great, as usual, Sid! we live in these antiquated bodies (with antique hormonal systems) in a modern social system and it just doesn’t FIT. next time you want something entirely different to read, pick up a copy of Charlotte Bronte’s “Shirley” for an interesting “modern” study that’s 200 years old….
tess, you impress me. I’m still re-reading the post for typos and here you are!
Thank you for the recommendation. My knowledge of Anglo fiction is embarrassing, non-existent. Back home you would have been reading all the ancient classics plus the Russian classics but that’s it.
i seem to have excellent timing — i sit down with a glass of wine JUST when you’ve posted….
reading is my passion, but there’s no way on god’s earth you can cover it all! i prefer British literature and Russian MUSIC, myself. …and French food, and Mexican charm, and US movies, and Oriental philosophy, and German opera, and … where shall i stop?
There you are drinking a glass of wine to my shit! This makes me LOL for some reason.
You have refined tastes, my dear. You could do like a favourites list. Me? An unsophisticated slob. You’d know what I mean if you saw the contents of my iPod.
It sometimes occurs to me that I know very little or nothing about many of my favourite blogger peeps except of course the ins and outs of their feeding habits. We haven’t even had a drink yet dahhhhling but you’ve already told me about the contents of your gut.
It’s true and sort of depressing/humbling to think how much stuff there is on our “must read” list but you’ll never ever get to read even a tiny proportion of these amazing works. I can’t remember the last time I read a fiction book. I attempted a much-hyped Martin Amis old novel recently but found it so idiotic and pompous and self-aggrandising I had to abandon it early on.
It sucks but I’ve been reading nothing but journal articles for years now, the most debased revolting form of writing imaginable. And blogs, obviously. I fucking love blogs.
Rihanna aint even that nice tbh, There was a black Ghanaian girl from my old job that was way more sexy, she even had a sane, down to earth personality.
If the population was atleast as sane as me these kind of people would never escape poverty because no-one would spend a penny on them or their junk showbiz.
Jeez christina, when did gaudy hooker snuff films become glamorous? Is it like a social statement on serial killer sadism??? Lower class vengence??? Im perplexed about that gal. But at least shes hotter than Aileen Wuornos. *shudder*
LOL! I’m still trying to understand that video. In fairness, Chrissy has always been a trashy ho at heart but at least she used to be smoking hot while debasing herself. See her Stripped tour. Now it’s just kind of sad and worrisome. She’s clearly decompensating.
I suppose the pop pays the bills, but her classic renditions at that Etta James funeral was truly amazing. The woman can sing. Rhianna? I just melt over her. She could yoddle dixie at a junk yard run by crackheads and Id pay to see her. Just one of many weaknesses of mine.
Very interesting regarding Rihanna. Are you male or female?
Regarding Xtina, yes, I agree, she always sounds better/more soulful singing the classics. If she quit the slut routine and came back with a more mature sound and image, she could still salvage her moribund career, IMO. But she kinda has to stick to vocally unchallenging pop these days like this Max Martin dreck Your Body, her vocals are much deteriorated compared to her prime, some haters would argue shot to shit. If you compare her rendition of At Last at Etta James’ funeral to the one she did during the Stripped tour in 2003, you’ll know what I mean:
Obviously no one is going to sound the same 10 years later but a professional singer should be able to still sing at 30. Sadly, Christina used to have a wonderful voice which she screamed/burned through without any training or finesse and now it’s just a burning pile of ashes. She struggles on notes as low as B4 these days which is shocking. But then, how much is permanent damage and how much is just inconsistency due to alcoholism, not rehearsing etc. I don’t know. Some days she stands up and really delivers a great live performance
and then the next day she sounds like she’s dying and I get a sharp pain in my throat just listening to her trying to reach for basic notes like C5.
God ur right. Poor Chris. Maybe the drink, the dope, and lazy daze wrecked it. Shame. My sex? Most days Im male, then sometimes female. At here on the net Ican just be me with no worries of sticking to one or the other. Do you charge by the hour Sid?
Old borderlines mellow out because as you said, no one cares about crazy women when they are fugly.
There’s this old crazy borderline called “the crackwalker” on youtube. She’s like 60 years old now and she basically lives alone and makes youtube videos for her attention/drama fix, and has modified her personality to be “loner” even though in her youth you knew she was shacking up with guys and having dramatic blow outs every other week. Loner is a label she’s been forced to adopt when her sexual appeal dropped to zero around 35 yrs old.
I suspect most borderlines end up like this… at least the ones stupid enough not to marry a rich guy and get his ass in court for alimony.
I’ve a relative who is similar… she was attractive in youth spent it being a dancer, drinking and partying and shacking up with various men. Spent all her money she earned dancing on fancy clothes. At around 40 years old she started living off of her daughter and that was the end of that. She too was stupid and never married a rich man.
I think the internet is good for old and unattractive crazy women because you can create a market for yourself as some kind of guru or victim for the attention/care you need, w/o requiring people see you and realize how old / unappealing you are. Normally a borderline would have to present youth and attractiveness to obtain support but the internet makes that a non-issue.
I agree, yes, the sad truth is for women: no one cares when you are old / ugly. Not just psych patients, but IN GENERAL.
On the other hand, only women expect and get attention for no reason, so it’s sort of like taking away a privilege that men never had in the first place. Like, if I’m in a store, and drop something, EVERY GUY around me picks it up. If I am approaching a door and a man is around, he will open it or hold it for me.
If I’m at work and tell a male coworker I need supplies, he VOLUNTEERS to go to the basement to dig through boxes and get it for me. These are benefits only young women get… or bosses/powerful people.
But then on THE OTHER hand, men are treated with respect and are automatically assumed competent/intelligent. When a woman ages, she loses her beauty and the power she has over men, but she doesn’t gain the assumed competency of a man. So really, the worst of all fates is to be an old woman, particularly one without children so she isn’t a mother either.
PS, happy birthday to me I just turned 30! Yay! They told me I would waste my life and I finally did it!
Christina has entered that cringe worthy state where no one gave her the memo she isn’t hot anymore and needs to lose a few pounds if she wants to prance aroud in those outfits.
True post is true, Woo. You nail the issue as usual. Old women (and young men, I would add) get the worst deal because old women have lost sexual currency whereas young men haven’t acquired it yet due to lack of status/income/accomplishments. But men are lucky because as they grow older (within limits, obviously), they get more desirable generally whereas women are consigned to the crazy cat lady status unless they have used their youth strategically. It’s so fucking depressing.
Happy birthday! Aw, don’t say you wasted your life. There is so much more to life than reproduction.
*WARNING, INCONSIDERATELY LONG rant below, feel free to skip*
Regarding being able to spot a patient within minutes know what is going on:
I think this is one of those things where psych professionals GET AWAY with being shitty. If you randomly make up diagnoses about people you can’t help anyway, how do you prove that you’re wrong? Say a patient comes in the door, triggers an emotional response in you the professional, and you say “borderline” in your head after like 10 seconds… how do you prove you’re wrong? Maybe she isn’t axis 1 but maybe she’s not axis II, either. It’s not like either or. Thing is, there is no way to prove someone is or isn’t borderline so naturally the professional thinks they’re right because the patient isn’t axis 1, but they are annoying so that means they’re borderline. It is an unfalsifiable diagnosis because it basically applies to any woman who is outwardly directed and annoying/needy/dramatic. Which is basically how most females process stress and emotions which are generalized symptoms of dysfunction.
Patient could have some kind of autoimmune disease causing emotional problems, but there is no way to prove or disprove borderline as basically any aggressive/outwardly directed yet feminine person who isn’t axis 1 can be considered borderline.
I’ve been in that situation. Now, I’ve only dared see a psych professional 2 times in my life. The second time it was a male doctor, and I walked in the door and within a few seconds he pegged me axis 2/borderline and I know this because the first question he asked is “does your mood become depressed when dealing with your relationships?”
Sure my personality is crap and I do see how I fit the ‘avoidant personality” very well, but I also definitely have a biologically real mood problem. this guy was basically unwilling to consider that, simply because I smiled and was wearing clean put together clothes. You don’t have depression for like 20 years and not learn how to do shit even when you feel horrible. Minutes before walking in that door guess what I was wearing dirty pajamas lying in bed. I am a seasoned pro of forcing myself to socialize when everything in my body wants to stay in the house and never go outside. This is a fundamental problem in psych services and it seems epidemic all over the world: psych professionals believe they can understand people in a few seconds and that substitutes for really doing a comprehensive medical work up and history taking. It’s a reflection of the lack of science or pathophysiological curiosity of psychiatry.
Yes, a medical work up should be part of ANY psych service because it’s usually true rather than occasionally true that health problems cause emotional/mental ones… and substance disorders can cause psych problems as well as being symptoms of it.
Immediate appearance and behavior is just a small part of the picture, not the whole picture… and I would say doctors are more diagnosing themselves than the patient when they label people with anything after a few seconds, or even a session.
IMO it’s a lot like people looking at fat asses and saying ‘ate too much”. Ok, even if they did eat too much, you still don’t know ANYTHING about the disease/disorder causing that.
Psych gets away with this because to be honest no one knows shit about psych illnesses and the meds are even worse. “Yep, definitely a case of the cooties!” says teh quack-chiatrist in response to the patient who he just doesn’t like very much in an emotional/human kind of way.
It’s possible for people to be annoying assholes w/o an axis 1 disorder and for them to not be borderlines in the sense of having a shitty maladjusted personality either.
I would also propose that being an asshole may just be a variant of normal, not pathological. so if it turns out your annoying harpy is totally healthy mentally and physically maybe that’s just who she is and she’s not crazy. I think women bank on crazy… crazy is like sex, mysterious and intense and emotional… men in general confuse crazy female for sexiness it seems so women have more of an interest of posing as this random illogical helpless ball of dysfunction in need of saving. Not many guys go to psychiatrists and talk about their sex toys, and if they did, the shrink would assume they had some kind of fetish or were like a sex offender or something especially if it was a female professional.
Sid, Im not trying to rattle ur blog, but I had this really for true and serious experience with my roomy that has horrified me till this day. Id like to shair it with u and the Wooo since you two are professionals: About 7 years ago I met my roomy. We fell in love , moved in together. She went through about 5 terrible losses back to back, one of which included her losing her nursing career of 20 years due to asentabular dysplasia (sp?) A rare hip condition. Well, she lost it , I mean broke down completely. Three violent suicide attempts, several hospitalizations. I took her to every ER in the bay area looking for any way to help her, a drug, a doctor, a therapy ,,,anything. After a period of court ordered forced drug administrations she finally started the drugs , ran up the ladder as her system fought them back. Each med eventually got maxed out, then another rx added. Nightmare…. To shorten it, she ended up with a top and final psychiatrist saying all he would offer her was ECT. She had been on 7 meds for years and the only benefit was no more overt suicidal ideation. After a year on ECT, shes now come back to me. Is only on adivan. Whats yalls thoughts on ECT and on weening off of it? Shes has no noticable memory loss,,,,but only gets it on one side of her head, never bilateral. Any thoughts or experience on successfully ending this therapy? *worried in texas*
Ps Wooos comment triggered this question since I remember doctor after doctor and social worker after social worker telling me she wasnt sick, just had a personality disorder. Funny, after she found the right doctor she majically had a treatable condition. It seems when she never responded to their drugs they just branded her a crackpot, or noncomplient and ignored her. It was shocking to me. Youd never guess how many ER docs sent her home with will she was in full blown panicked psychosis. They never cared if she lived or died. Sometimes id even her er nurses mocking and joking about us. Very cruel experience Ill never forget!
Most nurses are ignorant callous bitches in it for the paycheck. Sometimes I think nurses should be payed less just so the shitty fucks stop taking the job. Everyone becomes a nurse when tehy realize they need a job even if they hate nursing.
ER nurses attract more of the greedy assholes because they make so much money and you usually have to be insane, ADHD/impulsive, or on drugs to tolerate ER work. They generally deal with random crackheads and drunks and idiots for patients all day, as well. “MY KID HAS A SPLINTER AND I DONT WANT TO WAIT FOR THE PEDIATRICIAN SO I CAME TO THE ER” is a common one, or “I AM HAVING CHEST PAIN AND I AM ALSO SUICIDAL NOW GIVE ME SOME DILAUDID” says the obvious crackhead looking for an admission and a script. Or like “I cut my foot a week ago sustaining an easily treatable injury, but I’m diabetic and now it’s so infected it’s ready to be amputated woops”. In addition to the ER being more prone to attract the callous greedy assholes, it also causes people to become callous because the patients suck and its stressful.
On the other hand, the fact is ER staff do see dramatic borderline patents like ALL DAY, these people coming in with anxiety attacks after breaking up with their boyfriend being like “HELP ME, PLEASE GIVE ME ATTENTION, I’M GOING TO KILL MYSELF, SHOWER ME WITH LOVE I NEED I NEED, GIVE ME ATIVAN”.
From the perspective of medical staff, this incredibly selfish manipulative and financially wasteful behavior because there are actually REAL PEOPLE having medical emergencies who aren’t getting help because of this dramatic needy idiot. Yea, I mean the dramatic idiot is certainly not feeling well but you know what? I think the genuine manic patient or the guy having a heart attack takes priority and they can’t attend to those patients as well because they are wasting time with this asshole having an emotional drama melt down looking for some xanax because of their fake suicide attempt/fake suicidal thoughts.
In medicine everything is about priority. Every patient and every family think they are the priority but let me tell you as a nurse, you aren’t the priority most of the time. Unfortunately medicine is now a financial service and medical staff from nurses to doctors need to act like salesman and waitresses , sometimes putting peoples lives at risks just to give “customer service”. We can’t just tell annoying histrionic fucks to sit down and shut up while we help people with real medical problems. We have to kinda pretend their non-problem is a real problem, stealing valuable seconds from people with potentially real emergencies where every second counts..
So no experience or thoughts with ECT maintenance? My sweetheart never went to the ER begging for drugs or attension, she was literally psychotic. Chanting , pacing , seeing things. She didnt have the capacity for manipulation. One suicide attempt she drove a steak knife through her throat. The only thing that saved her was I came home early enough to call 911, and we were renting an off season condo on the beach already furnished with no real kitchen ware to speak of. Ive watched this beautiful woman go from a complete chanting psychotic to a bright , loving , articulate friend again, and we owe it all to carefully administered ECT. When she was in the ER her life was in danger, just no one believed it but me. I guess everyone seeing me thought I was a codependent chump, but I just knew the depth of her illness better. My big fear now is continuing ECT too long, or stopping it too fast. Her doc seems to let us do a prn type call in when she needs situation. Imma scared to be responsible for such decisions that could send her back to the abysss or fry her brain cells, any wisdom Sid? No worries if youd rather not comment, its too personal and Ive said too much already. Its just very few ppl beleive in ECT, and those that do seem sheepish to advise on it. New frontier I guess.
Since Im on a roll Id better get thiss off my chest. During her years of geodone, seroquil, trazadone ect ect, at least if not over 100,000 $ of either private
or state insurance money was payed out for it. Contrast that with a little ect treatment billed at only 400.00$ a pop and I think I can see why ECT is so demonized and no one with success stories gets much media attension . Ok wheww.
@myrealname
Thank you for your comments and I am really sorry to hear about your terrible experiences with the services. I wasn’t ignoring you, I just live in Europe and can’t respond to most comments in a timely fashion as I tend to be asleep when most comments hit my inbox.
Obviously, we can’t comment here on your girlfriend (or any other person) specifically. I can tell you what I know about ERs and ECT, generally speaking. As Woo already comprehensively covered in her post, ERs are generally a terrible place to be when you’re dealing with an acute psychiatric emergency. The ER staff are not psych specialists. Their one and only job is to get you out of there ASAP in a relatively stable condition. They are used to dealing with dregs of society who are in there looking for painkillers, benzos, shelter, attention, all sorts of scum and crazies, in addition to people experiencing genuine dire emergencies such as a psychotic episode. ER nurses tend to have coarsened personalities due to years of this kind of work. You won’t get any sympathy in there unfortunately which is very distressing for people going through a major crisis. I’m not trying to make any excuses for the system, I’m just describing reality as I see it.
Regarding medication and ECT for treatment-resistant depression, one could write a whole book about this and it’s difficult to answer this is any coherent fashion. As you probably know, psychiatry has been corrupted by other interests to the extent that dangerous polypharmacy with multiple agents of dubious antidepressant efficacy is now the norm in treatment of any kind of more complicated depression. It is not unusual at all to see people on 7 drugs these days. The rot in psychiatry has spread to the extent that some psychiatrists treat their depressed patients with cocktails of antiepileptic drugs (falsely rebranded as mood stabilisers), second-generation antipsychotics and benzos and other stupid shit like pregabalin and such instead of a proper dose of a proper antidepressant or an antidepressant + antipsychotic combo in cases of psychotic depression which is what the evidence says you should do. Approach varies from psychiatrist to psychiatrist and unfortunately I must say it’s really just dumb luck who you get when you are admitted. Treatment approach varies drastically from person to person working even in the same service. Patients and families don’t understand this. Everyone has their signature style and their favourite drugs and combos they believe are effective (for no reason other than gut feeling, previous good experience with some patients [and terrible experience with others but those are quickly discarded/suppressed due to self-serving confirmation bias], voodoo, or the latest journal paper they happened to read which was most likely a ghost-written infomercial by pharma). I know by looking at the medication list the patient is on who their psychiatrist is. The patient is interchangeable, the drug list is permanent. Sad but true. Our knowledge of psychopharmacology is on the level of witchcraft and really there is no scientific way of matching a specific patient to a specific therapy. It’s just trial and error, dumb luck and gut instinct. They will try to tell you otherwise but they are deluding themselves. Because the science is so terrible, you can have a situation like now where sedating but otherwise numbing (depressant in the long term drugs) like atypical antipsychotics are used to treat (actually, manage) non-psychotic depression. Madness.
ECT, as you know, has a terrible rep because of what used to happen. I think the public perceptions of it are unjustified because a treatment doesn’t abuse anyone, it was the psychiatrists and the nurses who used to abuse patients in institutional settings which enabled abuse. In actuality, and nobody wants to hear this but it’s true, it’s an excellent treatment option for treatment-resistant depression unresponsive to medication. The problem with ECT is that a course of it has little to no long-lasting effect and in addition to that, some people get memory side-effects and generally they are the only people you hear about creating the impression that they are the majority of ECT patients when they aren’t, it’s just that those who responded well to it go back to their lives going about their business quietly instead of posting about it on the internet.
Relapse, which is what you are asking about, is a huge problem though. In fact, if you look at the studies, you will find that relapse rate after ECT is 40-50% give or take in the first six months regardless of the method of continuation therapy used, it could be as rigorous as nortriptyline + lithium combo and they still relapse. This is a huge problem and there is presently no answer to it. Here I’m talking about an acute course of ECT (in the States, that means one session 3x week for a few weeks). What you are describing is maintenance ECT which is a different issue. Maintenance ECT has a long clinical history (over 60 years, I am thinking of a paper in the Am J Psych from 1949 where they already discussed this) but only two randomised controlled trials ever carried out to support it, both in exclusively or mostly older adults (Kellner et al 2006; Navarro et al 2008 are the only RCTs to my knowledge). Again, the evidence is terrible so we’re back in the realm of opinion and clinical lore. Clinical experience with maintenance ECT is good although most people don’t know how or when to use it so most just don’t use it or think of it as an option and they just kind of allow their medication-resistant patients to languish. It’s a sort of a dirty little secret no one talks about in polite society but some patients after years of being miserable on meds and relapsing every time on meds after an acute course of ECT end up finally getting maintenance ECT and from what I’ve seen it works really well and a lot of people never look back. Some people have quite a miraculous response to even just one zap, they go back to normal after relapsing after just one session. Others need more frequent administrations. Memory problems do tend to happen for some people but it’s hard to know is it due to age or what. Problems range from me having to reintroduce myself every time as if meeting for the first time a patient who knows me well and has met be lots of times in the past to zero memory loss. I’m reminded here of a case study I read once, the authors escape me right now, of a patient who had no memory loss from over 100 lifetime ECT administrations. It’s like everything else, the response and side effects totally vary from person to person.
I’ve never really seen anyone under the age of 60 getting maintenance so I’m pleasantly surprised this is an option in the States. Psychiatrists here would rather keep a person on lithium for maintenance despite evidence of kidney failure than consider ECT. Ignorant fools. Right unilateral as you point out tends to be associated with less memory side effects than bilateral so an added bonus there. Enlightened shrink you have there, I must say.
Again, generally speaking, one of the biggest problems in psych is getting the patient to stay on the treatment that’s working. Some people who respond wonderfully to medication decide one day they don’t need it anymore. I can’t say I get this reasoning. If I had a chronic heart condition which I knew had a 100% recurrence rate, and if there was a pill or another treatment (albeit unpleasant) that I knew would suppress my symptoms, I’d bloody well stay on the treatment. For some reason, in psychiatry it’s not like this and often you meet perfectly rational and intelligent people who insist on getting off the meds that are keeping them well ‘cuz they don’t want to be taking them pillz for the rest of their lives. Fine. Your choice. I just don’t get it.
Sid, Wooo , you guys are angels. Thank you! Shes under the direct care of the head of the psychiatry department of a hospital that many say is the best in Texas. Hes done lots of things like allow her adivan, honoring my mpa back when it was needed. He is the best. This forces us to live in a boring, tea bagged area of the state we really dont like but leaving would be foolish in the extreme. It took years to find such a doctor and I dont think I can trust anyother to perform such a delicate procedure on her. The experience and advice is greatly appreciated!!!
I am glad she is better now
I don’t work psych and my knowledge of ECT is that it’s done last resort to pull people out of severe mental episodes, not for maintenance. But if it’s helping her it’s probably worth it for the risks.
Oh and speaking of pig-ignorant dumb psychiatrists uncurious about true dx / pathophysiology never taking a proper hx or doing a proper medical work-up. I came across this about borderline personality while researching my mitochondrial psychiatry series: http://www.ncbi.nlm.nih.gov/pubmed/22579150
I don’t have the full text unfortunately but…
Sid, Woo, thank you! Lots of great info! One things certian, Im never letting go of this doctor. Hes head of a department of psychiatry in what many have said is the best hosp in the state. We are misfits in our little tea.bagger town, but to leave and let such a delicate procedure go to someone elses hands would be extremely foolish. Hes been confident enough to be flexible with us in too many ways to mention here. There some angelic ppl in medicine. You just have dig hard to find them sometimes. You guys are the best for your advice. Thanks A LOT!!!!
He sure sounds like a great psychiatrist and you’re right, hang on to him for as long as possible because they’re as rare as hen’s teeth. I would have guessed he was an academic psychiatrist. No way a random dumbass office shrink would have the knowledge or gumption to go for such an unorthodox approach. Sadly, a lot of psych patients languish or die eventually simply because they were never offered what could be a life-saving treatment for them for reasons that I don’t entirely understand. I don’t know if the medication mafia is just too strong or what but ECT is still the ugly stepchild of psychiatry, not just in the eyes of the public but many psychiatrists themselves. For what it’s worth, I have never seen any credible evidence of brain damage produced under modern treatment parameters (brief pulse or ultrabrief pulse, dose titrated relative to seizure threshold, right unilateral electrode placement, general anaesthesia/muscle relaxation). On the other hand, there is ample evidence of brain atrophy due to antipsychotics now also coming from hardcore biological psychiatrists themselves. Not saying don’t take antipsychotics, just saying there should be some balance in the debate.
Look, I’m very sorry for the cold/impersonal style of advice here and lack of normal human reassurance. I do want to say much more to you but none of us are MDs here and don’t play one on the internet either so since this isn’t chriskresser.com we can only speak in generalities. Feel free to contact me privately; my email address is in my profile.
Hi again, I just wanted to apologize if my previous response (regarding ER nurses/ dramatic women who go to the ER in panic attacks usually after breaking up with boyfriend). I didn’t mean to imply your partner is this type of patient, I was only trying to explain why ER staff are callous. Many if not most of the people they see are actually manipulative, dramatic, pretending to have emergencies for other gains or their own laziness/incompetence so they aren’t like the ideally compassionate type of medical worker. ER is kind of like half street cop, half medicine if that makes sense…they deal with the streets. Their attitude reflects as such.
I saw this episode of some reality show about real ERs (I dont remember the name of it) and one of their physicians was a retired police officer who went to medical school to become an ER doctor. I thought to myself “THAT MAKES TOTAL SENSE”. ER staff have to be almost like police… your patients are from the street and very often there is illicit stuff going on… even if they aren’t actual law breaking criminals (often they are) they are typically not being entirely truthful about things.
Its all good Wooo! Any insights you have I appreciate greatly. Ive done an externship in ekg training and a couple years phlebotomizing for the lab. I experienced enough of the er to know, that 1. Id never be strong enough to endure it, 2. We need to be forever grateful to those souls of steel who are there —- i would guess without thick skin adaptation your life would be shortened by 20 years in an environment that is basically like a war zone.at times and certian areas. Any one who survives long term nursing in any capacity has my forever awe.
Reply to Wooo @ 4:49. TL;DR ALERT If you randomly make up diagnoses about people you can’t help anyway, how do you prove that you’re wrong? Say a patient comes in the door, triggers an emotional response in you the professional, and you say “borderline” in your head after like 10 seconds… how do you prove you’re wrong?
Tehehe. That’s the CRUCIAL problem: you don’t. This is why the whole process sucks balls, patients suffer and/or die and the patient’s only way of obtaining adequate care after they have been placed in a certain box is to seek another opinion from another provider. There is no other way. I’ve seen this too many times. The shrink doesn’t have time for or interest in reality-testing (himself) and he has a narcissistic ego to protect so a treatment plan which he concocted for the patient he imagines is sitting in front of him will be implemented and it doesn’t matter how much the patient protests and tries to dispel the shrink’s erroneous opinions, any objection will be taken as further evidence of their illness.
First I should clarify, as you probably already know, the label borderline doesn’t necessarily apply to an actual disease. Aside from the actual syndrome with specific symptoms which some people have, borderline is used to describe so much more, basically any annoying young attention-demanding emotional female patient. So it’s more of a catch-all description for the negative countertransference reaction in the shrink. Some of these patients are just assholes, yep, neither Axis I nor II, you are right, but if you seek “help” you put yourself in a situation where a label will be found for you since they have to put SOMETHING in the chart and since anyone in the world can be matched to at least one DSM-IV diagnosis, you’re done, something will be slapped on you whether you like it or not. They can’t treat without a dx.
Also, as you well know, most of medicine is educated guessing, percentages game and covering your ass first and foremost. Let’s say 25 year old well-presented babe presents to a doctor with a terrible headache. It could be a brain haemorrhage yeah but most likely it’s not so she gets sent home with a migraine / sinus infection / female issues dx and is told to take two paracetamol and lie down. 99% of time time this might be a good strategy but the one time the patient needed a CT which would have revealed a bleed this generally correct strategy fails. Sucks for that person but it doesn’t mean the doc’s going to be doing detailed work-ups on every headache from now on. Resources are limited and it SUCKS BIG TIME but it’s just the way it is.
Analogously, a hypothetical 25 year old babe wearing a well-put together outfit and make-up presents to an older male psychiatrist with low mood. 99% of people who are able to look after themselves well enough to wear let’s say skinny jeans and make-up while saying they are in the midst of a crisis don’t have actual (treatable) depression but are “borderline” (broad definition discussed above, not borderline personality as such) and are here because they want to or already have slashed their wrists because the boyfriend just dumped them. It BLOWS for the one person who is actually in the depressive pit but made the superhuman effort to look decent/presentable and is genuinely depressed. IT SUCKS! But the shrink playing his snap judgment / percentages game would still have been right most of the time, no? Even if it’s not “borderline”, he would still be right to probe for narcissistic traits given the incongruent physical appearance vs verbal hx issue which is still cluster B. If you were the shrink, what would you do?
Generally, in my experience, people with severe depression look pale and don’t shave / have any make-up on and the greasy hair is hanging limply from their head and their attire is shabby. Also, generally, the “borderline” will be dressed up and made up even on the ward (unless she is currently trying to prove a point to her treatment team and will go around dishevelled and in night clothes in order to LOOK DISTRESSED and will walk into the ward round looking rough on purpose). If you ask her about her attire or even spontaneously she will point out that she can’t even look presentable, she’s so depressed, help. Whereas the depressed patient is in horrors and doesn’t focus too much on the fact they haven’t showered in a week, it’s the rest of us who are worried about their not having showered in a week.
It backfires horribly wrong at times of course. I could fill ten pages here with case studies of people with atypical depression, prodromal schizophrenia etc. who were dismissed as Axis II by the attendings I know. But there would be no medicine/health care system without this sort of quick heuristic judgement. I just wanna say I know how dehumanising/upsetting your experience must have been. I’ve been in a similar situation myself with an actual doctor (not shrink) and it was horrible. Allow me to share:
Basically, not too long ago, what happened was that I fell from a step in a rather public place. I felt faint with pain, couldn’t really stand/walk and couldn’t step on my foot due to pain. Within minutes it was swollen to twice the normal size and no one could be sure if it was broken or not. I was alone, no one to drive me/look after me. The employees of this organisation called an ambulance of course (cover your ass, remember). I thought it was a bit OTT but truth is I was quite unwell and would not have been able to make my way to a hospital any other way. So they brought me in, xrayed it, determined it wasn’t broken, I got painkillers, crutches, discharged and sent home in a cab. Before d/c the doc said it will probably require physio as the sprain was in the ankle, awkward place etc. Follow up with your GP she says.
So I did. I walk in limping on my damn crutches. Dude (I should say late 50s male, narcissist, overt sadistic traits, old skool attitude towards young women… to put it mildly) looks at me contemptuously and says in a totally sarcastic tone, “Christ Almighty, what happened here?” I explain, clearly embarrassed by the whole ambulance situation. Dude quietly sits there and doesn’t even look at me while taking a hx. Now, I should say that I had been well known to him previously due to my other complex/unusual dx which you and I previously emailed about. Also, at this point, the story doesn’t really make sense unless I note that he had previously made numerous passes at me, actual unambiguous/overt sexual comments, following which he quickly pretended like nothing was meant by it, silly girl, what sorts of ideas are you getting in your head sort of thing but proceeded to chat for 45 minutes with me every time about medically irrelevant things including his other patients. The usual sadistic power trip, very hot-and-cold, classic stuff. I should also say I never reciprocated, I behaved with him the same way as I would with any other Axis II patient like the vibrator woman whenever he would say reckless things. Crucially, at our last meeting prior to my leg incident I indicated I should probably find another doctor.
ANYWAY, long story short, calamity struck a few days later after our “fight” and what was I supposed to do? You don’t search phone directories, you seek help from the devil you know and who you know at least will give you attention if nothing else. So there I was in a very visible/dramatic state seeking his help after I had threatened to “break it off” last week. Can you imagine how this went down? Dude gives me a lecture while keeping his head turned away from me by about 45 degrees the whole time about healthcare resources and how it was a dreadful waste of money to get an ambo, an xray and CRUTCHES, for god’s sake, CRUTCHES cost money, for THIS stupid nothing thing. I was like uh can’t walk here, they said I need physio, could you, you know, LOOK AT IT FIRST BEFORE REACHING A CONCLUSION? Anyway, he proceeds with a sadistic exam during which I yelped in pain and he said to shut up, “no hysterics, no dramatics, OK?”
OK. Why was he behaving like this when last week I could have walked in with a blister and he would have spent half an hour looking at it while telling irrelevant self-aggrandising stories? Because I first dealt him a narcissistic injury and now he triumphally concluded I was a histrionic borderline bitch who fell on purpose to be able to get an excuse to see him again and get his attention. He didn’t say any of this, of course, but on the basis of what I know and what I would have thought/considered in his situation and judging by his personality, age, gender, behaviour during and prior to the interview, this is what he thought. He barked at me like a dog, the only thing missing was maybe a spit. To be honest, I know “crazy” would be on my differential too if I had been him since a narcissist like him can’t conceive of anything being about anything else other than him and his narcissistic concerns and the bitch wanting him so bad that of course she would injure herself on purpose to get his attention. He has to believe this; it’s the whole basis of his identity. But does it make it ok to be dismissed as a crazy bitch? No, it was incredibly upsetting.
This is my roundabout way of saying don’t mind what one specific shrink thought or said. A female doctor without narcissistic countertransference issues would have correctly dx’ed my problem and referred for physio instead of allowing me to limp along in pain and stiffness for six months. Oh, and I still would have fallen even if I’d never met that man in my life.
Everything you say makes total sense sid, of course the doctors need to consider a patient reporting severe depression isn’t severely depressed when they come to their doctor dressed to the 9s clearly able to function normally in a biological sense. By definition a patient can’t be severely depressed if they are functioning at that high level.
The issue at least in this case here, and possibly other cases, is the doctor is focused on one sign of the patient, usually because of their *own personal reasons* and ignoring the totality of evidence. Like, not conducting any assessment of symptoms or history or even the onset of the current problem, or prior drug use, etc. “Oh, you’re personality disordered” after 2 seconds. This isn’t acceptable.
Actually in my case , right away I told him I was feeling better (it took 2-3 weeks to see him, and I had started light therapy over a week ago). I wasn’t coming there dramatic in crisis I actually freely offered I was way better than I was weeks ago (from light therapy). I also specifically told him my depression started in october (it was january) but he didn’t seem to care that this pointed to an biological mood problem. Well actually he did say “good for you for not using drugs!” as if I was a simpleton looking for a pill to solve my problems.
Granted I don’t work in psych, but I would think by the time someone is so depressed they are living zombies staggering (or laying) in their own filth 100% of the time, odds are they don’t have the energy or will to live to leave the house/make an appointment with a doctor so expecting a depressed patient to look like shit outside of a psych ward is probably not going to be reliable.
It’s not like you go from being totally put together to being a complete fucking mess. It’s more like the mess consumes the put together/functioning gradually until you’re just living death. The goal of the psych worker should be to *prevent* people from getting that bad at lower intensities of dysfunction, right?
It’s like in medicine if you have a patient with diabetes, you don’t want them to “prove” they are diabetic by having them come to the ER in ketoacidosis or a hyperglycemic crisis, you want to pay attention to their complaints of thirst/blurry vision/hunger/weight changes and slightly high A1C and elevated postprandial sugar so that you can treat them and keep them healthy and teach them about diabetes control and encourage them to follow it so they don’t end up on a medical floor in a hospital.
I don’t see why in psych it’s like YOU’RE EITHER DEPRESSED OR YOU’RE A PERSONALITY DISORDER. Granted, maybe this is one of those things I just don’t understand because I’m not a psych worker, but my experience with mood problems is that they come in different intensities and they get worse or better.
God that sounds so awkward and embarrassing S… how unfortunate to get a real injury right before calling him out on his unprofessional behavior/saying you’re going to find a new doc. He must have been thinking you were being this dramatic hysterical female to a T.
I think a lot of older male doctors assume if a young woman comes to see them they’re making up excuses to see them and it’s personal. NO ACTUALLY I JUST WANT PHYSICIAN SERVICES duh. I suppose part of the problem is some women *do this* because they are pathetic and desperately want to be with a doctor on any pretense.
This is why I prefer female doctors. I’ve never had a bad experience with one in terms of being unprofessional or treating me from *their* perspective.
I w
That’s just inexcusable lazy rotten behaviour from the shrink who should have taken a proper history regardless of whether he suspected a personality disorder or not. What a jerk. I’m sorry you had such a terrible experience. It seems you were quite unlucky: you looked well, you knew more neuroendocrinology than him, you happened to improve prior to seeing him, you were already taking steps to treat yourself like the light box, you’d already developed coping skills to deal with your problem. You were an outlier.
Regarding physical appearance, I didn’t mean to imply that all depressed outpatients are expected to be filthy. It’s just that if a young woman comes in looking attractive and well presented, the whole session becomes about the shrink’s feelings and attempts to cope. This can get you an Axis II diagnosis, and once that’s suspected, it’s not like it’s an either/or situation, either depression or PD, obviously they can and do co-occur, it’s more that once you’ve been branded as personality disordered, everything will revolve around that fact because you are likely to be a poor responder to treatment and you deserve to be burned at the stake. Obviously, people with PDs are at a greater risk for Axis I disorders. It’s like in medicine if you have a patient with diabetes, you don’t want them to “prove” they are diabetic by having them come to the ER in ketoacidosis or a hyperglycemic crisis, you want to pay attention to their complaints of thirst/blurry vision/hunger/weight changes and slightly high A1C and elevated postprandial sugar so that you can treat them and keep them healthy and teach them about diabetes control and encourage them to follow it so they don’t end up on a medical floor in a hospital.
Unfortunately, this is EXACTLY what happens in psych. Patients’ families often remark that admissions told them their relative wasn’t sick enough for our service and to come back later if (when) they deteriorate. This is the equivalent of saying to a diabetic to come back later once they’re in DKA. So then when they end up in the ER psychotically depressed they have finally proven their bona fides and now we’ll take them. Makes your blood boil really but it’s not like we’re some uniquely satanic treatment centre. This happens everywhere because for the last 40 years we as a society have been pretending that mental illness isn’t real and that when it happens, it should be dealt with only briefly in hospital, followed by community “care” (read: welfare dependence, substance abuse, unemployment, homelessness, criminality). We have been getting rid of psych beds and shunting the money into other areas of medicine that deal with more interesting election issues and where patients actually vote.
Opaque ? Maybe – “through a glass darkly”. Clever peeps are able to decode – I’m not much interested in t’others.
My Maths Prof believed that the student should work it out for themself and then present the result. (The conclusion is left as an exercise . . . . !)
Rihanna ?? Mmmmm
“Those who live by the Butt shall die by the Butt.”
It all very well to shake yr booty, butt unless the promise is withheld, the Booty will not be collected. Madonna did it; but she now well past her sell-by date
RH will never be an Ella Fitz. Madonna did not do it – she could have.
More to a different point, are these Cultural Borderlines actually so, or are they selling themselves to a Borderline audience ?
The post-modern zeitgeist is extra-ordinarily self-referential & self-absorbed.
Leon, I don’t understand your riddles 100% of the time but I sure enjoy trying to decipher them! English isn’t my first (or second) language so there’s that too. It all very well to shake yr booty, butt unless the promise is withheld, the Booty will not be collected.
LMFAO. *DEAD*
Are they “for realz” or just lapping it up / catering to the extraordinarily narcissistic zeitgeist? I think if you were to follow Rihanna’s twitter even for a day the question would answer itself.
I think this blog entry is fantastic and your comments are even better,… I don’t at all mind how long they are. You are a great writer and your blog is awesome.
I have a disabling inability to write anything shorter than like 5 paragraphs so I apologize for TL;DR syndrome feel free to skip anything obnoxiously long/boring/rambling.
Aw Woo, right back at ya!
Don’t be silly, your comments are gold. You know, it was actually Guyenet’s blog of all places where I first spotted you. It was during the epic Taubes vs. Guyenet (and their homies) war last year. I was like, “Holy fucking shit, this woman is a GENIUS.”
Wooo & Sid
You both write authentic posts about hospital experiences & it comes thro’ in the writing. I have a little insight into this as I once had a lover who did nights on the dying wards. She had tales about quiet painless passings morphine aided.
The first I knew about it would be my awakening at 06:30 with my lady taking us both to orgasm – she to sleep, I off to shower, coffee & work.
Oh, the borderline personalities issues make me SAD! I suffered for half a decade with manic depressive cycles and nothing treated it so well as being called on my issues and learning to recognize them and cope BEFORE being enabled and spinning myself out of control. Eight years later and I can honestly say I’m as mentally healthy as I’m going to get and have a lovely, normal, boring life full of delightful family and friends. For someone who made her best friend hate her with the crazy, it’s a big step!
Watching it from the outside as it is happening is tragic, especially with these young women who just can’t seem to pull themselves together except in the most rare instances. And I think you nailed what happens to them – hormones, loneliness, and a general lack of attention to feed the psychosis. But it doesn’t make it non-existent, simply because it ceases to be sexy or entertaining.
[...] fame and rich horny idiots who will put up with this sort of thing. But once you hit old age, this will happen. Sitting in an office of someone like me, telling them about your date with your [...]
Thank you for the recommendation. My knowledge of Anglo fiction is embarrassing, non-existent. Back home you would have been reading all the ancient classics plus the Russian classics but that’s it.
reading is my passion, but there’s no way on god’s earth you can cover it all! i prefer British literature and Russian MUSIC, myself.
You have refined tastes, my dear. You could do like a favourites list. Me? An unsophisticated slob. You’d know what I mean if you saw the contents of my iPod.
It sometimes occurs to me that I know very little or nothing about many of my favourite blogger peeps except of course the ins and outs of their feeding habits. We haven’t even had a drink yet dahhhhling but you’ve already told me about the contents of your gut.
It’s true and sort of depressing/humbling to think how much stuff there is on our “must read” list but you’ll never ever get to read even a tiny proportion of these amazing works. I can’t remember the last time I read a fiction book. I attempted a much-hyped Martin Amis old novel recently but found it so idiotic and pompous and self-aggrandising I had to abandon it early on.
It sucks but I’ve been reading nothing but journal articles for years now, the most debased revolting form of writing imaginable. And blogs, obviously. I fucking love blogs.
If the population was atleast as sane as me these kind of people would never escape poverty because no-one would spend a penny on them or their junk showbiz.
Regarding Xtina, yes, I agree, she always sounds better/more soulful singing the classics. If she quit the slut routine and came back with a more mature sound and image, she could still salvage her moribund career, IMO. But she kinda has to stick to vocally unchallenging pop these days like this Max Martin dreck Your Body, her vocals are much deteriorated compared to her prime, some haters would argue shot to shit. If you compare her rendition of At Last at Etta James’ funeral to the one she did during the Stripped tour in 2003, you’ll know what I mean:
Obviously no one is going to sound the same 10 years later but a professional singer should be able to still sing at 30. Sadly, Christina used to have a wonderful voice which she screamed/burned through without any training or finesse and now it’s just a burning pile of ashes. She struggles on notes as low as B4 these days which is shocking. But then, how much is permanent damage and how much is just inconsistency due to alcoholism, not rehearsing etc. I don’t know. Some days she stands up and really delivers a great live performance
and then the next day she sounds like she’s dying and I get a sharp pain in my throat just listening to her trying to reach for basic notes like C5.
Like hookers and scummy “therapists”? No.
There’s this old crazy borderline called “the crackwalker” on youtube. She’s like 60 years old now and she basically lives alone and makes youtube videos for her attention/drama fix, and has modified her personality to be “loner” even though in her youth you knew she was shacking up with guys and having dramatic blow outs every other week. Loner is a label she’s been forced to adopt when her sexual appeal dropped to zero around 35 yrs old.
I suspect most borderlines end up like this… at least the ones stupid enough not to marry a rich guy and get his ass in court for alimony.
I’ve a relative who is similar… she was attractive in youth spent it being a dancer, drinking and partying and shacking up with various men. Spent all her money she earned dancing on fancy clothes. At around 40 years old she started living off of her daughter and that was the end of that. She too was stupid and never married a rich man.
I think the internet is good for old and unattractive crazy women because you can create a market for yourself as some kind of guru or victim for the attention/care you need, w/o requiring people see you and realize how old / unappealing you are. Normally a borderline would have to present youth and attractiveness to obtain support but the internet makes that a non-issue.
I agree, yes, the sad truth is for women: no one cares when you are old / ugly. Not just psych patients, but IN GENERAL.
On the other hand, only women expect and get attention for no reason, so it’s sort of like taking away a privilege that men never had in the first place. Like, if I’m in a store, and drop something, EVERY GUY around me picks it up. If I am approaching a door and a man is around, he will open it or hold it for me.
If I’m at work and tell a male coworker I need supplies, he VOLUNTEERS to go to the basement to dig through boxes and get it for me. These are benefits only young women get… or bosses/powerful people.
But then on THE OTHER hand, men are treated with respect and are automatically assumed competent/intelligent. When a woman ages, she loses her beauty and the power she has over men, but she doesn’t gain the assumed competency of a man. So really, the worst of all fates is to be an old woman, particularly one without children so she isn’t a mother either.
PS, happy birthday to me I just turned 30! Yay! They told me I would waste my life and I finally did it!
Christina has entered that cringe worthy state where no one gave her the memo she isn’t hot anymore and needs to lose a few pounds if she wants to prance aroud in those outfits.
Happy birthday! Aw, don’t say you wasted your life. There is so much more to life than reproduction.
Regarding being able to spot a patient within minutes know what is going on:
I think this is one of those things where psych professionals GET AWAY with being shitty. If you randomly make up diagnoses about people you can’t help anyway, how do you prove that you’re wrong? Say a patient comes in the door, triggers an emotional response in you the professional, and you say “borderline” in your head after like 10 seconds… how do you prove you’re wrong? Maybe she isn’t axis 1 but maybe she’s not axis II, either. It’s not like either or. Thing is, there is no way to prove someone is or isn’t borderline so naturally the professional thinks they’re right because the patient isn’t axis 1, but they are annoying so that means they’re borderline. It is an unfalsifiable diagnosis because it basically applies to any woman who is outwardly directed and annoying/needy/dramatic. Which is basically how most females process stress and emotions which are generalized symptoms of dysfunction.
Patient could have some kind of autoimmune disease causing emotional problems, but there is no way to prove or disprove borderline as basically any aggressive/outwardly directed yet feminine person who isn’t axis 1 can be considered borderline.
I’ve been in that situation. Now, I’ve only dared see a psych professional 2 times in my life. The second time it was a male doctor, and I walked in the door and within a few seconds he pegged me axis 2/borderline and I know this because the first question he asked is “does your mood become depressed when dealing with your relationships?”
Sure my personality is crap and I do see how I fit the ‘avoidant personality” very well, but I also definitely have a biologically real mood problem. this guy was basically unwilling to consider that, simply because I smiled and was wearing clean put together clothes. You don’t have depression for like 20 years and not learn how to do shit even when you feel horrible. Minutes before walking in that door guess what I was wearing dirty pajamas lying in bed. I am a seasoned pro of forcing myself to socialize when everything in my body wants to stay in the house and never go outside.
This is a fundamental problem in psych services and it seems epidemic all over the world: psych professionals believe they can understand people in a few seconds and that substitutes for really doing a comprehensive medical work up and history taking. It’s a reflection of the lack of science or pathophysiological curiosity of psychiatry.
Yes, a medical work up should be part of ANY psych service because it’s usually true rather than occasionally true that health problems cause emotional/mental ones… and substance disorders can cause psych problems as well as being symptoms of it.
Immediate appearance and behavior is just a small part of the picture, not the whole picture… and I would say doctors are more diagnosing themselves than the patient when they label people with anything after a few seconds, or even a session.
IMO it’s a lot like people looking at fat asses and saying ‘ate too much”. Ok, even if they did eat too much, you still don’t know ANYTHING about the disease/disorder causing that.
Psych gets away with this because to be honest no one knows shit about psych illnesses and the meds are even worse. “Yep, definitely a case of the cooties!” says teh quack-chiatrist in response to the patient who he just doesn’t like very much in an emotional/human kind of way.
It’s possible for people to be annoying assholes w/o an axis 1 disorder and for them to not be borderlines in the sense of having a shitty maladjusted personality either.
I would also propose that being an asshole may just be a variant of normal, not pathological. so if it turns out your annoying harpy is totally healthy mentally and physically maybe that’s just who she is and she’s not crazy. I think women bank on crazy… crazy is like sex, mysterious and intense and emotional… men in general confuse crazy female for sexiness it seems so women have more of an interest of posing as this random illogical helpless ball of dysfunction in need of saving. Not many guys go to psychiatrists and talk about their sex toys, and if they did, the shrink would assume they had some kind of fetish or were like a sex offender or something especially if it was a female professional.
ER nurses attract more of the greedy assholes because they make so much money and you usually have to be insane, ADHD/impulsive, or on drugs to tolerate ER work. They generally deal with random crackheads and drunks and idiots for patients all day, as well. “MY KID HAS A SPLINTER AND I DONT WANT TO WAIT FOR THE PEDIATRICIAN SO I CAME TO THE ER” is a common one, or “I AM HAVING CHEST PAIN AND I AM ALSO SUICIDAL NOW GIVE ME SOME DILAUDID” says the obvious crackhead looking for an admission and a script. Or like “I cut my foot a week ago sustaining an easily treatable injury, but I’m diabetic and now it’s so infected it’s ready to be amputated woops”. In addition to the ER being more prone to attract the callous greedy assholes, it also causes people to become callous because the patients suck and its stressful.
On the other hand, the fact is ER staff do see dramatic borderline patents like ALL DAY, these people coming in with anxiety attacks after breaking up with their boyfriend being like “HELP ME, PLEASE GIVE ME ATTENTION, I’M GOING TO KILL MYSELF, SHOWER ME WITH LOVE I NEED I NEED, GIVE ME ATIVAN”.
From the perspective of medical staff, this incredibly selfish manipulative and financially wasteful behavior because there are actually REAL PEOPLE having medical emergencies who aren’t getting help because of this dramatic needy idiot. Yea, I mean the dramatic idiot is certainly not feeling well but you know what? I think the genuine manic patient or the guy having a heart attack takes priority and they can’t attend to those patients as well because they are wasting time with this asshole having an emotional drama melt down looking for some xanax because of their fake suicide attempt/fake suicidal thoughts.
In medicine everything is about priority. Every patient and every family think they are the priority but let me tell you as a nurse, you aren’t the priority most of the time. Unfortunately medicine is now a financial service and medical staff from nurses to doctors need to act like salesman and waitresses , sometimes putting peoples lives at risks just to give “customer service”. We can’t just tell annoying histrionic fucks to sit down and shut up while we help people with real medical problems. We have to kinda pretend their non-problem is a real problem, stealing valuable seconds from people with potentially real emergencies where every second counts..
or state insurance money was payed out for it. Contrast that with a little ect treatment billed at only 400.00$ a pop and I think I can see why ECT is so demonized and no one with success stories gets much media attension . Ok wheww.
Thank you for your comments and I am really sorry to hear about your terrible experiences with the services. I wasn’t ignoring you, I just live in Europe and can’t respond to most comments in a timely fashion as I tend to be asleep when most comments hit my inbox.
Obviously, we can’t comment here on your girlfriend (or any other person) specifically. I can tell you what I know about ERs and ECT, generally speaking. As Woo already comprehensively covered in her post, ERs are generally a terrible place to be when you’re dealing with an acute psychiatric emergency. The ER staff are not psych specialists. Their one and only job is to get you out of there ASAP in a relatively stable condition. They are used to dealing with dregs of society who are in there looking for painkillers, benzos, shelter, attention, all sorts of scum and crazies, in addition to people experiencing genuine dire emergencies such as a psychotic episode. ER nurses tend to have coarsened personalities due to years of this kind of work. You won’t get any sympathy in there unfortunately which is very distressing for people going through a major crisis. I’m not trying to make any excuses for the system, I’m just describing reality as I see it.
Regarding medication and ECT for treatment-resistant depression, one could write a whole book about this and it’s difficult to answer this is any coherent fashion. As you probably know, psychiatry has been corrupted by other interests to the extent that dangerous polypharmacy with multiple agents of dubious antidepressant efficacy is now the norm in treatment of any kind of more complicated depression. It is not unusual at all to see people on 7 drugs these days. The rot in psychiatry has spread to the extent that some psychiatrists treat their depressed patients with cocktails of antiepileptic drugs (falsely rebranded as mood stabilisers), second-generation antipsychotics and benzos and other stupid shit like pregabalin and such instead of a proper dose of a proper antidepressant or an antidepressant + antipsychotic combo in cases of psychotic depression which is what the evidence says you should do. Approach varies from psychiatrist to psychiatrist and unfortunately I must say it’s really just dumb luck who you get when you are admitted. Treatment approach varies drastically from person to person working even in the same service. Patients and families don’t understand this. Everyone has their signature style and their favourite drugs and combos they believe are effective (for no reason other than gut feeling, previous good experience with some patients [and terrible experience with others but those are quickly discarded/suppressed due to self-serving confirmation bias], voodoo, or the latest journal paper they happened to read which was most likely a ghost-written infomercial by pharma). I know by looking at the medication list the patient is on who their psychiatrist is. The patient is interchangeable, the drug list is permanent. Sad but true. Our knowledge of psychopharmacology is on the level of witchcraft and really there is no scientific way of matching a specific patient to a specific therapy. It’s just trial and error, dumb luck and gut instinct. They will try to tell you otherwise but they are deluding themselves. Because the science is so terrible, you can have a situation like now where sedating but otherwise numbing (depressant in the long term drugs) like atypical antipsychotics are used to treat (actually, manage) non-psychotic depression. Madness.
ECT, as you know, has a terrible rep because of what used to happen. I think the public perceptions of it are unjustified because a treatment doesn’t abuse anyone, it was the psychiatrists and the nurses who used to abuse patients in institutional settings which enabled abuse. In actuality, and nobody wants to hear this but it’s true, it’s an excellent treatment option for treatment-resistant depression unresponsive to medication. The problem with ECT is that a course of it has little to no long-lasting effect and in addition to that, some people get memory side-effects and generally they are the only people you hear about creating the impression that they are the majority of ECT patients when they aren’t, it’s just that those who responded well to it go back to their lives going about their business quietly instead of posting about it on the internet.
Relapse, which is what you are asking about, is a huge problem though. In fact, if you look at the studies, you will find that relapse rate after ECT is 40-50% give or take in the first six months regardless of the method of continuation therapy used, it could be as rigorous as nortriptyline + lithium combo and they still relapse. This is a huge problem and there is presently no answer to it. Here I’m talking about an acute course of ECT (in the States, that means one session 3x week for a few weeks). What you are describing is maintenance ECT which is a different issue. Maintenance ECT has a long clinical history (over 60 years, I am thinking of a paper in the Am J Psych from 1949 where they already discussed this) but only two randomised controlled trials ever carried out to support it, both in exclusively or mostly older adults (Kellner et al 2006; Navarro et al 2008 are the only RCTs to my knowledge). Again, the evidence is terrible so we’re back in the realm of opinion and clinical lore. Clinical experience with maintenance ECT is good although most people don’t know how or when to use it so most just don’t use it or think of it as an option and they just kind of allow their medication-resistant patients to languish. It’s a sort of a dirty little secret no one talks about in polite society but some patients after years of being miserable on meds and relapsing every time on meds after an acute course of ECT end up finally getting maintenance ECT and from what I’ve seen it works really well and a lot of people never look back. Some people have quite a miraculous response to even just one zap, they go back to normal after relapsing after just one session. Others need more frequent administrations. Memory problems do tend to happen for some people but it’s hard to know is it due to age or what. Problems range from me having to reintroduce myself every time as if meeting for the first time a patient who knows me well and has met be lots of times in the past to zero memory loss. I’m reminded here of a case study I read once, the authors escape me right now, of a patient who had no memory loss from over 100 lifetime ECT administrations. It’s like everything else, the response and side effects totally vary from person to person.
I’ve never really seen anyone under the age of 60 getting maintenance so I’m pleasantly surprised this is an option in the States. Psychiatrists here would rather keep a person on lithium for maintenance despite evidence of kidney failure than consider ECT. Ignorant fools. Right unilateral as you point out tends to be associated with less memory side effects than bilateral so an added bonus there. Enlightened shrink you have there, I must say.
Again, generally speaking, one of the biggest problems in psych is getting the patient to stay on the treatment that’s working. Some people who respond wonderfully to medication decide one day they don’t need it anymore. I can’t say I get this reasoning. If I had a chronic heart condition which I knew had a 100% recurrence rate, and if there was a pill or another treatment (albeit unpleasant) that I knew would suppress my symptoms, I’d bloody well stay on the treatment. For some reason, in psychiatry it’s not like this and often you meet perfectly rational and intelligent people who insist on getting off the meds that are keeping them well ‘cuz they don’t want to be taking them pillz for the rest of their lives. Fine. Your choice. I just don’t get it.
I don’t work psych and my knowledge of ECT is that it’s done last resort to pull people out of severe mental episodes, not for maintenance. But if it’s helping her it’s probably worth it for the risks.
http://www.ncbi.nlm.nih.gov/pubmed/22579150
I don’t have the full text unfortunately but…
Look, I’m very sorry for the cold/impersonal style of advice here and lack of normal human reassurance. I do want to say much more to you but none of us are MDs here and don’t play one on the internet either so since this isn’t chriskresser.com we can only speak in generalities. Feel free to contact me privately; my email address is in my profile.
I saw this episode of some reality show about real ERs (I dont remember the name of it) and one of their physicians was a retired police officer who went to medical school to become an ER doctor. I thought to myself “THAT MAKES TOTAL SENSE”. ER staff have to be almost like police… your patients are from the street and very often there is illicit stuff going on… even if they aren’t actual law breaking criminals (often they are) they are typically not being entirely truthful about things.
If you randomly make up diagnoses about people you can’t help anyway, how do you prove that you’re wrong? Say a patient comes in the door, triggers an emotional response in you the professional, and you say “borderline” in your head after like 10 seconds… how do you prove you’re wrong?
Tehehe. That’s the CRUCIAL problem: you don’t. This is why the whole process sucks balls, patients suffer and/or die and the patient’s only way of obtaining adequate care after they have been placed in a certain box is to seek another opinion from another provider. There is no other way. I’ve seen this too many times. The shrink doesn’t have time for or interest in reality-testing (himself) and he has a narcissistic ego to protect so a treatment plan which he concocted for the patient he imagines is sitting in front of him will be implemented and it doesn’t matter how much the patient protests and tries to dispel the shrink’s erroneous opinions, any objection will be taken as further evidence of their illness.
First I should clarify, as you probably already know, the label borderline doesn’t necessarily apply to an actual disease. Aside from the actual syndrome with specific symptoms which some people have, borderline is used to describe so much more, basically any annoying young attention-demanding emotional female patient. So it’s more of a catch-all description for the negative countertransference reaction in the shrink. Some of these patients are just assholes, yep, neither Axis I nor II, you are right, but if you seek “help” you put yourself in a situation where a label will be found for you since they have to put SOMETHING in the chart and since anyone in the world can be matched to at least one DSM-IV diagnosis, you’re done, something will be slapped on you whether you like it or not. They can’t treat without a dx.
Also, as you well know, most of medicine is educated guessing, percentages game and covering your ass first and foremost. Let’s say 25 year old well-presented babe presents to a doctor with a terrible headache. It could be a brain haemorrhage yeah but most likely it’s not so she gets sent home with a migraine / sinus infection / female issues dx and is told to take two paracetamol and lie down. 99% of time time this might be a good strategy but the one time the patient needed a CT which would have revealed a bleed this generally correct strategy fails. Sucks for that person but it doesn’t mean the doc’s going to be doing detailed work-ups on every headache from now on. Resources are limited and it SUCKS BIG TIME but it’s just the way it is.
Analogously, a hypothetical 25 year old babe wearing a well-put together outfit and make-up presents to an older male psychiatrist with low mood. 99% of people who are able to look after themselves well enough to wear let’s say skinny jeans and make-up while saying they are in the midst of a crisis don’t have actual (treatable) depression but are “borderline” (broad definition discussed above, not borderline personality as such) and are here because they want to or already have slashed their wrists because the boyfriend just dumped them. It BLOWS for the one person who is actually in the depressive pit but made the superhuman effort to look decent/presentable and is genuinely depressed. IT SUCKS! But the shrink playing his snap judgment / percentages game would still have been right most of the time, no? Even if it’s not “borderline”, he would still be right to probe for narcissistic traits given the incongruent physical appearance vs verbal hx issue which is still cluster B. If you were the shrink, what would you do?
Generally, in my experience, people with severe depression look pale and don’t shave / have any make-up on and the greasy hair is hanging limply from their head and their attire is shabby. Also, generally, the “borderline” will be dressed up and made up even on the ward (unless she is currently trying to prove a point to her treatment team and will go around dishevelled and in night clothes in order to LOOK DISTRESSED and will walk into the ward round looking rough on purpose). If you ask her about her attire or even spontaneously she will point out that she can’t even look presentable, she’s so depressed, help. Whereas the depressed patient is in horrors and doesn’t focus too much on the fact they haven’t showered in a week, it’s the rest of us who are worried about their not having showered in a week.
It backfires horribly wrong at times of course. I could fill ten pages here with case studies of people with atypical depression, prodromal schizophrenia etc. who were dismissed as Axis II by the attendings I know. But there would be no medicine/health care system without this sort of quick heuristic judgement. I just wanna say I know how dehumanising/upsetting your experience must have been. I’ve been in a similar situation myself with an actual doctor (not shrink) and it was horrible. Allow me to share:
Basically, not too long ago, what happened was that I fell from a step in a rather public place. I felt faint with pain, couldn’t really stand/walk and couldn’t step on my foot due to pain. Within minutes it was swollen to twice the normal size and no one could be sure if it was broken or not. I was alone, no one to drive me/look after me. The employees of this organisation called an ambulance of course (cover your ass, remember). I thought it was a bit OTT but truth is I was quite unwell and would not have been able to make my way to a hospital any other way. So they brought me in, xrayed it, determined it wasn’t broken, I got painkillers, crutches, discharged and sent home in a cab. Before d/c the doc said it will probably require physio as the sprain was in the ankle, awkward place etc. Follow up with your GP she says.
So I did. I walk in limping on my damn crutches. Dude (I should say late 50s male, narcissist, overt sadistic traits, old skool attitude towards young women… to put it mildly) looks at me contemptuously and says in a totally sarcastic tone, “Christ Almighty, what happened here?” I explain, clearly embarrassed by the whole ambulance situation. Dude quietly sits there and doesn’t even look at me while taking a hx. Now, I should say that I had been well known to him previously due to my other complex/unusual dx which you and I previously emailed about. Also, at this point, the story doesn’t really make sense unless I note that he had previously made numerous passes at me, actual unambiguous/overt sexual comments, following which he quickly pretended like nothing was meant by it, silly girl, what sorts of ideas are you getting in your head sort of thing but proceeded to chat for 45 minutes with me every time about medically irrelevant things including his other patients. The usual sadistic power trip, very hot-and-cold, classic stuff. I should also say I never reciprocated, I behaved with him the same way as I would with any other Axis II patient like the vibrator woman whenever he would say reckless things. Crucially, at our last meeting prior to my leg incident I indicated I should probably find another doctor.
ANYWAY, long story short, calamity struck a few days later after our “fight” and what was I supposed to do? You don’t search phone directories, you seek help from the devil you know and who you know at least will give you attention if nothing else. So there I was in a very visible/dramatic state seeking his help after I had threatened to “break it off” last week. Can you imagine how this went down?
OK. Why was he behaving like this when last week I could have walked in with a blister and he would have spent half an hour looking at it while telling irrelevant self-aggrandising stories? Because I first dealt him a narcissistic injury and now he triumphally concluded I was a histrionic borderline bitch who fell on purpose to be able to get an excuse to see him again and get his attention. He didn’t say any of this, of course, but on the basis of what I know and what I would have thought/considered in his situation and judging by his personality, age, gender, behaviour during and prior to the interview, this is what he thought. He barked at me like a dog, the only thing missing was maybe a spit. To be honest, I know “crazy” would be on my differential too if I had been him since a narcissist like him can’t conceive of anything being about anything else other than him and his narcissistic concerns and the bitch wanting him so bad that of course she would injure herself on purpose to get his attention. He has to believe this; it’s the whole basis of his identity. But does it make it ok to be dismissed as a crazy bitch? No, it was incredibly upsetting.
This is my roundabout way of saying don’t mind what one specific shrink thought or said.
The issue at least in this case here, and possibly other cases, is the doctor is focused on one sign of the patient, usually because of their *own personal reasons* and ignoring the totality of evidence. Like, not conducting any assessment of symptoms or history or even the onset of the current problem, or prior drug use, etc. “Oh, you’re personality disordered” after 2 seconds. This isn’t acceptable.
Actually in my case , right away I told him I was feeling better (it took 2-3 weeks to see him, and I had started light therapy over a week ago). I wasn’t coming there dramatic in crisis I actually freely offered I was way better than I was weeks ago (from light therapy). I also specifically told him my depression started in october (it was january) but he didn’t seem to care that this pointed to an biological mood problem. Well actually he did say “good for you for not using drugs!” as if I was a simpleton looking for a pill to solve my problems.
Granted I don’t work in psych, but I would think by the time someone is so depressed they are living zombies staggering (or laying) in their own filth 100% of the time, odds are they don’t have the energy or will to live to leave the house/make an appointment with a doctor so expecting a depressed patient to look like shit outside of a psych ward is probably not going to be reliable.
It’s not like you go from being totally put together to being a complete fucking mess. It’s more like the mess consumes the put together/functioning gradually until you’re just living death. The goal of the psych worker should be to *prevent* people from getting that bad at lower intensities of dysfunction, right?
It’s like in medicine if you have a patient with diabetes, you don’t want them to “prove” they are diabetic by having them come to the ER in ketoacidosis or a hyperglycemic crisis, you want to pay attention to their complaints of thirst/blurry vision/hunger/weight changes and slightly high A1C and elevated postprandial sugar so that you can treat them and keep them healthy and teach them about diabetes control and encourage them to follow it so they don’t end up on a medical floor in a hospital.
I don’t see why in psych it’s like YOU’RE EITHER DEPRESSED OR YOU’RE A PERSONALITY DISORDER. Granted, maybe this is one of those things I just don’t understand because I’m not a psych worker, but my experience with mood problems is that they come in different intensities and they get worse or better.
God that sounds so awkward and embarrassing S… how unfortunate to get a real injury right before calling him out on his unprofessional behavior/saying you’re going to find a new doc. He must have been thinking you were being this dramatic hysterical female to a T.
I think a lot of older male doctors assume if a young woman comes to see them they’re making up excuses to see them and it’s personal. NO ACTUALLY I JUST WANT PHYSICIAN SERVICES duh. I suppose part of the problem is some women *do this* because they are pathetic and desperately want to be with a doctor on any pretense.
This is why I prefer female doctors. I’ve never had a bad experience with one in terms of being unprofessional or treating me from *their* perspective.
I w
Regarding physical appearance, I didn’t mean to imply that all depressed outpatients are expected to be filthy. It’s just that if a young woman comes in looking attractive and well presented, the whole session becomes about the shrink’s feelings and attempts to cope. This can get you an Axis II diagnosis, and once that’s suspected, it’s not like it’s an either/or situation, either depression or PD, obviously they can and do co-occur, it’s more that once you’ve been branded as personality disordered, everything will revolve around that fact because you are likely to be a poor responder to treatment and you deserve to be burned at the stake. Obviously, people with PDs are at a greater risk for Axis I disorders.
It’s like in medicine if you have a patient with diabetes, you don’t want them to “prove” they are diabetic by having them come to the ER in ketoacidosis or a hyperglycemic crisis, you want to pay attention to their complaints of thirst/blurry vision/hunger/weight changes and slightly high A1C and elevated postprandial sugar so that you can treat them and keep them healthy and teach them about diabetes control and encourage them to follow it so they don’t end up on a medical floor in a hospital.
Unfortunately, this is EXACTLY what happens in psych. Patients’ families often remark that admissions told them their relative wasn’t sick enough for our service and to come back later if (when) they deteriorate. This is the equivalent of saying to a diabetic to come back later once they’re in DKA. So then when they end up in the ER psychotically depressed they have finally proven their bona fides and now we’ll take them. Makes your blood boil really but it’s not like we’re some uniquely satanic treatment centre. This happens everywhere because for the last 40 years we as a society have been pretending that mental illness isn’t real and that when it happens, it should be dealt with only briefly in hospital, followed by community “care” (read: welfare dependence, substance abuse, unemployment, homelessness, criminality). We have been getting rid of psych beds and shunting the money into other areas of medicine that deal with more interesting election issues and where patients actually vote.
Corollary 2(a) of Luke 4:23
(This post & comments has been superb.)
Slainte
So. As a man: Rihanna, yay or nay?
My Maths Prof believed that the student should work it out for themself and then present the result. (The conclusion is left as an exercise . . . . !)
Rihanna ?? Mmmmm
“Those who live by the Butt shall die by the Butt.”
It all very well to shake yr booty, butt unless the promise is withheld, the Booty will not be collected. Madonna did it; but she now well past her sell-by date
RH will never be an Ella Fitz. Madonna did not do it – she could have.
More to a different point, are these Cultural Borderlines actually so, or are they selling themselves to a Borderline audience ?
The post-modern zeitgeist is extra-ordinarily self-referential & self-absorbed.
It all very well to shake yr booty, butt unless the promise is withheld, the Booty will not be collected.
LMFAO. *DEAD*
Are they “for realz” or just lapping it up / catering to the extraordinarily narcissistic zeitgeist? I think if you were to follow Rihanna’s twitter even for a day the question would answer itself.
Refers to Hamlet’s goodbye to Ophelia:
“Sweets to the sweet, farewell”
I have a disabling inability to write anything shorter than like 5 paragraphs so I apologize for TL;DR syndrome feel free to skip anything obnoxiously long/boring/rambling.
Don’t be silly, your comments are gold. You know, it was actually Guyenet’s blog of all places where I first spotted you. It was during the epic Taubes vs. Guyenet (and their homies) war last year. I was like, “Holy fucking shit, this woman is a GENIUS.”
You both write authentic posts about hospital experiences & it comes thro’ in the writing. I have a little insight into this as I once had a lover who did nights on the dying wards. She had tales about quiet painless passings morphine aided.
The first I knew about it would be my awakening at 06:30 with my lady taking us both to orgasm – she to sleep, I off to shower, coffee & work.
Watching it from the outside as it is happening is tragic, especially with these young women who just can’t seem to pull themselves together except in the most rare instances. And I think you nailed what happens to them – hormones, loneliness, and a general lack of attention to feed the psychosis. But it doesn’t make it non-existent, simply because it ceases to be sexy or entertaining.