barrel: doctors who need the referrals because they couldn't stay in business otherwise. I could seldom stay with a doctor for more than a year or two, sometimes because I wanted someone less crazy than myself, and sometimes because they left the business or moved elsewhere. I live in an area that is poorly served because state laws are not very doctor-friendly. That means, whether a family doctor, a psychiatrist, or any specialist, about half the doctors around here are really altruists, serving where they know they are needed, and the rest are here because they couldn't make it in a more competitive environment. I have had some of both, in all areas (Luckily for me, when I needed cancer surgery, I got a true expert! But that's a story for another day).

I have to mention one example of "barrel bottom" psychiatry. I was sent to a psychiatrist because I had a suicidal episode. I was stopping a drug that made me gain weight and didn't help with depression all that much anyway. After a short, almost cursory interview, the doctor prescribed Depakote and gave me a bag with some samples. I was shocked. A friend of mine, who has more severe Bipolar than I, had been on Depakote and gained 90 pounds. I already weighed about 30 pounds more than I liked. I started to leave, and then I put the bag back on the desk and said, "You must be insane. This medication will make me even fatter than I am already. How will that improve my depression?" I walked out and I didn't pay the copay.

With many decades of experience with psychiatrists and psychologists under my belt (starting at age 12, but with significant gaps before middle age), I was quite interested to see Shrink Rap: Three Psychiatrists Explain Their Work, by Drs. Dinah Miller, Annette Hanson, and Steven Ray Daviss. The book is based upon the blog Shrink Wrap and the podcast My Three Shrinks, but it is much more than a simple compilation.

Each chapter uses one or two example "patients" to illustrate various facets of the work of the three doctors. Each "patient" is a composite, so as not to expose too much about any one person, who might be harmed by public exposure. Considering that some of the "cases" are mild, while others are quite severe, this is a valid concern. Consider "Josh", who is mostly pretty ordinary but has had some reverses. It is quite usual these days for an extended period of depression to prompt a doctor to prescribe Zoloft. "Josh" and his doctor found out what I and my doctor did: hidden Bipolar gets manifested by the general mood-lifting action of Zoloft. Josh's experience was more extreme than mine. And then, when he had a medical condition that was treated with steroids, he went full-blown manic, and needed to be hospitalized for a while. He missed a semester of college. The doctors who treated him had quite a job on their hands. It is kind of like accidentally starting a raging fire, and then trying to put it out without drowning everybody. And this was one of the milder cases.

I've had experience with clinical and therapeutic psychiatry. I was most interested in the discussions around forensic psychiatry. Previously I knew nothing about it. The word "forensic" conjures up doctors sifting for clues to a crime, or using DNA to confirm an identity, or not. "Forensic" is derived from an old word for "legal", so forensic psychiatry is its practice related to legal matters, such as determining the competence of a defendant whose lawyer is claiming an insanity defense, or judging the fitness of a parent in a divorce case who is accused of criminal abuse (if there is no criminal complaint, a different psychiatric specialist is consulted). A forensic psychiatrist will also interview a newly-arrested suspect who exhibits abnormal behavior.

There are a couple of chapters that weigh the relative merits of talk therapy versus medications. Both have their uses, but it is often quite a puzzle to determine which might be more effective. It has been said that the human brain is so complex that if there were only one human brain in the universe, it would contain within itself more than half the total complexity of the universe. Dealing with brain malfunction is thus the most difficult task of all. For many decades people have been studying human personality and its ills (actually, many millennia, though we usually set the starting point "only" two millennia ago with Aristotle). The study intensified in the past two centuries, beginning with Freud and Jung. Now in the early 21st Century, we are about an inch beyond the starting line in a "race" to figure out how to help people with emotional, personality, and brain malfunctions.

There is a lot more I could go into, and it is all very interesting, but I will bow out here. The book is like a textbook in some ways, though it is mercifully brief by comparison, and yet comprehensive. I came away with a better appreciation for the complex decisions that these doctors must make, and the great gulfs of unknown they must navigate. Heart surgery has been likened to doing an engine overhaul while the engine is running. Psychiatry is similar, except you can't even lift the hood to get at the engine. That limits things. I am glad that not every psychiatrist I dealt with was a bottom feeder; at least two or three were very helpful to me, in different ways and quite different times. The three authors of the book are based in the Baltimore area. If I need a shrink again (I hope I don't; I manage well without medication now), I might contact one of them!