Category Archives: Adverse Adult Experiences

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Shame and anger in overuse illnesses

“amongst those who treat addicts of any kind generally agree that anger and shame help no one and is actively counter-productive.”*

Wait.

I have to think about that statement.

I do not agree at all.

Ok, for the physician/ARNP/PAC, anger at the patient and shaming the patient are not good practice, don’t work, and could make them worse. BUT anger and shame come up.

In many patients.

Sometimes it goes like this with opioid overuse: the person shows up, gets on buprenorphine, and is clean.

It may be a long time since they have been “clean”.

One young man wants to know WHY I am treating him as an opioid overuse patient. “Why are you treating me like an addict?”

I try to be patient. I recommended that he go inpatient, because I don’t think we will cut through the denial outpatient. Very high risk of relapse. “You have been buying oxycodone on the street for more than ten years.”

“I’ve been buying it for back pain, not to party.”

“Did you ever see a doctor about the back pain?”

“Well, no.”

“Buying it illegally is one of the criteria of opiate overuse.”

“But I’m not an addict! I’ve never tried heroin! I have never used needles!”

“We can go through the criteria again.”

He shakes his head.

He is in denial. He is fine. He doesn’t need inpatient. He is super confident, gets work again, is super proud.

And then angry. “My family still won’t talk to me!”

“Um, yes.”

“I’m clean. I’m going to the stupid AA/NA groups! Though I don’t need to. I’m fine!”

“What have you noticed at the groups?”

“What a bunch of liars!” he says, angry. “There are people court ordered there and they are still using! I can tell. They are lying through their teeth!”

“Obvious, huh?”

“Yeah!”

“Did you ever lie while you were taking the oxycodone?”

Now he ducks his head and looks down. “Well, maybe. A little.”

“Do you think your family and friends could tell?”

He glances up at me and away. “Maybe.”

“Your family may be angry and may have trouble trusting you for a while.”

“But I’ve been clean for four months!”

“How many years did you tell untruths?”

“Well.”

Shame and anger. Anger from the family and old friends, who have heard the story before, who are not inclined to trust, who are hurt and sad. The first hurdle is getting clean, but that is only the first one. Repairing relationships takes time and some people may refuse and they have that right! Sometimes patients are shocked that now that they are clean, a relationship can’t be repaired. Or that it may take years to repair. My overuse folks are not exactly used to being patient. And sometimes as they realize how upset the family and friends are, they are very ashamed. And some are very sad, at years lost, and friendships, and loved ones. I have had at least one person disappear, to relapse, after describing introducing someone else to heroin. He died about two years later, in his forties.

Shame and anger definitely come up in overuse illness.

The above is not a single patient, but cobbled together from more than one.

______________________

*from an essay titled “F—ing yes, I’m a fatphobe” on everything2.com. Today there are two with that title. The quotation is from the second essay.

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Negotiating peace

I spend a long day wrestling with love
arguing with myself back and forth
I am no angel descended from above
Those undeserving of my love make me wroth
yet my core argues that it still loves them
and agrees their cruelty’s beyond the pale
I snarl and cough and choke on bitter phlegm
Defend my self staying far away and hale
My core agrees I shall not tolerate abuse
Forgive yet we despair we’ll ever reconcile
They show no guilt nor shame for their misuse
My core says let them be: she is so mild
Negotiation done: Agreed. I may love those who I love
But I leave contact with them to the angels and Beloved.

_____________________

Sonnet 10

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Medicare Disadvantage

Medicare Advantage plans, from for profit insurance companies, are being rebranded Medicare Reach.

They seem like a good deal. They are if you are healthy forever! So what is the catch?

In Michigan I go to look at a nursing home with a friend. The administrator shows us around. Small rooms with two beds. We also look at an assisted living. Much larger rooms, the friend can stay overnight in the private room with the parent, at a cost of $4000.00 per month. Her insurance will not cover it.

But back to the nursing home. The administrator tells us that it’s good that her parent does NOT have a medicare advantage or medicare reach plan. “It is nearly impossible to get the insurance companies to approve a rehabilitation stay at a nursing home.”

“Really?” I say.

“Oh, really.” She says. “The insurance companies certainly don’t want you to know that when you buy their “deal”.”

So, the for profit insurance companies want you if you are of medicare age and are well. BUT the catch is that they really don’t want to cover if you are sick. Think carefully before you buy a pig in a poke!

Physicians for a National Healthcare Program is working to stop the insurance companies from skimming profit off the healthier elders and then abandoning them when they are not healthy. I wish that the United States citizens would clue in, get mad, and vote for single payer! Write your congresspeople and put pressure on them! They listen to money but in the end, they live by votes. Make sure you look at the fine print, because the insurance company is there to make a profit off you, not preserve your health.

The picture is Mordechai, our plastic clinic skeleton, distrusting Profit-Over-Health Insurance Companies.

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Walk with rabbits

Some days I can’t chuckle
when the news rolls in
my heart could buckle
shootings again

US gun habits
What’s up doc? Dagnabbit.

Shootings on the year of the rabbit
dancers dead as they celebrate
Why are guns such a habit?
I refuse to fill my heart with hate

Gun sales stab it
Year of the rabbit

Forgive but do not reconcile
let my resolve not buckle
mental health takes a while
let no demented chuckle

Fearful gun habits
online snared like rabbits

They argue they must defend their homes
daughter teacher on the line
fearful males online alone
think that guns will make them fine

Fear is a habit
Stop being rabbits

Leave your basement
Help another
Walk the pavement
Earth as mother

Make it a habit
To walk out with rabbits

_______________________

For the Ragtag Daily Prompt: chuckle.

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Petty lie

What old deep wound causes you
to hurt me and other friends you’ve had
in past. What terrors hidden in that brew
make you glory in making others sad?
You boast to me of throwing people out
of your life forever, never friend
again. You don’t explain what crimes reroute
your heart to where you never speak again
to him or me. How many people discarded
from your heart and at what interval?
How many “friendships” have you departed?
And yet you boast that others call you spiritual.
“Friends forever,” you said. I wonder why
you tell yourself and me that petty lie.

______________________

Sonnet 8

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Immunomodulation

I wrote this for a group of physicians, so it’s heavy on the science. BUT I think everyone can benefit from understanding the difference between the sympathetic nervous system and the parasympathetic. Also, we can survive without the sympathetic but not without the parasympathetic.

My essay yesterday was about antibodies to tubulin, what tubulin is and how antibodies work. This doesn’t seem very useful if the only thing we can do about the antibodies is remove them by theraputic plasma exchange or give anti-inflammatories. However, there are other approaches. As a rural Family Physician, I have an ever expanding toolbox that I learn from multiple specialties and patients. Mothers of children with PANS/PANDAS may already have figured out many of these techniques.

Our bodies have two basic modes for the nervous system. The well known mode is the sympathetic nervous system. This is the amped up fight or flight system. When we have a very activated sympathetic nervous system, we make less thyroid hormone and less sex hormones and switch production to more cortisol and adrenaline. This helped me to understand adult patients who say they are constantly tired, don’t want sex, they keep getting sick and they also have trouble sleeping. Borderline low thyroid, low sex hormones, elevated cortisol and elevated adrenaline, though it may be at the upper range of normal. The sympathetic nervous system readies muscles for flight or flight, turns digestion to low, reduces secretions everywhere (eyes, salivary glands, stomach, gall bladder, urine, etc) and tightens fascia around the muscles. Blood pressure and heart rate rise. High cortisol over time is not good for the immune system.

The other mode is the parasympathetic nervous system. This is the relaxed system. Digestion and urination works well, muscles relax, cortisol and adrenaline come down, thyroid and sex hormones are manufactured. Blood pressure is lower and heart rate is lower.

The first technique I use to change from sympathetic to parasympathetic is breathing. Swedish hospital is teaching the anxious patients, chronic pain patients and veterans slow breathing. Five seconds in and five seconds out. They recommend building up to 20 minutes over time. If done for 20 minutes, they said that almost everyone calms from sympathetic to parasympathetic. Some people endorse square breathing: in, hold, out, hold, in. I did daily Zen Buddhist meditation facing a wall for 40 minutes during college. This also works and some children might find it an enjoyable challenge. I find Zen meditation easier in a group than alone. I asked a 30 year veteran of the Special Forces to try the 5 in and 5 out breathing because he would find his muscles tight just watching television. He was reluctant, but he returned and said that he is surprised that it works. He also said that he is not used to the relaxed feeling and it feels weird.

Other ways of activating the parasympathetic nervous system for adults include walking, rocking, laughing, magazines seem to love hot baths, anything that relaxes. Playgrounds include places to climb, spin, swing and hang upside down, for children to get a break and play. Again, different people find different things relaxing. During my second strep A pneumonia, an antibody titer came back at 600 with normal being 200 and below. I have read that children can have titers of 2000. I could barely function with a titrer of 600 (off work, obviously) and thought that if my titer was 2000 I would hide under my bed and not come out. I would like input from child psychiatry on downregulating the sympathetic nervous system to parasympathetic in children, but my guess would be that a safe place is very important. Where is that safe place for each child and when they are not having a flare, can they practice going to it in their minds?

Another helpful parasympathetic activity is games or puzzles. My father died leaving an out of date will and a difficult estate. For the year that I worked on it, I did a suduko every day. I could not solve the estate quickly but I could solve the number puzzle every day and that gave me a small window of feeling good and relaxation. Board games or puzzles could work as well. I am less certain about computer games: my understanding is that the visual cortex is activated along with other parts of the brain. This seems more sympathetic than parasympathetic but I could be wrong. The familiarity of a video game may feel very safe and more predictable than the illness. Old movies and reading beloved books is parasympathetic for me. Oddly, sex is parasympathetic in women but both sympathetic and parasympathetic in men. Music can relax many people, and repeating the same music or album over and over. Comics and silly cat videos are parasympathetic.

As a physician, I often acted in a high sympathetic nervous system. A friend of my son’s said, “Your mother is crazy.” My son replied, “No, she’s just intense. About EVERYTHING.” I had to learn not to be intense about everything. We can model relaxation and parasympathetic activity and slowing down for our children, but we may have to set more boundaries at work.

Here is the best write up I have found on the internet about the parasympathetic nervous system: http://www.wisebrain.org/ParasympatheticNS.pdf. They have a great explanation as well as exercises to calm to parasympathetic.

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Arty’s warning

Trigger warning: non graphic mention of child abuse.

_____________________________

I don’t notice that things are frozen at first, because the cats aren’t frozen. I do notice the light. Also I notice the change in sounds. The car outside in the street is not moving nor making sound. Uh-oh.

I go to the front door. Might as well if everything is frozen. I just finished putting on make up, which always means a dangerous mood.

She lands first, on a white flying horse. Who smiles at me, showing fangs. Smoke is coming out of the Pegavamp’s nostrils. Eeeee.

Arty herself is in silver and black today. Silver cloth with black embroidery that seems to be writing a little.

“Good morning, Goddess.” I say, bowing. The other horses and dragons and flying motorcycles and pterodactyls are landing as well. Sol Duc is in the window. Elwha has gone to hide, quite sensibly, I think.

Arty stomps her staff on the ground. “I am really pissed.” she says.

“They named a rocket after you.”

“That penis toy? That is supposed to please me while they are killing virgins who refuse to tent their heads?”

“Sorry.” I hang my head.

“And do you know how much the smoke is going to shorten the lives of my birds and stags?”

“A lot, I think.”

“Do you all want to starve in the dark?’

I look up at her then. “No. I want grandchildren and a healthy earth.”

“Work harder.” she snarls. The rest of the dangerous crowd is muttering and snarling and the local cats have come out. They are sitting very respectfully at a distance. Rooftops. The ridge above my house three blocks up. The tree tops are frozen too.

“Do you need prescriptions again?” I ask. “I see that there have been a lot more rapists jailed. Thank you, Goddess.”

She looks tired for a moment. “We are hunting them everywhere: cities, countryside, hovels, palaces, movie sets, where ever.”

“You don’t turn them into stags any more?”

“Yes, sometimes. My hounds love to tear them apart. But sometimes prison is slower and crueler and a better punishment.”

I kneel. “What service can I do, Goddess?”

She touches me with the staff. I feel a hard bright shock, pain that roars through me and is gone.

“Write this. Write my warning. If this continues, it is death in the cold dark of nuclear winter and we will begin again.”

“Is that the only choice?”

“Oh, no, we are all being very creative. One suggestion has been the sperm banks. There is nothing that says they can’t be used to make one gender only. The one that rapes less and doesn’t kill young girls for what they wear.”

“Thank you for your warning.”

“Stand up.” she says. “You and every abused child, male or female, are under my protection. Yet the cycle must be broken and the abused must not become abusers. Write this.”

The Pegavamp drops one knee and she steps up easily. The other riders start to roar and shout and howl. Her winged creature jumps in the air and the whole group follows. There is a snap and they are gone.

The car in the street is moving and the treetops as well. The cats stand and move away.

I keep writing.

___________________

October 22, 2022

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Embodying a dream

I wrote about the two dreams I had one night, with seven people. Two babies, a boy and a girl. Two professionals, a woman physician and a male policeman. Two rebels, a woman and a man, the man lying or at least misleading the rebel woman. The rebel woman trying to do something that she suddenly realizes is not important and is, in fact, foolish and dangerous. And a quiet woman.

I have been thinking about the quiet woman ever since. My Meyers-Briggs type in medical school came out INTJ, but we are not one thing or another. We have preferences, but we all have to use all the skills. I can be extroverted. I had to work on feeling, that was the really difficult one for me after a frightening childhood. I can pay attention to facts though I sweep them into the intuition very quickly. Medical school is facts and facts and facts, except then there are parts that turn out to change as science changes.

The eighth person is a quiet man. He is not present in the dream. I am thinking about him. I wonder if I will have another dream when I am ready.

I am attending some workshops on line for treating trauma. It is quite fascinating. They talk about working with clients who have aspects like my dream: a small child with trauma. A “fake adult”, aka “adaptive child”, with the tools that the child develops to survive in their childhood. Helping the “fake adult” recognize that some of coping tools may not be helpful or necessary any longer. First, they thank the “fake adult”, for protecting the traumatized child and for surviving at all and for not giving up. I think this is so important, to acknowledge that we have to thank that part of ourselves that did what it had to, that did what it could, to survive. And this can include things that we are ashamed of or fear that others would hate us for if found out. We had a temporary doctor at the hospital who described being a boat person escaping Vietnam at age 8. They were picked up by pirates. “We were glad to see the pirates, because we had run out of water. If the pirates had not picked us up, we would have died.” So there is perspective: death by dehydration or pirates? And she went from a refugee camp and then through medical school and became a physician. Survival and success and I hope that she is thriving.

I like it when a dream has such recognizable symbols. My now retired Unitarian Universalist minister says that we can sit with dreams for a time. What do the symbols mean to me? What is the dream telling me? My dream is in part telling me that I do not need to have the rebel woman lead: she can rest and let the quiet woman take over. And that I am very tired of rebel men who mislead me or run away. I woke up and thought, oh, yes, I see! I am tired of that and ready for change.

Change and transformation can happen throughout our lives, at any age. I welcome it.

Blessings and peace you.

___________________

The photograph is Sol Duc and Elwha enjoying doll bunkbeds. And acting like siblings do sometimes. And then they curl up together.

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Arty scores some ludes

Trigger warning: non graphic mentions of date rape, child abuse. A dark story for the Halloween season.

_______________________________

Mr. Smith is telling me about his daughter’s addiction to meth when the commotion starts.

He doesn’t seem to notice. I ignore sirens because the fire house is 6 blocks up the street, but I hear hooves. And people in the waiting room. Loud.

And Mr. Smith…. appears to be frozen mid-sentence. Uh-oh.

I am not frozen. I open the exam room door.

Artemis is there. Breastplate, feather headdress, inlaid turkish recurve bow, and she is not wearing a lady like toga. She is wearing armour. She is grinning at me.

There are lots of people milling around the exam room. Horses outside. I suspect 200. Or more.

“Quaaludes.” says Artemis.

“Ok.” I say. “Um.” I am thinking about the DEA. I get my paper prescription pad. Controlled substance, of course.

“We’re going to do a little pillaging.” says Artemis. “Kind of like date rape. Only in reverse.”

“Happy to help.” I say. “Uh, Bill?”

Artemis grins. “Well, he’s not the only one. You’d… well, you probably wouldn’t be surprised, would you.”

“No,” I say grimly. There are men in the waiting room too. That’s a bit of a surprise. I know two of them. Attended their funerals. Aids.

“I need enough for all 200 to…. well, discourage date rape and Cosbying.”

“So 600? Or 1000?” The DEA will throw me in jail. I write the prescription. Artemis touches it and it blooms in her hand, to 200 prescriptions.

“Don’t worry. The pharmacy is in Hades. The earthly DEA won’t have a problem.”

My receptionist is frozen too. I nod towards Artemis’s band. “I thought it was virgins?”

“We were all virgins once,” says Artemis, fierce. I can’t argue with that. She smiles again. “Thank you. We are going to have some fun. Sweet sweet revenge.”

I don’t really want details. My imagination is way too active. “Blessings.” I say.

“You too.” She turns, holding up the prescriptions. “Mount up!” Two women are riding velociraptors. Some of the horses have wings and other have horns. Three glow red and breathe fire. Some people are riding stags. They all have bows.

“You do need a bow.” says Artemis, looking back at me. “You’re a good shot.”

“Ok,” I say. I watch them leave in the air. The air starts looking a little thick and I go back in the room with Mr. Smith. I return to my position as best I can remember and then…

Mr. Smith is talking again.

__________________________

First posted elsewhere 2015.

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Practicing Conflict

An essay from my church talks about the writer avoiding conflict, fearing conflict and disliking conflict. This interests me, because I do not avoid conflict, I don’t fear conflict and actually, I like it. Our emeritus minister once did a sermon in which he said that when you are thinking about two conflicting things at once, that is grace. I have thought about his words many times, especially when I am not in agreement about something.

Does this interest in conflict mean I fight all the time? Well, sort of, but not in the way you think. I don’t fight with other people much. I fight myself.

What? No, really. Most topics have multiple sides. Not one, not two, but many. Like a dodecahedron or a cut gem. Hold it up to the light, twelve sides, each different. I argue the different sides with myself.

I learned this from my parents. My parents would disagree about something, they would discuss or argue about it, and then they would bet. Sometimes they bet a penny, sometimes a quarter, sometimes one million dollars. Then one of them would get up and get the Oxford English Dictionary, or the World Atlas, or some other reference and look it up. This was pre-internet, ok? 1970s and 1980s.

Sometimes my parents would even pay each other. The penny or quarter. My father spoke terrible French and my mother had lived in Paris for a year after high school, so he could get her going by insisting that his French was correct. It wasn’t. Ever.

There were other arguments in the middle of the night that were not friendly and involved yelling, but the daytime disagreements were funny and they would both laugh.

Once my sister is visiting after my mother has died. My father is present. My father, sister and I get in a three way disagreement about physics. I’m a physician, my sister was a Landscape Architect and my father was a mathematician/engineer, so we are all three talking through our hats. However, we happily argue our positions. Afterwards, my gentleman friend says, “That was weird.” “What?” I ask. “That was competitive and you were all arguing.” “It was a discussion and we disagreed.” “I won’t compete.” “We let my dad win, because it makes him happy.” “That was weird.” “Ok, whatever.”

My gentleman friend is also shocked when my teen son challenges me at dinner. My son says, “I am researching marijuana and driving for school and there isn’t much evidence that it impairs driving.”  I reply, “Well, there is not as easy a test as an alcohol test and it was illegal, so it has not been studied.” We were off and having a discussion.

Afterwards my gentleman friend says, “I am amazed by your son bringing that up. We weren’t allowed to discuss anything like that at dinner.” I say, “We pretty much discuss anything at dinner and both my kids are allowed to try to change my mind. About going to a party or whatever.” He shakes his head. “That is really different.” “Ok,” I say.

This habit of challenging authority, including adults, did not go over well when my son was an exchange student to Thailand. It did not occur to me to talk to him about it. He figured it out pretty quickly.

Back to my internal arguments. If I take a position, I almost immediately challenge it. I think of it as the old cartoons, with the angel on one shoulder and the devil on the other. The devil will make fun of things and suggest revenges and generally behave really badly. The angel will rouse and say, “Hey, you aren’t being nice.” Then they fight. The internal battle very quickly becomes comic with the two of them trading insults and bringing up past fights and fighting unfairly. When it makes me laugh inside, I can also be over the driver who cut me off, or someone who spoke nastily, or whatever. My devil is very very creative about suggested revenges. When the angel says, “You are meaner than the person who cut you off!” I am over it.

When I was little and disagreeing with my family, my sister could tell. “You have your stone face on!” That meant I was attempting to hide a feeling, especially fear or anger or grief. Siblings and family are the most difficult because they can read us and see through us like glass. My physician training also teaches control of feelings. I have sometimes wanted to grab a patient and scream “Why are you doing this to yourself?” but that really is not part of the doctor persona. I am doing it inside, but I can put it aside until later. Then the devil goes to town! And the angel tries to calm the devil down.

Maybe we all need more of this skill. Pick a mildly controversial topic. Argue one side of it. Then switch positions and argue the other side. Go back and forth until it gets ridiculous. Let each side get unreasonable and inflammatory and annoying. This can play in your head and not on your face. Once you can do a mild topic, move on to something a bit more difficult. If you only know the arguments on your side, read. You can find the other side, the internet is huge. Start gently.

A friend says, “You always argue about things.” I say, “I prefer to think of it as a discussion.” “You always take the other side.” “Well, it interests me. And if there is no one to discuss something with, I discuss it with myself!” “Weirdo,” says the friend. I think he’s jealous, really I do. Don’t you?