Phrase of the day: Mall Intervention

Psychosocial Rehabilitation (PSR) Mall

The PSR Mall is a centralized approach to delivering services where the individuals served and the staff from throughout the hospital come together to participate in services. Malls represent more of a centralized system of programming rather than a reference to a specific building or certain location. Mall interventions are provided, as much as possible, in the context of real-life functioning and in the rhythm of life of the individual. Thus, a PSR mall extends beyond the context of a building or “place,” and its services are based on the needs of the individual, not the needs of the program, the staff members or the institution.

PSR Malls are designed to ensure that each individual receives individualized services to promote his increased wellness and ability to thrive in the world. All decisions regarding what is offered through each mall are driven by the needs of the individuals served. Mall services are provided in an environment that is culturally sensitive and strengths based.

Services facilitated through the mall include courses and activities designed to help with symptom management, personal skills development and life enrichment. The mall capitalizes on human and staff resources from the entire hospital to provide a larger diversity of interaction and experiences for all individuals in the mall.

Deus Ex Miller Faucher and Cafferty L.L.P.

Just as I was running out of money (temporarily) because the government thingy was being slow and bureaucratic and dumb, something happens that never, ever happens. I was part of the class in a class action suit against SmithKline Beecham about Paxil. They lied about withdrawal symptoms, essentially.

Based on the (large) amount of money I spent on Paxil over the years, I just got a check for $477.08.

Suck it, Smith and Kline and Beecham. That withdrawal was worth more than $477.08 in pain to me, but I’m glad to have it right now.

good times with little pills

My doctor and I are changing the medications I take to make my brain behave better. This is probably a good thing, and I’m game. Especially since I’m not working right now I can afford to take some chances in order to improve things. Plus: SCIENCE!

The first thing we’re doing is switching out Wellbutrin for a drug called Lamictal. As the “ictal” in the name suggests, this stuff is used to reduce seizures. It’s also given to people with bipolar disease, which I don’t have. However, the problems I do have include some things that bipolar people get too like racing thoughts and mood swings. And this drug is also good for plain old depression, which is one of my symptoms. The other benefit of Lamictal is that part of the plan calls for dumping the Lexapro too, and that is apparently much easier with this stuff added. I applaud that because I tried to quit Lexapro before and the discontinuation symptoms were just as bad as the recurring depression. Ecch.

Lamictal is also a tricky drug. You have to start it very slowly. This is mostly because one of the (rare) side effects is a rash. If you get the rash you stop taking the stuff right away, because it can be lethal. Therefore the FDA requires that you start with a very small dose so that you’ll know to stop it before you take enough to make yourself sick. Good call. Another problem is that Lamictal acts weird with other drugs, much more so than most of its colleagues. A quote from the always useful and amusing crazymeds.org site: “Will interact with medications you aren’t even taking.” Apparently it can also give you headaches. I’d notice that for sure because I never get headaches.

If I don’t get a rash and/or die and if it seems to be treating me well at full dose, then we’re going to phase out the Lexapro. The likely next step is that I will take one of a class of drugs called MAO Inhibitors (MAOI). These have been recommended to me before because of my particular symptomatology. They are very powerful and useful in a lot of cases. Unfortunately, they also come with dietary restrictions. They mess with a digestive enzyme and certain foods become toxic. A lot of good foods: real cheese, red wine, real beer. It’s a huge pain in the ass and a big quality of life hit. I’d also worry that I would just forget and eat the wrong thing and die.

The good news is that one of them is now available here in a patch. The patch makes the dietary problems way less, especially at low dosages, because it’s not mixing up with food in the gut. So I might be able to get the benefit of the MAOI without dying or giving up lots of foods.

The whole business is tricky and complicated. I trust the guy who’s working on it to know about as much as anyone in the field does, but everything is a science project in psychiatry especially when there are multiple drugs going on. No matter what it seems that I’m likely to be on four separate neurologic or psychiatric medications for quite a while, and I wonder if anyone even knows what’s going on.

Here we go…

Reverse engineer your brain

More than 40 years ago, my father wrote a short story called “Dr. Pettigott’s Face.” The eponymous doctor of the story has a theory that pushing the face into happy expressions will make people happy, and has constructed a machine to do this. I remember that for years he had a correspondence with some neuro researcher who was interested in facial expressions because the guy liked the story so much. The title has been a shorthand in our family for people trying to reverse engineer things in weird ways.

The polyvagal theory and some of its implications suggest that there may be a grain of truth in this. The connections between emotion and facial expression are very tight and it’s possible that it “goes both ways”. This story from the LA Times on Sunday is fascinating:

botox for a better brain?

Interesting news from the phrenology ward

Today in a psychotherapy session I was discussing my problems with relationships, and more specifically my lack of intimate relationships. The working theory is that my own emotional life is too intense to communicate to others and that I shut them out in ways I’m not consciously able to control, mostly nonverbal.

This is particularly true if I have an attraction to someone, because my feeling of attraction is tightly coupled with unacceptably strong fear, shame, and self-hatred so that I become exceptionally false and not “present”.

Okay, interesting theory. But what’s the mechanism here? One theory is that the problem lies in the 10th cranial nerve. This is the vagus nerve, which goes to both the gut and the lungs from the brain. The “polyvagal theory” holds that separate branches of the vagus nerve, when stimulated, produce strong and opposed feelings: either you feel very safe, or not at all safe.

This has implications for a number of problems, including some autistic spectrum disorders, PTSD, panic attacks, and social adjustment problems. If the two systems become, as my therapist puts it, “overcoupled”, then it can be impossible to make a serious connection with someone without being overwhelmed by unpleasant emotions. The result is a kind of neural shutdown, which makes people like me seem distant or standoffish when we’re feeling exactly the opposite.

Stephen Polger, the originator of the polyvagal theory, has had some promising results at the University of Illinois treating autism with sound. There are also some suggestions and tips for dealing with these problems in this interview with Polger, which is intended for a lay audience. The other information I’ve found about this so far has been much more technical.

In my own case, since I am not autistic, PTSD, or suffering from panic attacks, the goal is to get the neural function more normal through a combination of neurofeedback, EMDR, somatic therapy, and medication. It’s kind of a science project though, since some of these ideas are very new and raw and will undoubtedly be further refined later.

Elliot Valenstein, the history of lobotomy, and more

“Physicians get neither name nor fame by the pricking of wheals or the picking out thistles, or by laying of plaisters to the scratch of a pin; every old woman can do this. But if they would have a name and a fame, if they will have it quickly, they must do some great and desperate cures.” —John Bunyan

Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness

Interview with Elliot Valenstein on the History of Lobotomy

Elliot Valenstein’s page at umich

The War of the Soups and Sparks, The Discovery of Neurotransmitters and the Dispute Over How Nerves Communicate, by Elliot Valenstein.

Alcohol, table saws, and flannel shirts just do not mix.

mendel send me this medical shop talk forum thread, which contains stories about emergency room patients from doctors and other ER folks on the theme: “Things I Learn from my Patients”.

We’ve all seen the funny/awful lists of things in butts, or heard about lamers who beg for drugs, etc. Hey, I watched that TV show sometimes too in the 90s. I don’t think they ever had a patient on E.R. with a lost TV remote located in an abscessed gluteal fold, though.