The chances of a poet reaching us are slim

I wrote this after working at Madigan Army Hospital in 2009 for three months as a temporary doctor. I am posting it here because Shoreacres sent me this link about poetry and medicine.

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I would pray if I could. It seems ludicrous to pray for a poet, but there it is.

It started with two soldiers. The Army was embedding a behavioral health specialists (the new politically correct term for mental health specialists) in units starting before 2010. Soldiers were trained in suicide prevention, instructed to stay with a buddy if they made any comments about suicide. A soldier was to walk his or her buddy directly to the behavioral health specialist or to to higher rank. As soldiers went on their fourth and fifth tours, post traumatic stress disorder, depression and traumatic brain injuries were rampant. Unfortunately, psychologists basically felt like they were putting Power Ranger band-aids on hemorrhaging brain arteries. It wasn’t working.

A soldier was accompanying a convoy in Iraq when an IED went off. Right through the bottom of a convoy truck. The driver died screaming from an arterial groin bleed. Two of the eight soldiers were killed. The truck was abandoned and the rest of the convoy got back to the safe (mostly) zone. That soldier had the glassed ghost look in her eyes and got quiet. The usual response was to avoid someone’s eyes and hope for the best, but another soldier wouldn’t let her alone. She kept asking, “Tell me. What happened?”

The first soldier finally snarled out part of the story.

The second soldier pinned a poem to her pillow, describing the event. Our first soldier came in screaming and threw the crumpled ball of paper at her chest. “That’s not what happened! That’s not how I felt! Not even close!”

“Well, what DID happen!” The rest of the unit tried to hide in plain sight or disappeared to the bathroom or got really interested in books or watching the same video over and over, but the two of them stood face to face and went at it. Words, not fists. The crumpled paper was retrieved, the poem rewritten. It took two weeks before soldier one suddenly said, “That’s it. That’s pretty good. For a poem.” But she was back, her gruff foul mouthed efficient self.

Of course it wouldn’t have gone anywhere if the behavioral health specialist hadn’t joked about it to his superiors. The Army was really desperate. In spite of all the work, the suicide rate was still challenging the combat death rate, and there just weren’t enough people to deploy.

The Army went looking for poets. Four were promptly deployed into units. Two of them turned out to be pretty useless, but the other two: the units thrived. Word started getting around. The poets were swamped with people from other units.

The recruiting campaign: “We want you, yes we do, poet show your heart so true!” was painful, but the Army did not care. And poets stepped forward from within the ranks! Don’t ask, don’t tell turned on it’s head. In spite of the medical community’s cries for waiting until more scientific studies were done, and the press and cartoonists drawing pictures recruiters welcoming wimpy pale asthenic writers with open arms, the Army embedded a poet in every unit, right beside the behavioral health specialist. Oh, of course they tried prose too. The academics had a field day fighting about why prose didn’t work. But it didn’t.

It’s the height of irony that we’re cut off with everything we need, except a poet. A water source, food, ammunition. We’re holding our position. Our back up poet is dead ten days ago, but our main poet got an IED blast. Traumatic brain injury, two weeks ago. We can’t get him out, of course. You would think someone would bleed if they were that bad, but he just can’t hold on to any memory. The soldiers tell him their stories, he struggles and tries, but he can barely hold on to one line. Can’t read, though he can write. Can’t see very well either.

The whole unit is starting to look glass-eyed and haunted. Smith asked to go in the jail yesterday and for the door to be closed. He promptly started screaming. It got quiet after a while so they went in. He was sitting on bunk. “Ok.” he said. “I might come back tomorrow.” Some soldiers are writing their own limericks or free verse. It’s ironic that it hurts morale so much, knowing there’s help available. Knowing the chances of a poet reaching us in time are very slim.

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I will use this for the Ragtag Daily Prompt: comeback.

Illness Anxiety Disorder

“Please write something from a medical perspective about anxious people who worry every little thing is some serious disease.” — reQuest 2018

This is quite a brilliant and timely question.

Here: https://www.anxiety.org/hypochondriasis-replaced-by-two-new-disorders-in-dsm-5.

The DSM V was published on May 18, 2013. This is the Diagnostic and Statistical Manual of Mental Disorders version 5,  and it redefines various disorders. For example, opiate dependence has disappeared and so has opiate addiction. Instead, there is one diagnosis: opiate overuse syndrome. Which really combines both opiate addiction and opiate dependence and makes it a spectrum.

The DSM V drops hypochondriasis. Wait, you say, that diagnosis no longer exists? Well, yes, correct. So the diagnoses are made up? Yes, as my daughter says, “All the words are made up.” So psychiatry changes and the diagnosis definitions change and some diagnoses disappear. Medicine is like the Oregon Dunes, really. The information is changing daily. I went into medicine thinking it is like a cookbook, where I just have to learn all the recipes. Nope, sand dunes: the wind and waves and new information change the contours daily. It drives my patients nuts. “My insurance won’t cover the medicine I’ve been on for 26 years.” Um, yeah, sorry, work for single payer and shut down the insurance companies, ok? “This combination of medicines has never killed me yet.” Um, yeah, sorry, but you are in fact getting older and we no longer think that combination is safe and first do no harm: I can’t prescribe combinations that I think may kill you.

Hypochondriasis has been replaced by two diagnoses: Somatic Symptom Disorder and Illness Anxiety Disorder.

From the Mayo Clinic website: https://www.mayoclinic.org/medical-professionals/clinical-updates/psychiatry-psychology/diagnostic-statistical-manual-mental-disorders-redefines-hypochondriasis.

“Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels.”

“To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.”

So, subtle difference. Broadly, the illness anxiety disorder people are sure they have SOMETHING and are worried about ALL THE SYMPTOMS. The somatic symptom disorder people are worried about A SPECIFIC SYMPTOM OR SYMPTOMS and WHY HAVEN’T YOU FIXED ME.

Some of the people complaining of weird symptoms do have a medical diagnosis that has not been sorted out. Take multiple sclerosis for example. The average time from the start of symptoms to diagnosis is 4-5 years.

Here: http://biketxh.nationalmssociety.org/site/DocServer/Facts-about-MS.pdf?docID=54383).

Also here: https://www.nationalmssociety.org/Symptoms-Diagnosis/Diagnosing-Tools.

Another one is sarcoidosis: https://www.mayoclinic.org/diseases-conditions/sarcoidosis/symptoms-causes/syc-20350358. It’s hard to diagnose, can affect different parts of the body, and it’s still pretty mysterious. Add to that list chronic fatigue, fibromyalgia, chronic pain, and numerous other diagnoses.

With multiple sclerosis, you may be thinking, well, if they had just done the brain MRI sooner, the diagnosis would be made. Not necessarily. I did find a patient with a bunch of MS brain lesions: made the diagnosis. She had had a brain MRI 3-5 years before because of suspicious symptoms during pregnancy. At that time her MRI was entirely normal.

The DSM V does not have a diagnosis called psychophysiological disorder. This is an ongoing discussion:
1. https://pdfs.semanticscholar.org/7f7f/21a9b524fb677d575428bea11aab4c8d70c5.pdf
2. https://thoughtbroadcast.com/2011/01/21/psychosomatic-illness-and-the-dsm-5/
This site: http://www.stressillness.com/ is my current favorite about psychophysiological disorders. I heard a lecture from the physician who runs the site. He is at OHSU in Portland and gets the gastrointestinal patients where “they can’t find anything wrong” from all over the state. He is really good at this. He and I are in agreement: the symptoms are real. However, the symptoms may come from emotional suffering and from emotional trauma in the past and present.

It is clear that fibromyalgia is a “real” disorder: functional MRI of the brain shows the pain centers lighting up more with a standardized pain stimulus than “normal” patients. PTSD is “real”. It is interesting that there is more stigma surrounding fibromyalgia and chronic fatigue than PTSD: is that because the former two are more often diagnosed in women, and the latter is legitimate (finally) for male (and a smaller number of female) veterans?

And what do I, your humble country doctor, think? I think that chronic fatigue and PTSD and fibromyalgia and illness anxiety disorder and the others all may be variations of the same thing. Our body will handle and “store” or “stuff” emotions that we cannot handle or are not in a safe situation to handle it. Eventually our body decides that we are now safe enough and will notify us that we have to handle the emotions. Currently our culture is terribly unsupportive of this and there is huge stigma attached to dealing with it. We are all supposed to just be nice.

In the end, we can’t judge how a friend feels or whether they are well or not. We have to treat them with respect and kindness.

The photograph is me on my grandfather’s lap. He became a psychiatrist and I am a family physician. Taken in 1962 or 3. We are at cabins in Ontario, Canada. What a pair of grubs, but happy…..

Not quite acculturated

And she was unsympathetic
That doctor
That immigrant doctor
I heard she told a patient
“You’re too fat.”
This was whispered
In accents of pleased shocked horror

She came to dinner
That unsympathetic doctor
Southeast asian
Told a little of her story
To my wide eyed children

When she was 10
They were boat people
Escapees
Refugees
Pirates caught them
Real pirates
“They weren’t so bad,” she said
“We were about to die from lack
of food and water
Though we heard other stories
that were very bad.”

My daughter could imagine the boat.
She moved to my lap.
The pirates were too real.

Perhaps plenty is not always taken
for granted
And sympathy is a matter of degree.

 

previously posted on everything2.com in 2009 and here too, though I have not figured out how to find it….

for the Daily Prompt: enlighten.

Luminous night of the soul: https://www.youtube.com/watch?v=0OaRZrdoTQ0

 

Adverse Childhood Experiences 9: crisis wiring

I spoke to a patient recently about ACE scores. A veteran. Who has had trouble sleeping since childhood.

“What was your childhood like?” I say. “Was sleeping safe?”

“No, it wasn’t. We were in (one of the major cities) in a very bad part of town.”

“So not sleeping well may have been appropriate. To keep you safe. To survive.”

We both think this veteran has PTSD.

“I think I had PTSD as a child. And then the military made it worse.”

I show the veteran the CDC website and ACE pyramid: https://www.cdc.gov/violenceprevention/acestudy/about.html.

Adverse childhood experiences. Leading to disrupted neurodevelopment. Leading to a higher risk of mental health disorders, addiction, high risk behavior, medical disorders and early death.

Ugly, eh? Damaged children.

“But I don’t agree with it.” I say.

My veteran looks at me.

“Disrupted neurodevelopment.” I say. “I don’t agree with that. Different neurodevelopment. Crisis neurodevelopment. We have to have it as a species in order to survive. Think of the Syrian children escaping in boats, parents or sibling drowning. We have to have crisis wiring. It isn’t wrong, it’s different. The problem is really that our culture does not support this wiring.”

“You can say that again.”

“Our culture wants everyone to be raised by the Waltons. Or Leave it to Beaver. But the reality is that things can happen to any child. So we MUST have crisis wiring. Our culture needs to change to support and heal and not outcast those of us with high ACE Scores.”

My Veteran is quiet, thinking that over.

I say, “You may read more about ACE scores but you do not have to. And we can work more on the sleep. And we do believe more and more that the brain can heal and can rewire. But you were wired to survive your childhood and there is no shame in that.”

 

I took the picture in Wisconsin in August.

 

Update on PTSD 2017: hope!

I have just spent a week in San Antonio, Texas at the AAFP FMX: American Academy of Family Physicians Family Medicine Experience.

Whew. Long acronym.

However, I attended two programs on PTSD. One was a three hour offsite one put on by the U. of Texas Health Sciences Department of Family Medicine. The other was a one hour program about active duty military and PTSD.

The biggest message for me is HOPE. Hope for treatment, hope for diagnosis, hope for destigmatization, hope for remission. I am not sure if we should call it a “cure”. Once a diabetic, always a diabetic, even if you lose 100 pounds.

In medical school 1989-1993 I learned that PTSD existed but that was about it. There was no discussion of medicines, treatment, diagnosis or cure.

Ditto residency. I learned much more about psychiatry reading about addiction and alcoholism and Claudia Black’s books then I did in residency.

Fast forward to 2010, when I opened my own clinic. I worked as a temp doc at Madigan Army Hospital for three months.

The military was aggressively pursuing treatment and diagnosis of depression, anxiety, PTSD and traumatic brain injury. I worked in the walk in clinic from 6:30 to 8:00 four days a week. Every walk in had to fill out a screen for depression. They were trying to stem the suicides, the damage, the return to civilian life problems and addiction too. They were embedding a behavioral health specialist in every section of the military. I was amazed at how hard the military was working on behavioral health.

In 2010 I took the buprenorphine course, which is really a crash course in addiction medicine, at the University of Washington Med School. I took it because it was free (I had just opened a clinic) and I thought we were as a nation prescribing WAY too many damned opioids. Yes! I found my tribe!

This gave me a second DEA number, to prescribe buprenorphine for opiate overuse, but also hooked me up with the University of Washington Telemedicine. I presented about 30 opiate overuse problem patients (anonymously, there is a form) to the team via telemedicine over the next year. The team includes a pain specialist, addiction specialist, psychiatrist and physiatrist. They do a 30 minute teaching session and then discuss 1-2 cases. They often do not agree with each other. They reach consensus and fax recommendations to me. The Friday addiction one was shut down and now I present to the Wednesday chronic pain one.

But, you say, PTSD? Well, chronic pain patients and opiate overuse patients have a very high rate of comorbid psychiatric diagnoses. It’s often hard to sort out. Are they self medicating because they have been traumatized or were they addicted first and then are depressed/traumatized and anxious? And what do you treat first?

There was an ADHD program at this conference that said we should deal with the ADHD first. One of the PTSD courses said deal with the PTSD first. The thing is, you really have to address BOTH AT ONCE.

Tools? PHQ-9, GAD-7, PCLC and there is an ADHD one too. These are short screening tools. I don’t diagnose with them. I use them to help guide therapy along with the invaluable urine drug screen. Love your patients but verify. That is, the chronic pain patient and the addiction patient tell me the same thing: but one is lying. I don’t take it personally because they are lying to themselves. Also, studies have shown that many patients lie, about their hypertension medicine or whatever. If they have to choose between food and medicine…. I think food may come first.

The San Antonio program has a behavioral health person embedded in their clinic (like a diamond) and if a PTSD screen is positive, the doctor or provider can walk them over and introduce them and get them set up. This is more likely to get the person to follow up, because there is still stigma and confusion for ALL mental health diagnoses and people often won’t call the counselor or psychologist or god forbid, psychiatrist.

They have a protocol for a short term four week treatment. Four weeks? You can’t treat PTSD in four weeks! Well, sometimes you can. But if you are making no progress, the person is referred on if they will go. I have the handouts. I do not have an embedded behavioral health person. I wish I did. I am thinking of setting a trap for one or luring them in to my clinic somehow, or asking if the AAFP would have one as a door prize next year, but…. meanwhile, I may do a trial of DIY. No! you say, you are not a shrink! Well, half of family medicine is actually sneaky behavioral health and I have the advantage of being set up to have more time with patients. Time being key. Also I have seven years of work with the telemedicine and access to that psychiatrist. Invaluable.

So what is the most common cause of civilian PTSD? Motor vehicle accidents. I didn’t know that. I would have said assault/rape. But no, it’s MVAs. Assault and rape are up there though, with a much higher PTSD rate if it is someone the victim knows or thought loved them. Rates in the US general population is currently listed at 1%, but at 12% of patients in primary care clinics. What? One in ten? Yes, because they show up with all sorts of chronic physical symptoms.

Re the military, it’s about the same. BUT noncombatant is 5%. High intensity combat has a PTSD risk of 25%, which is huge. One in four. Not a happy thing. In 2004 less then half the military personnel who needed care received it. PTSD needs to be destigmatized, prevented, treated compassionately and cured.

The risk of suicidality: 20% of PTSD people per year attempt. One in five.

Men tend to have more aggressiveness, women more depression.

Back to that PCLC. A score of over 33 is positive, over 55 is severe. There is sub threshold PTSD and it does carry a suicide risk as well. In treatment, a score drop of 10 is great, 5-10 is good and under 5, augment the treatment. Remember, the PCLC is a screening tool, not a diagnosis. I often ask people to fill out the PCLC, the GAD7 and the PHQ9 to see which is highest, to help guide me with medicines or therapy. If I need a formal diagnostic label, off to psychiatry or one of my PhD psychologists or neuropsych testing. Meanwhile, I am happy to use an adjustment disorder label if I need a label. If the patient is a veteran and says he or she has PTSD, ok, will use that.

Untreated PTSD, the rate of remission is one third at a year, the average remission is 64 months.

Treated PTSD, the rate of remission is one half at a year, and the average duration is 36 months. So treatment is not perfect by any means.

Pharmacology: FDA approved medicines include paroxetine and fluoxetine, and both venlafaxine and one other SSRI help.

Benzodiazepines make it worse! Do not use them! They work at the same receptor as alcohol, remember? So alcohol makes it worse too. There is no evidence for marijuana, but marijuana increases anxiety disorders: so no, we think it’s a bad idea. Those evil sleep medicines, for “short term use” (2 weeks and 6 weeks), ambien and sonata, they are related to benzos so I would extrapolate to them, don’t use them, bad.

Prazosin helps with sleep for some people. It lowers blood pressure and helps with enlarged prostates, so the sleep thing is off label and don’t stop it suddenly or the person could get rebound hypertension (risk for stroke and heart attack). I have a Vietnam veteran who says he has not slept so well since before Vietnam.

Part of the treatment for the PTSD folks at the U. of Texas Medical Center is again, destigmatization, normalization, education, awareness and treatment tools.

Hooray for hope for PTSD and for more tools to work with to help people!

flooded

I wrote this after the tsunami in Japan. I was thinking about PTSD and triggers and being overwhelmed. And the flooding now in Texas….

Flooded

I cry because
the laundry overflowed
the sewer blocked again
we might have to pull up the floor
and lay it down a third time
I hate the laundromat
water runs across the floor
as fast as the tsunami
crossing the fields
crushing the houses
catching the trucks
in Japan

I cry because
I have to ask for help again
Help comes
but the memories of asking
when it didn’t
help didn’t come
and I was abandoned or humiliated
rise up and overwhelm me
I am flooded
I am helpless
someone help those people
The shaking earth is bad enough
But the ocean rolling inland
Over all
Breaking all
Beams to toothpicks
Those are the memories that rise up
And flood me
I think of the soldiers
and victims of wars and disasters
and PTSD
tsunami
of memory

 

previously published on everything2.com

For the Daily Prompt: memorize. In PTSD, the memories are not what people want to memorize.

music  Randy Newman Louisiana 1927

 

damage

This is not about one patient. It is about many. I have permission from the person I gave a copy to: one of many.

what do you say
to the person
with the terrible childhood
with addiction and chaos
and suicide attempts and hospitals
and that was the parents
that they ran away from

and then numbed themselves
in addiction for years
multidrug and chaos
and now stable
working their 12 steps

and grieving
their lost years
and their behavior
unforgiven, it takes time
to build trust after
thirty years of damage

and grieving
the next generation
following the same
path and feeling helpless
to stop them
and guilt for their
contribution

it is not a matter
of a pill
of a diagnosis

the simplicity of stopping
of getting clean
joy and pride
yes

and then the hard work
of grieving
begins

 

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I took the photograph at the Renwick Gallery.