Ron Norman  


2305 Camino Ramon, Suite 221
San Ramon, CA 94583 (925)264-4069

 
line decor
  Jun 24, 2017
line decor
Psychopharming – thoughts on psychiatry and quality of life

Finding Health in the Psychiatric Patient:

The Psychobiological Modules as a Clinical Compass
by Sarah Perrin, OMS III,  Touro University-CA

Finding health should be the object of the doctor. Anyone can find disease.
-Dr. A.T. Still (1828-1917)

Classification of disorders in psychiatry began in the mid-1800s as a means for the collection of statistical data. The first Diagnostic and Statistical Manual of Mental Disorders was published in 1952. In 2013 the transition from DSM-IV to DSM-V was made but with few appreciable differences.  Some arbitrary lines were erased-the bereavement exclusion was removed from the criteria of Major Depressive Disorder. Some new differentiating designations were made-Panic Disorder and Agoraphobia are now two separate entities with separate codes as opposed to overlapping ones as in DSM-IV.  The diagnostic sensitivity for some disorders has been increased by removal of a criterion or by increasing the applicable age (as with ADHD). Other significant changes included disposing of the subtypes of schizophrenia and the lumping together of Autism Spectrum Disorders.

Like the DSM-IV, the DSM-V serves as a guide for ICD-coding and to provide labels that allow providers to communicate a patient’s history efficiently.  What the current classification system does not provide is insight into the nature and pattern of the dysfunction. The DSM is not as useful for making clinical diagnostic and treatment decisions as it could stand to be.

In Dr. Levin’s AMPERIC Model, seven psychobiological modules are identified. They include the Arousal system, the Mood and Reward system, Perseveration system, Executive function network, Reality testing system, Interpersonal skills system and cognitive system. Simply put, a deficit or abnormally high activity in one or more systems can lead to symptoms. If the symptoms are such that the patient has difficulty functioning in their environmental contexts, a disorder is present. The closest we have come to looking through the psychobiological lens in DSM-V was the placement of Gambling disorder among the Substance-related disorders, because the shared feature is implication of the Reward system. The details of the healthy and dysfunctional states of the seven brain modules can be found in Dr. Levin’s proposal of the new classification system. Here we consider how this model aids the physician in finding the health of the patient. Health can be described as when the constellation of symptoms are so well controlled that they do not interfere with functioning in the patient’s environments.

Though there are disorders that involve patterns of dysfunction in more than one of the seven modules, it is rare that a patient would have deficits or dysfunction in all systems. In fact, patients can sometimes compensate in one system, to some extent, for deficits in another. An example of this might be a child who has symptoms of ADHD with high arousal (hyperactivity) and low executive function (regulation control, attention) but with robust enough interpersonal and cognitive skills to navigate his environment somewhat effectively. With a thoughtful patient interview both dysfunctional and healthy modules can be elucidated. In the intake interview purposeful questions are aimed not only at finding out which systems are contributing to the patient’s difficulty functioning in their environmental contexts, but also at finding out which ones do not. Questions like, “What are you good at?” and “What do you like to do?” can be as telling as “What would like to change about yourself?” The patient benefits from having both what is disordered and what is healthful identified.

The way in which the current classification scheme of the DSM describes disorders presents a twofold problem for treatment. It is not organized in a way that lends itself to clinical extrapolation about potential pharmacologic or other therapeutic treatment intervention. Furthermore, once a diagnosis is received, the treatment administered will often be a response to the diagnosis rather than a response to the dysfunctional system. While the particular medication that will work best for an individual patient cannot be determined by establishing which system is malfunctioning, we will be guided to potential pharmacologic interventions because we know enough about the structure and function of those systems. Clinical judgment and our interpretations of the literature will take us the rest of the way to the treatment plan and ultimately the patient’s health. Presently it is all we have because DSM-V makes no attempts to guide us there. Classifying dysfunction in terms of Psychobiological Module it manifests from shifts the goal of  “finding the health” into focus which, after all, is the object of good medicine.

Is Depression an Adaptation?

By Ms. Cynthia Kim
DO Candidate, 2017
College of Osteopathic Medicine
Touro University-California

Depression, a pathological state defined by low mood or anhedonia, is universally viewed in a negative light as a mood disorder. Despite the view of depression as an unfavorable defect, there seems to be additional research with strong arguments in favor of depression developing as an adaptation. As the most complex organ in the body, the brain holds monumental complexities, which are reflected in the inherently difficult analysis of depression. Given the brain’s complexity and its residual effects on the rest of the body, a number of researchers have embarked on efforts to identify the possible causes and benefits of depression. In the following paragraphs, we will explore the adaptation hypothesis using Dr. Randolph Nesse’s article “Is Depression an Adaptation?

Dr. Nesse makes a number of persuasive arguments for the adaptive quality of depression.  He acknowledges many possible ways in which actions exhibited by depressed patients may have evolved out of necessity such as communicating a need for help, signaling yielding in hierarchy conflict, and fostering disengagement from unreachable goals. He argues that low mood provides a coping mechanism, allowing one to detach from unfavorable situations. The disengagement from unreachable goals provides individuals with exit opportunities and allows them to conserve their efforts in favor of a more attainable pursuit. The advantage of preservation of energy in low mood is also demonstrated by the theory of foraging. An organism will give up a patch of land and search for an alternative source when the rate of return of food is low. Alternatively, the organism’s continued fruitless efforts to forage for food in a depleted patch are detrimental to its survival.

Aligning with Dr. Nesse’s view of depression as an adaptation, one can compare the functional qualities of depression with that of physical muscle movements. The muscles in your body have adapted in a multitude of ways to manage the daily rigors placed upon them. Similar to your muscles, your brain is expected to handle and survive varying levels of stress. Depending on one’s medical and genetic history, clinical depression can occur when an individual faces an extended period of increased stress that exceeds their personal limit.  This phenomenon mirrors that of muscle injuries when individuals over-exert their bodies. When placing excessive strain on a muscle, your golgi tendon sends a message to the brain, inhibiting contraction and relieving tension. If the individual decides to push the limits of this stress management, physical injuries occur. Similarly, low mood creates a feedback response to disengage from the stressful situation. The inability to disengage for an extended period of time can lead to clinical depression.

The continued exploration of low mood and depression as positive adaptations is crucial to our understanding of the human psyche. As our society continues to transform from a physically dominated one to a mentally rigorous one, the ability to cope with stress and manage emotional well-being will be increasingly valuable. Thus, we can expect to see not only increased occurrences of diagnosed depression but also increased ability to handle mental challenges across individuals. Continued research on this topic will ideally contribute to our ability to prevent, correctly diagnose, and treat those suffering from depression or low mood. 

Personality Disorders: DSM of Harry Potter

Written by
Ariff Mohamed Moolla, OMS III
DO/MPH Candidate of 2016
Touro University College of Osteopathic Medicine, CA

Piggy-backing off my classmate’s last post about The Power of Analogy, I wanted to write (and doodle) about a topic in psychiatry using an analogy. I find the idea of using characters from the magical world of Harry Potter intriguing for this blog entry (secretly because I was attracted to the idea of doodling them).

Personalities

Personality disorders are permanent and maladaptive traits that define the way a person is. They are egosyntonic meaning that they are so engrained in an individual’s personality that one does not see it as a problem (making them harder to treat).

They are divided into three clusters –

Cluster A – Paranoid, Schizoid and Schizotypal. These disorders reflect the “weird.”

Cluster B – Anti-social, Borderline, Histrionic and Narcissistic. These disorders reflect the “wild.”

Cluster C – Avoidant, Dependent and Obsessive-Compulsive. These disorders reflect the “weak.”

Beginning with cluster A, Paranoid Personality Disorder are individuals who are mistrustful, suspicious of others and usually interpret benign behaviors as malevolent. Such traits make “Mad-Eye” Moody and his catchphrase of “Constant Vigilance” a good analogy for Paranoid PD. Having encountered many dangerous experiences through out his career, Alaster “Mad-Eye” Moody was hyperparanoid, and thought by many as being delusional. He prepared his own meals and drank only from his personal flask in case someone was trying to poison him. He was also very distrusting of most people, attacked a witch who shouted “boo” at him on April Fool’s Day and even destroyed a birthday present believing it was a cleverly disguised basilisk egg.

People with Schizoid Personality Disorder do not desire or enjoy social relationships and often don’t have any close friends. They will often seem to be aloof and have no tender or warm feelings towards others. Severus Snape fits this description – He is aloof, avoids others, speaks very little. And, between his unstable home life, constant teasing growing up and rejection/death of the only person he ever truly loved, his schizoid personality starts to make sense. 

Individuals with Schizotypal Personality Disorder have interpersonal difficulties similar to those of the schizoid personality, while exhibiting odd beliefs or magical thinking (such as being clairvoyant/telepathic). Very few in the magical world of Potter-verse are as schizotypal as Luna Lovegood – just imagine her talk about “invisible Wrackspurts floating through your eyes and making your brain go fuzzy.”

In cluster B, individuals with Anti-Social Personality Disorder have no regard for the rights of others, are impulsive, and lack remorse. I am not even going to try hard to convince you that these traits are pathognomonic when it comes to describing Lord Voldemort.   

Borderline Personality Disorder has the core features of impulsivity and instability in relationships, mood and self-image.  All these traits stem from the primary fear of abandonment. These individuals attempt suicide in order to seek attention and frequently exhibit “splitting” (either something/someone is awesome or horrible). These traits make Moaning Myrtle a likely candidate with her affective instability, inappropriate anger, recurrent suicidal threats and seeing people as all good or all bad.

Histrionic personality disorder is a disorder applied to people who are overly dramatic, attention-seeking with excessive contrived emotions, over-the-top actions and hyper-sexuality. They use their physical appearance to be seductive and behave very theatrically. Again, I do not need to try much harder to convince you that the over-the-top and seductively dressed Bellatrix Lestrange fits this personality disorder. She craves her master’s (Lord Voldemort) attention and is very upset when she doesn’t receive his approval.

People with Narcissistic personality disorder, much like Gilderoy Lockhart, have a grandiose view of their own uniqueness and abilities and they are often preoccupied with fantasies of great success. They are self-centered, require constant attention and admiration, and they believe that only the elite can understand them. These traits primarily stem from a lack of empathy central to Cluster B. Lockhart builds his fame on the achievements of other wizards in Potter-verse and uses that fame to take advantage of others.

Lastly, we have Cluster C. People with Avoidant Personality Disorder are shy, fear criticism, and have a constant feeling of inadequacy. They desperately want friends but avoid them for the fear of rejection. Though Hagrid has found many friends in his life (Harry, Ron, Hermoine, Dumbledore, etc) – his personality and secluded occupation as the Keeper of Keys at Hogwarts does have many similar characteristics to an avoidant personality.

Dependent personality disorder lack self-confidence and lack a sense of autonomy. They see themselves as weak. They have an intense need to be taken care of. They can’t be alone and are filled with fears of being left alone to take care of themselves. Peter Pettigrew shows his need for a relationship by how he worships his master Lord Voldemort in the series. It is not out of affection but out of fear – since his need to be taken care of and not be left alone is so severe.

Then we have the Obsessive-Compulsive Personality Disorder. People with this personality are perfectionists, preoccupied with details, rules, schedules, etc. The preoccupation with orderliness and control is so intense that it is at the expense of efficiency. Dolores Umbridge is a perfect fit – she needed everything to go her way. She needed to be in complete control

I hope any reader enjoys my analogy of personality disorders through the lens of Potter-verse. I apologize if my imagination got carried away but this was done in hopes to bring some levity to this topic. In spirit of the series of book I grew up with, I would like to conclude this post by reciting phrase that reveals the contents of Marauder’s Map – “I solemnly swear that I am up to no good.”

 

The Power of Analogy (by Jeremiah Pamer)

When I was a younger some of the best times with friends involved philosophical meanderings that only a teenager could sincerely believe were original revelations. An idea that I “happened upon” was based on the premise that all of the physical tools we used in the world (hammers, pulleys, fasteners, wheels, and even motors share mechanical principles with the highly conserved “9+2” arrangement of the flagella) could be traced back either in direct or indirect etiology to an anatomical structure or functional component. At the time I was not filled with a burning desire to be a physician and my knowledge of the history of anatomical studies — one of the ancient scientific disciplines was all but unknown to me. But, even at that supremely awkward season that is post-pubescence, I was in love with the idea of knowing and interpreting the world through analogies and metaphors. If I had only read something like this fascinating article by Robert B Trelease, Ph.D, that discusses how to bring the storied history of thousands of years of anatomical study into the informatics age. I did not know it at the time, but the driving force that pushed me into medicine was germinating even back then. As I’ve gone through years of intensive training one tool that has proven to be invaluable is tying abstract ideas to familiar ones – better comprehension through analogy.

Analogies can serve more than one function – this excerpt from this collection of articles detailing medical analogies and their various functions details how the man who first came up with the stethoscope did just that:

In 1816, I was consulted by a young woman labouring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned [application of the ear to the chest] being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, and fancied, at the same time, that it might be turned to some use on the present occasion. The fact I allude to is the augmented impression of sound when conveyed through certain solid bodies, – as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a sort of cylinder and applied it to one end of the region of the heart and the other to my ear, and was not a little surprised and pleased, to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear.

Not too dissimilar to the penchant the general public has for consumption of “top 10” or “top whatever” lists is our ability and sometimes, compulsive need to quantify all aspects of life. Analogies are just this same pattern of comparison but instead use the ability for comprehending a novel process by associating it with a known process

Just as the movement of the thorax and the hundreds of individual components all moving in concert to allow us to breath is fascinating on a level that elicits contemplation concerning the origins of us as individuals and species; so much more is the wonder of the human mind. A mind that has, in billions of individual brains throughout history, proven to have a pattern of using analogies to understand new or perhaps, more abstract concepts. Elegant analogy employment sees two normally disparate things provides a relationship all in the aim to provide understanding about one of the processes not in merely an additive way, but in a synergistic manner.

Now I am a medical student, a little over a year away from actually being a doctor. I have spent countless hours studying anatomy and the relationships between structure and function. While it is notoriously difficult to learn the relationships between the startling distinct components of the central nervous system compared to, say, testing for ligament damage in a knee, recognizing both is a huge component of psychiatry — it is the recognition of dysfunction and the discernment between acceptable parameters and pathologies. It is this ability to discern which has resonated with me more than anything in my time spent with Dr. Levin for the past month.

I now see certain childhood behavioral issues not as a collection of neurotransmitter issues and immature prefrontal cortices (of course, knowing these things is imperative – and at certain stages, communicating with patients and patient’s families using analogies becomes valuable, once the practitioner masters a concept) but as a powerful muscle car with a ridiculously reactive accelerator, coupled with weak brakes, low-fidelity steering and of course, an inexperienced driver. While it is helpful for me, as a student, to see these things in simplified terms, I have witnessed numerous worried parents come to a better understanding of what their child is going through. They see them as a vulnerable child trying their best to operate a car that is years beyond their level of capability. Of course this doesn’t excuse bad behavior, but a working analogy can serve to guide a parent in how best to manage behavioral issues.

While describing a blood vessels as pipes that carry water in a house miss much of the vital function that blood vessels can serve, such as constriction, dialation and even allowing cells to go right through their walls, we can all agree that the basic function is very similar to our home’s water pipes. And so I will leave you with this: an analogy is like a car; if you take it too far, it will break down.

Learning wariness of emotions and the elegant balance between function and dysfunction

Treating children medically has a special dynamic in that while the reward for success may be sweeter, the pitfalls are just as hazardous and, in my mind, potentially terrifying. Just as a community especially mourns the death of a child in a way that reflects the loss of an unlived life, the reverse is true when “saving” a child from impending doom.

Dr. Levin sees many children in his practice and observing his demeanor and ability to connect with an otherwise uncommunicative angst-ridden teenager is nothing short of awe inspiring. And, of course each patient is different and requires individualized contemplation concerning treatment plans and communication methods, a common thread is reminding the teenager not to trust their emotions. This is a lesson that all of us, on some level can appreciate – I know I can, and should be more mindful that emotions are reactive and not always from a good-natured wellspring. Like most adults, I survived the teenage years with minimal grace and elegance – partly to the fact that I trusted my emotions. What else are they there for if not to guide my immediate decision making process? That is a good question, although, practically it hardly matters why they are there and why they can be so unbelievably overpowering – it is what we do with them that partly determines our course in life

There is a term called “depersonalization” that describes a disorder characterized by persistent or recurrent feelings of detachment from one’s self or environment, where they feel separated from their own bodies and mental processes – often described as if they are watching themselves as a moviegoer would watch a film. Episodes are often accompanied by anxiety or panic, coupled with the fact that episodes also are more common during periods of stress. Diagnosis requires that episodes be persistent or recurrent, as transient systems. I bring this dynamic to light to illuminate the delicate balance between a utilization of some tools/behaviors associated with “depersonalization” and actually having functional impairment due to “depersonalization.” Obviously, to be able to understand that emotions are not to be implicitly trusted and to be able to actually be wary and thoughtful in the face of overwhelmingly powerful emotions takes executive function capacity that can be similar to what occurs during “depersonalization.” Does an ability to distance oneself psychologically from endogenous emotions lead to a “depersonalization” disorder? Inherent in this line of thinking and questioning is the crux of the art of medicine as employed in the field of psychiatry

Medications and when to use them and when to not use them, awareness of contraindications and all the other minutiae is hardly an art – incredibly important, yes but the difficult part is discernment. And, a big part of this discernment is parsing functional impairment from a normal variant comprising the same behaviors and thought patterns. If a child presents with wheezing and shortness of breath to your clinic, getting an oxygen saturation level quantifies the level of functional impairment, and assuming that this child didn’t just come from flat out sprinting for the last 5 minutes, discernment between physiologic and pathologic hypoxia is not a difficult decision. A patient that presents to the psychiatrist’s office with certain complaints, it is not always obvious, at first, whether the issue is physiologic (normal variant) or pathologic (functional impairment) and there is no analogous objective test like an O2 saturation test to easily and quickly make that judgment. Instead, the physician must rely on the patient’s narrative and reporting

This reliance on the patient for any and all feedback other than observation of in office behavior and affect is scary for me, a medical student. Much of my clinical training has taken place in facilities that almost exclusively treat the most depressed segment of the socioeconomic class of our society. Often, for these patients, life is comprised of survival tactics and crisis mitigation and energy and money that others are able to devout to their mental health is just not there. My time in Dr. Levin’s office was one of the first times where I felt like most of the patients were people I could easily and effortly identify with, people with whom I had much in common. On some level, it was most excellent for me to take part in less crisis management (as most of my training has centered around) and engage in subtler care of any given patient. Hearing parents describe how small dose regimens of methyl-phenidate has allowed their daughter or son to become a good student is very gratifying. To be able to work with parents who are themselves capable and highly functioning citizens is also comforting and allows for hope. If one’s worldview is constantly being shaped and molded by current experience and surrounding, mine has shifted into a much more hopeful place – which, considering I’ve spent the last month in a psychiatric office, is significant.

Jeremiah Pamer
Touro University OMS3

Verbal Math and Autism Spectrum Disorder

It is well known that children on the spectrum do not follow the same developmental path as their neurotypical peers. Dysgraphia (a learning disability that affects writing), apraxia (a disorder of motor planning), and dyslexia are common learning disabilities that are often associated with  this group. Young children, especially, struggle with the mechanical skills, and resist any task requiring handwriting.

The prevailing thought is that children hate math. You hear it all the time – children find math frustrating and boring, and refuse to do their worksheets or learn multiplication tables. In a seminal work titled Mathematical Talent Linked To Autism, published in Human Nature Journal (July 3, 2007),  researcher Simon Baron-Cohen and colleagues demonstrated a five-fold increase in mathematical talent in an autistic population versus a control group of non-autistic children. The spectrum group demonstrated higher interest in systematizing and quantitative skills. The study concluded that Asperger syndrome [Autism Spectrum Disorder] is not a barrier to achieving maximum potential in systematizing domains such as mathematics, physics, or computer science. And yet, these children often do not perform well in math.    

When children approach math in a different way, they take it with ease and enthusiasm. In most public schools, teaching of math involves copying long pages filled with math problems, showing work, and writing down answers. It might be an impossible task for a child with poor fine motor skills who find handwriting tiresome. These children would dislike arithmetic not for their lack of skill, but because they find traditional math exercises so tedious. Children with reading disorders won’t do well either. They will struggle to understand written problem before even attempting the math portion.

The Verbal Math Lesson Series, an innovative and unique set of three books, avoids these pitfalls and teaches children to do math mentally. There is no need for paper and pencil, and no need for copying problems from the worksheet to paper. They only need to focus on math and nothing else.  

Verbal Math Lesson Books are engaging and easy way to teach children on the spectrum and those with vision problems, reading and writing disabilities.  Verbal or, as it used to be called, Mental Math is neither new nor untested. In fact, in the nineteenth century, elementary math was successfully taught this way. With the availability of low cost paper and pencils, the method was all but forgotten, only to be resurrected in this century by math enthusiasts. 

Here are the ways verbal math can help your child:

1)  Handwriting is the barrier to young children learning math. The Verbal Math Lesson Books address this issue directly. The books completely remove handwriting from the process of learning math, allowing the child to learn concepts without usual frustrations. They learn to visualize numbers in their heads, and don’t have to worry about having to write anything down.

2)  Children with ASD crave predictability, system, and structure. Often, their world is chaotic and confusing with ever-changing scenery and rules. These children like familiarity and prefer simple repetition and gradual approach to flood of instructions and numbers. Common Core standards for math place emphasis on verbose conceptual explanation of mathematical principles. In combining equal portions of language and math, the latter loses. Children on the spectrum get overwhelmed easily with this approach.

The Verbal Math series uses an intuitive approach to math, starting with simple and familiar exercises and movies steadily to more complex concepts. Most basic mathematical concepts are already programmed in children’s minds and don’t require elaborate explanation.

The Verbal Math Lesson program is a clear, and brilliantly structured program. It naturally leads children from one concept to the next. In a step-by-step fashion, each chapter builds on concepts learned in the previous chapter and book. There is no confusing or irrelevant information – just a focus on important concepts, and quiz-like questions to reinforce them.

3)  The Verbal Math Lesson helps build better auditory processing skills and sustained auditory attention. Because the books are taught completely verbally and without the use of pencil and paper, children do not split their attention on multiple tasks and focus on what you, the instructor, is saying. They learn to focus on what is being said and not get distracted by “busy” pictures, words, and numbers on a page.

4)  The Verbal Math Lesson can be taught by anyone, in any setting. The book requires no special props, anything in your view (paper clips, matches, toothpicks, etc.) can be used as a manipulative. No educational credentials are required – anyone can teach math! The books can be used at home or in waiting rooms. The teaching methods are self-explanatory and the books are compact and easy to use.

The Verbal Math series is unique – it presents math in a way that other books and classrooms do not. The books are affordable and comprehensive but most of all practical. Verbal Math skills are essential. After all, math we need for daily life (adding items on the bill, calculating discounts, figuring out tip, etc.) we do in our heads, not on worksheets.    

To find out more, visit www.MathLesson.com   

The masthead painting is by Ron Norman, a well-known artist of California landscapes.