Selling my soul

If a drug company buys the lunch does that mean we've sold out? Maah. Undecided.

If the lunch comes with a medication spruik by a top 6 Master-Chef Contestant then is the sell-out worth it?

Possibly.

Alvin has a PhD in biochemistry and comes from the science dept. of Astra-Zeneca. As a science bloke he can talk about off-label prescribing (research into using a medication for an illness not covered in its current PBS + or - TGA indications). Our friendly (and lunch-bearing) sales rep is not supposed to talk off-label.

So Alvin gave a teuously linked talk about anxiety and being on Master Chef. He recommended taking a little S-----l XR to cope with performance anxiety on the show.

I hope he was joking....

Seriously, the impact of drug company involvement and visits are subtle. I hope I don't prescribe on the basis of who talked medication with me last or who made me feel good. But the evidence, discussed here, and reported here, is that I do. Drug companies spend money this way because it works.

We have a lunch to get registrars together. People come if there is food, and we want them there to give an opportunity for support and feedback in a stressful job. I am trying to think of some ways to get food there but not be unduly influenced.

Story of Anorexia

One of the fascinations of psychiatry is to hear each person's story. Each unique journey.

Emily has written about some of her experience of anorexia and the anxieties underlying it. I recommend reading her honest and brave words.

And here is part two.

And part three.

Skills in Psychiatry #2

Asking difficult questions - being tactfully direct.

A conversation that may include questions about hearing voices, thoughts of killing yourself, childhood abuse and sexual dysfunction can get uncomfortable. And at the end of the uncomfortable conversation, there needs to be enough rapport to engage someone into a treatment plan. This can be a delicate juggle.

I find it helpful to...

• Normalise - "Some people with the symptoms you describe, also get ... . Has that happened to you?"

• Ask open, general questions first - "Have you had any strange or confusing experiences?" can yield all sorts of answers.

• Acknowledge the intrusive nature of questions - "I know this can be embarrassing/difficult to talk about, but the answers can give us information that really helps."

• Ask an important question in a couple of different ways.

• Listen carefully, and use it to direct further questions - "You mentioned ... earlier, I'm wondering how often that's been happening recently?"

• Say clearly what you mean. Try not to use euphemisms. - "How often do you drink alcohol?", is preferable to "Are you a drinker?". Even better is "People who are having trouble sleeping sometimes find alcohol can help get them to sleep. Is that something you have done?"

Having said all this, sometimes words just come out clumsily. I have asked a 15 year old boy if he was "still having thoughts of killing people?" Unfortunately, he'd never had such thoughts and from that point he wanted to escape from the room as quickly as possible. I never saw him again.

Trouble with rapport due to uncomfortable questions can be repaired with patience and listening well. Just be willing to laugh and acknowledge your mix-up or faux pas. Most people cannot resist humility and someone who can laugh at themselves.

Denial #2

We each lay our hope and dreams in the vessel that is our children. The child-to-become lives vivid in our minds as we plan and prepare.

A child's diagnosis with any serious illness is a jagged knife tearing this mind's eye picture to threads. The dreams recover, but always bear the seams of patient mending.

Talking to a parent whose cusp-of adulthood son or daughter carries a heavy mental health label is a glimpse of the rending knife. I struggle to disagree as he desperately clings to the idea that she is not really ill. That she will be fine with good nutrition and enough sleep. That if she is at home they can love her back to clear thinking.

He thinks I am deluded to insist she must stay in hospital. That I have been tricked by Evidence Based Medicine and Pharmaceutical Companies and teams of Psychiatrists who see disordered minds every day.

He denies her brokenness. And I understand why. The tears of the knife are sheering him and he can't bear it.

He will not be convinced. He insists I have disappointed him and failed him by not having enough faith. Not religious faith, just faith in him and in his daughter, who is unbroken. He knows she cannot bear the mark that will brand her different and break his dreams.

I write emotively of his struggle, because sitting in the room with him, face to face, was a glimpse of his grief and his wail of terror. He sat impassive and patiently pleading, but still I saw his anguish.

What would I do if my child were involuntarily in hospital, receiving strong psychotropics? What if my child were entering a world of labels and stigma and CTOs and stays in strange hospital wards?

I am scared about the answers.

Defences - Denial

Denial is saying "I don't drink alcohol", when your blood alcohol level is 86mmol/L*

Anna Freud proposed that we have a range of possible psychological defences which protect us from extreme anxiety about our experiences and situations. Everyone uses them, and we have favourites. We learn them from those around us (either by imitation or reaction), and we use them without conscious reflection.

"Defenses operate to protect us from uncomfortable or unacceptable self-awareness."

Denial is believing that something has not happened (a death, a diagnosis, a disagreement, a failure) in order to avoid consequences of that information. Avoidance of the consequences is because they are too distressing to face.

Denial is a more 'primitive' defence and becomes difficult to sustain as an anxiety-provoking situation progresses and remains present. Denial may be part of a coping progression, with rates of denial falling as time from diagnosis with cancer elapses. Michael Kinsley reflected, in Time Magazine, on the role denial played in his experience of having Parkinsons Disease.


*0.05 (legal driving limit) = 10.9mmol/L

"He uses statistics as a drunken man uses lamp posts - for support rather than illumination."

Andrew Lang (1844-1912), Scottish writer.