Shrink's Views

ramblings of an unknown psychiatrist

Archive for the ‘Diagnosis’ Category

Important Content: a story

Posted by Dheeraj Kattula on June 12, 2011

“Don’t irritate me, even a bit more mama”, Shravan Iyer said rushing into his room. He closed the door behind his back and muttered to himself “I am sick of these females”. He lay in his bed, pillows covering his ears. The soft Carnatic music that his mother was playing in the dining room could not be heard in his room.

About a hundred kilometres away was the Azad family, a high class business family which was English speaking but had retained its traditions. They had been having trouble controlling Salma, since her teen years. Her behavioural problems never ceased even after visits to many dargas. Many holy men tried to get the ‘Jinn effect’ out of her, but all was in vain.

Sandeep went to Shravan’s room to get his ipod as he prepared to go for his evening jog. When he went in he smiled at his brother, who was in no mood for any humour. Shravan was pacing in his room, running his hand through his hair, turning to and fro, clenching his teeth and kept muttering to himself. Sandeep asked if he needed something. Shravan denied wanting anything. Just as Sandeep left the room, there was a loud noise. There was a shout “Stop it, you bitch”. Shravan had broken the desktop computer in his room with his Cricket bat.

After a lot of shopping for a magical remedy Azad’s wanted to try out medical help, after a cousin told them that Salma could be mentally ill. “I AM NOT MAD.YOU ALL ARE….”,Salma shrieked. Her neighbourhood knew her shriek. It was because the Azads had done a lot of philanthropy in the neighbourhood for two generations that people put up with the drama of their home. Otherwise it was a pain to be woken up by Salma’s shouts.

Sandeep and his mother came running into Shravan’s room. It was not acceptable to destroy a computer. It was OK if he punched or threw pillows at the wall to let his frustration. They had been thinking that he probably had a ‘love failure’. They had been very tolerant of him to get over it, but things had only been getting worse. He stopped going to work for the past two months and had been increasingly preoccupied. They had been encouraging him all the while fearing that he might harm himself, but that day’s aggression was clearly beyond the limits.

Salma was taken to a psychiatric facility. The doctors could not conclude about her illness. They wanted to clarify her diagnosis by observing her in the ward. After all her only behavioural problems were a bit of adamancy and problematic shouting to get her way through.

Shravan was evaluated in the same hospital. It was found that he had been having auditory hallucinations. The psychiatrist just asked him if the voices spoke to him or spoke among themselves regarding him or gave a running commentary on his actions. He replied that the voice abused him. The psychiatrist moved on to assess other areas in his mental status. He recorded second person auditory hallucinations in the medical records. He was admitted into the facility due to risk for property.

Salma was admitted in the same facility in room no 3. Her family had requested for room no 10, which was the last room in the corridor. It would give them some more privacy and that Salma would not be a disturbance either. The doctor insisted that treatment in all rooms would be the same and did not change her room. He wanted to avoid few extra steps he might have to make during rounds.

Salma shrieked that night in the corridor. Shravan realized that the one who had been tormenting him was near. He had been hearing a similar voice shouting at him and abusing him all this while. Salma looked at him and was shocked. His thin built, fair complexion and brown eyes reminded her of the school teacher, who abused her when she was 12 years old. She shouted even more.

Shravan could hold himself no longer. He charged towards her and caught her neck with his hands. She fell backwards and opened her room door and fell on the table. In her agitation she got a knife which was on the fruit tray. She picked it and drove it into her assaulter’s abdomen. He bent on himself. There was a gush of blood. Salma fainted.

Shravan was operated upon and he survived. The knife had nicked the spleen. It had to be removed to save his life. Iyer family did not want to pursue the legal case. Azads paid a good amount to the police and saw that FIR was not filed.

The psychiatrist was clueless about what had happened. Was he wrong in where he placed them as inpatients? He was convinced that he was following the diagnostic manuals. He had picked the phenomenology right. He was right in the diagnosis. He was following treatment guidelines and he was right in the drug treatment.

What he did not realize is that diagnosis depends on the ‘form’ of psychopathology but risks are due to the ‘content’ of the psychopathology. In his management, he should consider content as seriously as form.

Shravan and Salma continued their treatment in the facility and did well.

Dargas- A Sufi shrine built over a grave of religious figure usually frequented by Muslims.

Jinn effect- Effect of Demons

Posted in Diagnosis, fiction, medicine, psychiatry, schizophrenia | 4 Comments »

“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.

Posted in challenge, children, Diagnosis, distress, economics, education, ethics, indian society, medicine, philosophy, social | Tagged: , , , , , , , , | 3 Comments »

The Cultures of Depression

Posted by Dheeraj Kattula on October 21, 2009

Here is an article written by my teacher Prof KS Jacob. It is a well articulated argument for need for a wider perspective on depressive illness.This article appeared in newspaper “The Hindu” on the 18th of October 2009.Here is the link and the article follows:-

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Diverse models of depression have been proposed and debated. Much of the confusion that exists in this area is because of disputes about the nature of mental illness. The confusion is compounded by the fact that core depressive symptoms, such as sadness and feelings of hopelessness and helplessness, are also found in medical diseases, as reactions to stress and as part of normal mood.

Medical model: The medical model considers psychiatric disorders as diseases, supposes brain pathology, documents signs and symptoms and recommends treatments. The disease halo reserved for the more severe forms of depression is also conferred on people with depressive symptoms secondary to stress and poor coping skills. The focus for diagnosis of depression centres on symptom counts without assessment of context, stress and coping skills. The provision of support by health professionals mandates the need for medical models, labels and treatments to justify their input. Insurance reimbursement also necessitates the use of disease labels. Consequently, psychiatric culture now tends to view all depression and distress through the disease/medical lens.

Perceptions in primary care: Patients visit general practitioners (GPs) when they are disturbed or distressed, when they are in pain or are worried about the implication of their symptoms. Bereavement, marital discord, inability to cope at work and financial problems also lead people to seek help from their doctors. In this context, the major challenge is to distinguish between distress and depression. Depression in patients encountered by GPs is often viewed as a result of personal and social stress, lifestyle choices or a product of habitual maladaptive patterns of behaviour. Consequently, GPs often subscribe to psychological and social models of depression.

Population perspectives: Social adversity is often seen as a cause of depression by the general population. Under such circumstances, people are reluctant to consult their GPs, counseling is the preferred treatment and antidepressants are viewed with suspicion by patients as they are considered addictive. Religious models are also popular. The general population seems to simultaneously hold multiple (and often contradictory) models of illness. They seek diverse treatments from assorted centres offering healing. The protracted course of depression secondary to chronic stress, lifestyle and poor coping results in people shopping for varied solutions.

Pharmaceutical approach: The pharmaceutical industry has espoused the cause of the medical model for depression. It has aided and abetted the medicalisation of personal and social distress to its advantage. Sponsoring educational activities and professional psychiatric and user meetings and conferences have helped shape medical and patient opinions. While pharmaceutical companies play a major role in the development and testing of new treatments firmly rooted in the medical model, in actual practice theirs is a culture driven by profit rather than by science.

Competing cultures: The medical model is defended by the powerful biological psychiatry movement within the specialty of psychiatry and by the pharmaceutical industry. But the other models and cultures of depression emphasising psychological and social issues are equally valid in the contexts of primary care and the community, but lack the academic clout and financial resources to present their points of view. The different ‘cultures of depression’ and the pressures from these divergent perspectives need to be acknowledged.

The issues which need to be re-examined include: (i) the heterogeneity of the concept of depression, (ii) the (in)adequacy of a single label of depression, relying solely on symptoms counts, to describe the diverse human context of distress, (iii) the need for clinical formulations which clearly state the context, personality factors, presence or absence of acute and chronic stress and extent of coping, (iv) the fact that antidepressant medication is not the solution to mild and moderate depression and should be reserved for severe forms of the condition, (v) re-emphasising the need to manage stress and alter coping strategies, using psychological treatment for people with such presentations, (vi) de-emphasising medicalisation of personal and social distress and, (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights.

Clinical presentations: The syndrome of depression includes depressed mood, loss of pleasure in almost all activities, poor concentration, fatigue, medically unexplained symptoms, insomnia, guilt and suicidal ideation. Three categories of depression can be identified from a clinical and treatment point of view. The first, called adjustment disorder, is a normal reaction to acute and severe stress in people with a past record of good coping. The magnitude of the stress would temporarily destabilise many people with good coping strategies. By definition, the condition is time-limited and people usually settle back to normal lives within a few weeks or months. There is an absence of a family history of depression or suicide. The self-limiting nature of the condition means that support is all that is usually required and results in good outcome.

The second type of depression is characterised by its chronic nature (called dysthymia). Stressors, usually mild and multiple, precipitate, exacerbate and maintain the symptoms. The onset of such depression is usually in early adult life and such people usually have a long history of depressive symptoms. Their moods fluctuate and are usually responsive to changes in the environment. They also have a history of maladjustment and poor coping in response to past stress. The mainstay of treatment is psychological interventions which focus on improved coping, changes in personality, attitude, philosophy and life style.

The third category is called melancholia. In addition to the basic syndrome of depression, symptoms of melancholia include a pervasive depressed mood with minimal response to environmental change, global insomnia, early morning awakening with low mood worse in the mornings, significant loss of weight and restlessness, agitation or slowed movements. Melancholia usually occurs later in life and there may be a family history of similar depression or suicide. Such presentations may be also part of a bipolar disorder (manic depression), which has extreme mood swings, or may be due to medical, neurological and endocrine disease. The treatment of choice is antidepressant medication, management of the underlying medical causes and hospitalisation.

Management: Clinicians and psychiatrists managing patients with depression should be able to hold multiple models of depression. They should be able to appreciate the diverse cultures of depression and choose appropriate treatment strategies. Clinically, there is a need to look beyond symptoms and explore personality, situational difficulties and coping strategies in order to comprehensively evaluate biological vulnerability, personality factors and stress. The treatment package for such presentations should include psychological support, general stress reduction strategies (for example, yoga, meditation, physical exercise, leisure, hobbies) and problem-solving techniques (for example, cognitive therapy) for subjects presenting with ‘depression’. Antidepressant medication should be reserved for the severe forms of depression with hospitalisation and electroconvulsive therapy for those with high risk of harm to themselves and to others. People can present with a mixture of clinical presentations requiring a combination of approaches. A psychosocial formulation of the clinical presentation, background and context will put issues in perspective.

The progressive medicalisation of distress has lowered thresholds for the tolerance of mild symptoms and for seeking medical attention for such complaints. Patients visit physicians when they are disturbed or distressed. Grief at loss, frustration at failure, the apathy of disillusionment, the demoralisation of long suffering and the cynical outlook of pessimism usually resolve spontaneously without specific psychiatric intervention. Distress and emotions should not be mistaken for pathology; fear and apprehension should not be labeled as anxiety, or sadness as depression.

The failure of individual models and cultures to explain all aspects of depression seen in diverse settings has led to the development and use of multiple models, which argue for the need to accept the many perceptions as partial truths. These models should be viewed as complementary rather than competitive, with some being more valid in a specific context than others. Patients present to physicians with their illnesses while doctors diagnose and manage disease concepts. The failure to bridge the gap between disease and illness and healing and cure is a major cause for the contemporary confusion in the diagnosis and management of depression. There is a need for more pragmatic approaches which move beyond the specific models of depression and narrow ‘cultural’ perspectives.

( K.S. Jacob is Professor of Psychiatry at the Christian Medical College, Vellore.)

Posted in adjustment disorder, depression, Diagnosis, mood disorders, psychiatry, psychotherapy, religion, social, suicide | Tagged: , , , , , , , | 2 Comments »

Battle with Malaria: a personal sickness story

Posted by Dheeraj Kattula on July 23, 2009

Background

Towards the end of June 2009 I went to Kandamaal district, an interior hilly area in Orissa endemic for Malaria. This was as a part of a medical team conducting medical camps in different parts of the district. I was there for five days. My experiences there deserve to be a separate post in my blog. I would write that later.

On my way back, in the train it felt a bit cold. I got up from my upper berth to switch of all the fans, thinking I was helping others in a cold night. A couple of hours later I found the fans switched on! Only then I realized that probably it was MY problem and not for others. I also had a bad migraine. I reasoned it to be due to sleep deprivation and physical exhaustion. But as soon as I landed back in home/hospital, I got my blood tested. It was positive for Malaria parasite Plasmodium falciparum. Out of 1000 red blood cells about 3 were infested with the bugs. Probably, during the time spent in Kandamaal, I was bitten by one of the female Anopheles fluviatilis mosquitos carrying the Malaria bug Plasmodium falciparum.

Treatment:

I started taking medicines immediately. I respect Falciparum bug. It could do ANYTHING. I also had a board meeting to attend. I took Tab Sulphadiazine + Pyrimethamine, Chloroquine and also Artesenuate. It was surely an over-kill but I wanted to be safe.

Three days passed. Fever did not come down. I also began to vomit and could not hold anything in my tummy. I was admitted in the hospital and was given intravenous fluids. A physician friend visiting us started me on intravenous antibiotics, ‘just to be safe’. I complied in good faith. This was carpet bombing in my system. Tab Artesenuate became Injection Artesenuate.

dheeraj on sickbed

on sickbed

7 days passed. My last dose of Artesenuate was given. I still had fever. As fate would have it, I became deeply jaundiced. It was not the typical hemolytic jaundice seen in Malaria but was deeper one seen in Liver injury. I stopped all injections and i.v fluids as I began to tolerate oral foods. I started Cap Doxycyline the fourth antimalarial. Fever came down after 2 more days. Jaundice was persisting. We knew we cannot do anything about it. Malaria Hepatopathy was the diagnosis. I was supposed to have some dietary restrictions and that is all. My staff insisted that I took some liver tonic. They forced me to buy some ayurvedic stuff Syp. Amlicure DS. I take it, to please them.

Milestones:

It was the first time that I got admitted in a hospital, first time got an IV canula, first time received ‘saline’, first time IV antibiotics etc. Of course I was living in my own room but my room was made into a special ward with IV stand coming in etc!

It was the first time I did not shout ‘mummy’ when I was getting pricked with needles. I could stomach the fact that situation is grave and that killed the fear of needles and pricks.

Reflection:

It was not easy for my friend Siva to take care of me. We had physicians, gastroenterologists, malaria experts as our friends but did not have facilities to do few of the tests that could be easily done elsewhere.

Siva had to allay anxiety of my parents, who called regularly to enquire about my status. He had to balance the risks of keeping me here and risk of transporting me in a very weak state.

He and I, both of us learnt to be cool when we knew we have to wait and watch, as we do not know what was happening. I learnt that in desperation people don’t look at evidence but act in faith. Eg: my friend giving Injection Ceftriaxone and me taking Ayurvedic medicines!

My staffs were like a family. They took care of me just I would have been cared at home by my family. They made fruit juices of different kinds apple, lime, mousambi, grape, dalimbo ( a local fruit), mango, pomegranate etc and supplied at periodic intervals. They tried to give injections as painlessly as they could. They kept a watch as needed. Of course they were always praying for my recovery.

My family stood strong. They felt bad that they could not come to take care of me. I tell them that their trouble was not needed. They had faith that nothing bad will happen.

I lost 2 inches of my waist and 6.5 kgs of weight in a week’s time. I loved it. At last the ‘all round development’ that I hated has come down. Many of my old clothes have got a new lease of life. Few days ago, I comfortably fit into a pant that I had last fit into more than a year ago. I hope I do not put on weight as my appetite is slowing improving. I watched a couple of Bruce Lee movies day before yesterday. I am now waiting to get out and exercise. I started to walk today with a little extra jump in my gait.

My jaundice is not yet gone. I look as yellow as I looked a week ago. I started feeling much better though. At one point I took four breaks to send a 5 sentence email, today I could sit in the OPD and see patients. In fact I had a 1 hour psych session with a patient today.

Jaundiced eyes

Jaundiced eyes:for clarity compare the eye colour with the colour of the teeth 🙂

Thank God, I am not entering into ‘half pay leave’ zone.

Ops I almost forgot to mention…I had never purchased ‘Real- fruit juice’ till now. Rs 75/- for food products never enters my budget, but this time I bought myself many liters of such juice lichee, pineapple, apple, orange, mixed fruit etc. I also bought oats and chocos for the first time. Sickness had made me enter new markets!

I have probably treated more than 1000 patients with malaria last year. Whenever someone came with side effects, I used to tell them without even listening fully, “I know…You will feel….etc. Don’t worry. Just do…”. I do not think I would be the same now. I might listen more and then say “I understand…Why don’t you try…You might not like to do it, but it is good for you to…If you are unable, do come back. We will help you.”

I feel I have matured through the sickness experience. Felt like this after many milestone experiences, but I am not sure if I really did mature !

Posted in Diagnosis, distress, medicine | 4 Comments »

“Normal”, “Abnormal” and “Label”

Posted by Dheeraj Kattula on June 26, 2009

Warning:

The post might have a lot of jargon,which you might not enjoy. It might be written in a fashion, which may make you feel that author and his thinking is complicated. Don’t worry. He is ‘normal’ only. If you want to stop reading the post mid-way, It might be absolutely ‘normal’. So, no problems with that too. If you call this post bad, I would say you are a ‘label-er’ but not ‘abnormal’. If you say this is written splendidly in Sanskrit, it is only then I could consider you abnormal. Assuming normalcy of some sort I invite you to read the post:

“Normal”, “Abnormal” and “Label”

There would always be debates on defining, what is ‘normal’. There are many models to define what is abnormal.

‘Statistical infrequency’ is one of the models to define what is abnormal. If some thing is rare then it is abnormal. If that be the case gifted people are abnormal as they are rare!

‘Failure to function adequately’ is another model to help not labeling gifted individuals as abnormal. But, who defines what is adequate and what is functioning? Is there a consensus?

‘Deviation from social norms’ is another such model. Social norms vary with culture, context, situation, age, gender, development and historical context (time).

Identifying parameters that are abnormal, considering the possible causes and treating them is a part of routine medical practice. In psychiatry, the parameters are more behavioral in nature.

Is “normal” a dichotomous construct (yes/no), a continuous construct (0-fully dysfunctional, 100-Mahatma Gandhi), or a dimensional construct (Einstein- professionally a genius, politically eccentric, interpersonally deficient)?

If we observe, we might find ourselves in different areas of the normal curve in different aspects. For example when I dance (as I sometimes do), people don’t see me in awe but rather laugh in amusement :-/ ( not so sadly :-)) Dancing Dheeraj

Or when I play cricket, I know the timing of my shots is awful. I might discuss the physics behind ‘reverse swing’ but would never be able to read its trajectory and time a ‘square-cut’ to the boundary. This just shows that I probably am low in Body Kinesthetic Intelligence. A not so sophisticated ‘labeler’ might call me ‘Kinesthetically Retarded’! (Ops! I labeled him a ‘labeler’ :-)) .The more specialized psychiatrists have even a diagnosis for it ‘Developmental Coordination Disorder’. “Diagnoses for all by 2025” seems to be the motto of some psychiatrists.

It is interesting that though we draw clear lines and cut across the parameters as normal and abnormal, most parameters are distributed normally. There are individuals very close to the line drawn but on different sides of it. They end up with different labels/ diagnosis and probably different treatments. Is this not quite terrifying?

Not just that, if the line is drawn somewhere close to the mean, then we have more problems. Take for example Complicated grief, Atypical PTSD (Post Traumatic Stress Disorder), High-functioning Asperger’s syndrome, Developmental Coordination Disorder etc. Besides, some conditions that are abnormal in a majority of settings become desirable in very narrow contexts. For example Anti-Social Personality Disorder in politicians and businessmen, Histrionic Personality in actresses and performers, Schizoid Personality in mathematicians and physicists and so on.

Good news is that most medical researchers consider these statistical issues before formulating guidelines and are not keen on labeling everything and everyone as abnormal. Most Clinicians go by patterns of symptoms, signs, laboratory results and diagnostics not isolated laboratory findings. Clinicians are not bothered, so thankfully not confused about statistical issues!

A good doctor picks up most of the abnormal parameters in his history taking, clinical examination and diagnostic work up, logically thinks through and explains these with the most judicious explanation, considers rarer possibilities and tries to rule them out or in and treats appropriately covering for most possible causes and always tries to relieve symptoms and is less bothered about the ‘label’ he gives to his patients.

Posted in Diagnosis, grief, medicine, personality, psychiatry, statistics | 4 Comments »