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Make Balieve

On the road again. I think Willie Nelson really understands my life. It’s amazing the things you have time to think about when you’re not in a hospital. 

 
My kids play this game on their phones. One draws a picture, sends it to the other, then s/he has to guess what the picture is. Correct answers get points. The points add up. Everything is magically peaceful in the car as we drive for four hours. Except when something goes wrong and my daughter’s phone won’t work and she can’t enter her guess. The screen is frozen. Chaos. She decides the only way to solve the problem is to delete the current game and start over. However, this means losing the massive total of 53 points. My son can’t let it go. He’s worked so hard for these points, his life will be meaningless without them, etc. Then my daughter utters the most interesting statement I’ve heard in a while: “Just pretend it’s okay.” I nearly had to pull over I was laughing so hard. I was flooded with all of the situations I face to which that statement would apply so well. Most of all, elections. “Well, I know so-and-so is an axe-murderer, but he’s our (fill in elected office title here), so just pretend it’s okay.”
 
In some ways, one could call this an exaggeration of a compromise position. I want this, you want that, we need to agree somehow, so we each give in a little and accept what we can get. It works, so long as we both can agree to pretend it’s okay that our initial position wasn’t really all necessary anyway. 
 
In other ways, we could see this as embracing denial. If I really can’t stand my boss, but I feel there’s no way to leave my job and find another, I accept the terms of my employment as they are. It works, if I can pretend it’s okay. Unless neurotic symptoms start to appear.
 
So I’m lecturing the medical students about substance use disorders. And we come to cocaine withdrawal. Cocaine is a dopamine reuptake inhibitor. That’s what makes it feel good – a big blast of dopamine to your nucleus accumbens. Then, when it wears off, the dopamine gets sucked back up, and the patient experiences a “crash” – an acute dysphoria that is generally recognized as an intense craving for more cocaine (crack and IV cocaine are worse for this, due to the short half-life). And the cycle is repeated, and repeated, and repeated. Each time, however, a little of the dopamine is destroyed by monoamine oxidase, so if you do this over and over, you might actually deplete your dopamine stores a bit. And since dopamine is involved in registering the pleasure from your experiences, you might have a reduced ability to feel that pleasure. Psychiatrists might call that state anhedonia. And it will persist until you regenerate your dopamine. What you would have could be called a “cocaine-induced mood disorder, with depressed features, with onset during withdrawal.” No psychological explanations necessary, this is pure pathophysiology. 
 
So you and your little mood disorder come to my hospital, because you’re so depressed you’re thinking of killing yourself. I admit you. I work you up – history and physical, tests, etc. We provide you a nice warm bed, three meals a day (no comment on taste or presentation), and lots of support. You begin to feel better. We agree you’ll stop using cocaine and make a plan for it. 
 
On your chart, I write the diagnosis: “Depressive disorder NOS.” Why? Have I suffered some kind of lapse and forgotten what I have just lectured to the medical students? No, of course not. I simply want to be paid by your insurance for your treatment. And if I write “substance-induced” anything, I can’t get paid, because I am a psychiatrist and substance use is “carved in” along with all “medical disorders,” unlike “mental disorders” which are “carved out.” I know what the problem is, you know it and your insurance probably knows it too. But we all agree to pretend it’s okay and do things this way. 
 
In the coming year, there will be a movement in Maryland to combine psychiatric and substance use in the same group. I don’t know if this will mean mental health will be “carved in” with everything else, or if substance use will be “carved out” along with mental health, but the movement is in the direction of dropping the current world of make-believe that the two are unrelated. We’ll see what neurotic symptoms are relieved by this action, and what new situations we have to pretend are okay.

 

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