I just want to give a shout out to University of Iowa Health Care and the Rounding@Iowa podcast for an outstanding presentation on the hazards of smoking tobacco, vaping, and dabbing.
The program originally aired on May 14, 2024 and the guests included two ICU doctors who are pulmonologists I’ve worked with as a psychiatric consultant. They are very dedicated.
There was a third guest and he is a patient who vaped and suffered disastrous consequences leading to lung transplant surgery. His insights are invaluable.
Breathing is good; not breathing is bad.
88: Modifiable Risk Factors for Breast Cancer –
Rounding@IOWA
In this episode of Rounding@IOWA, Dr. Gerry Clancy sits down with breast cancer experts Dr. Katherine Huber‑Keener and Dr. Nicole Fleege for a discussion of modifiable and non‑modifiable risk factors, modern screening tools, and practical strategies clinicians can use to guide prevention and early detection. CME Credit Available: https://uiowa.cloud-cme.com/course/courseoverview?P=0&EID=82146 Host: Gerard Clancy, MD Senior Associate Dean for External Affairs Professor of Psychiatry and Emergency Medicine University of Iowa Carver College of Medicine Guests: Nicole Fleege, MD Clinical Assistant Professor of Internal Medicine-Hematology, Oncology, and Blood and Marrow Transplantation University of Iowa Carver College of Medicine Kathryn Huber-Keener, MD PhD Clinical Associate Professor of Obstetrics and Gynecology – General Obstetrics and Gynecology University of Iowa Carver College of Medicine Financial Disclosures: Dr. Gerard Clancy, his guests, and Rounding@IOWA planning committee members have disclosed no relevant financial relationships. Nurse: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this activity for a maximum of 0.75 ANCC contact hour. Pharmacist and Pharmacy Tech: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this knowledge-based activity for a maximum of 0.75 ACPE contact hours. Credit will be uploaded to the NABP CPE Monitor within 60 days after the activity completion. Pharmacists must provide their NABP ID and DOB (MMDD) to receive credit. JA0000310-0000-26-035-H99 Physician: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other Health Care Providers: A certificate of completion will be available after successful completion of the course. (It is the responsibility of licensees to determine if this continuing education activity meets the requirements of their professional licensure board.)
I heard the Big Mo Pod Show, which relates to the quiz about 5 songs he played on the Big Mo Blues Show last Friday night. He got all the artists right, just missed 3 song titles!
I had a couple of thoughts about the song lineup related to the theme “Music Changes Context.” Actually, the point was that one of the songs had what might have made some people mad. It was “Funky B***h.” The idea was that some words might be offensive if you say them, but when words are sung, that might make them not offensive, in a way. It’s a matter of opinion.
How that happens is not clear. Big Mo’s example of it was in a historical context related to slavery. Slaves could not say certain words while they were working in the fields. But the overseer would let them get away with if they used the words in a song.
I heard one song that was not part of the Big Mo Pod show that might put a different spin on the idea of how music changes context. It’s about brotherly love, in a manner of speaking—or in a manner of singing, I should say.
May is Mental Health Month! Have I said that already? Anyway, this is yet another one of my Dirty Dozen lectures. It’s on Psychodynamic Psychotherapy.
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Dirty Dozen on Psychodynamic Psychotherapy by Jim Amos, MD
Psychodynamic Therapy Core Beliefs
-We feel and behave as we do for specific reasons.
-We’re often unaware of why we feel and behave in certain ways.
-Past experiences, often outside our awareness, determine how we feel about ourselves and our world.
-The need to master psychological pain is compelling and accounts for why many of us behave consistently and predictably in often self-defeating ways.
Psychodynamic Therapy Core Beliefs, cont.
-The power of the therapeutic relationship is built on the physician’s ability to provide a safe environment for examining emotions and psychological problems in a nonjudgmental, empathic way, i.e., rapport.
-The past experiences of both patient and therapist play a role in determining the power and valence (positive or negative) of the therapeutic relationship.
-Successful treatment must integrate both affective and cognitive components of patient’s self-awareness and includes supportive as well as interpretive interventions.
Essential Assumptions
-Maladaptive relationship patterns are learned in the past.
-Such maladaptive patterns are maintained in the present.
-Dysfunctional relationship patterns are reenacted in vivo in the therapy.
-The therapeutic relationship has dyadic quality.
-The therapeutic focus is on the chief problematic relationship pattern.
Behavior Is Not Haphazard
-Therapists ask “Why is the patient expressing this topic now?”
-Process communication (complementary to content)
-Listen for understanding
-Patients communicate on multiple levels and often indirectly
-Jokes, revelations at end of session, metaphors, sudden shifts in topic
Behavior Is Not Haphazard, cont.
-Resistance: Paradoxical phenomenon of ambivalence that all pts have about treatment
-Tends to provoke subtle, covert, and sometimes overt oppositional behavior that prevents deeper understanding of problems
-Protects pt against threatening feelings and fantasies
-A form of defense mechanism-a way of relating to internal and external worlds in an attempt to avoid unpleasant and strong feelings. There are both adaptive and maladaptive defense mechanisms
Defense Mechanisms
-Defenses (or resistance, which amounts to the same thing) are one of the three different means by which people cope with threats, the other two being social supports and cognitive coping strategies.
-Defenses are coping processes. They are unconscious distortions of inner and outer reality for protecting the ego from disorganizing anxiety and depression. They may seem odd. They may also mature over time.
-Confronting people with their defenses can be unwise. Recognizing them in order to make sense of otherwise inexplicable behavior and to make rough predictions about response to therapy is helpful.
Defense Mechanism Examples
-Denial: refusal to appreciate information about oneself or others
-Projection: attribution of conflicted thoughts or feelings to another or to a group of people
-Identification: patterning of oneself after another
The Past is Present
-Implicit memory and the need to avoid unpleasant, disruptive feelings
-May explain why some traumatic experiences are not accessible
-Transference & countertransference: responding to someone in the present as if that person were an important figure from the past.
-Used for corrective experiences and encouraging more adaptive behavior as pt becomes of aware of this phenomenon
Self-Defeating Behavior
-Making the same mistake repeatedly, e.g., marrying abusive, alcoholic partners
-Might understand this as attempts to master enduring conflict or trauma in order to finally resolve the painful experience
-Remembering can replace reliving-challenge of psychodynamic therapists is to foster this
Essential Operations of Psychodynamic Psychotherapy
-Accepting: Therapist affirms the pt’s past and present subjective experience.
-Understanding: Therapist appreciates both the conscious and unconscious contributions to the pt’s emotional problems.
-Explaining: Therapist expresses, through interpretations, his or her understanding to the pt.
References
-Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004
-Focus: The Journal of Lifelong Learning in Psychiatry. Psychotherapy. Ed. Jerald Kay, MD. Spring 2006. Vol. IV, No.2.
Back in 2018, one of my emergency room staff physicians asked me to do a Pecha Kucha on what a consultation-liaison psychiatrist does. If you know what a pecha kucha is, you can understand why it was challenging for me to put it together and present it.
Although you may have seen the video I made of the pecha kucha 5 years ago on this blog, I think it’s OK to present it here again.
Briefly, PechaKucha is Japanese for “chitchat.” It’s a presentation format using 20 slides displayed for 20 seconds each. It took a while to rehearse to get it right.
I think it’s also worth emphasizing because most of the ideas in it are still relevant to consultation-liaison psychiatry. See what you think.
Hey, because May is Mental Health Month, this is another one of my Dirty Dozen lectures. It’s on Interpersonal Psychotherapy.
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Dirty Dozen on Interpersonal Psychotherapyby Jim Amos, MD
Definition of IPT
–Time-limited, dynamically informed therapy.
–Goals are to relieve symptoms and improve interpersonal functioning and social support.
–Focuses specifically on interpersonal relationships to bring about change.
Applications for IPT
–Major Depression
–Postpartum and peripartum Depression
–Dysthymia
Essential Characteristics of IPT
–Focuses specifically on interpersonal relationships as a point of intervention.
–Time-limited when used as an acute treatment (12-16 sessions).
–Interventions used do not directly address the transference relationship.
Premises of IPT
–Interpersonal distress closely associated with psychological symptoms.
–Helping people improve communications in relationships or change their expectations about those relationships relieves symptoms.
–Helping people build or improve social support network improves ability to cope with crises that precipitated distress.
IPT Contrasted with CBT & Psychoanalytic Approaches
–CBT focus is on cognitions.
–Psychoanalytic focus is on understanding contributions of early life experiences.
–IPT focus is on improving interpersonal communications in the present.
Theoretical Framework of IPT
–Attachment Theory
–People are driven instinctively to form attachments to get and give care.
–Hallmark of good mental health is ability to form flexible attachments.
Theoretical Framework of IPT cont.
–Communication Theory
–Securely attached persons able to communicate needs effectively.
–Insecurely attached persons communicate in an indirect, ambivalent way that may elicit neutrality or hostility.
Problem Areas of Focus for IPT; Conducting IPT
–Grief
–Interpersonal Disputes
–Role Transitions
–More important than technique is the focus on extratherapeutic interpersonal relationships and fostering of productive therapeutic alliance.
Conducting IPT
–Opening Phase: diagnose, frame the treatment, relieve symptoms.
–Middle Phase: develop strategies for problem areas: identify situations which elicit feelings, validate feelings, explore and role play options, summarize sessions.
–Conclusion and Maintenance Phases: reinforce independence.
Conducting IPT cont.
–Communication Analysis and Interpersonal Incidents (accurately describe in detail).
–Use of both content and process affect (what happened outside and inside).
–Observe transference but don’t comment on or interpret it.
IPT References and Links
–Core Competencies in Psychotherapy. The Art and Science of Brief Psychotherapies: A Practitioner’s Guide, eds. Dewan, Steenberg, Greenberg. APPI 2004
–Stuart, S. (2012). “Interpersonal psychotherapy for postpartum depression.” Clin Psychol Psychother 19(2): 134-140.
In keeping with May being Mental Health Month, here’s another slide set on psychotherapy. This one is on the basics of Cognitive Behavioral Therapy. Once again, it’s in WordPress shortcode. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size.
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Dirty Dozen on Cognitive Behavioral Therapy by Jim Amos MD
Origins of CBT
–Psychoanalytic theory dominant in 1960s
–A. Beck, the creator of CBT, was trained as a psychoanalyst
–Conducted experiments in late 1950s and early 1960s intended to support psychoanalytic constructs-found the opposite to be true
CBT Definitions & Assumptions
–Focused therapy based on model that psychological disorders involve dysfunctional or unhelpful thinking
–We often feel what we think and behave accordingly
–Assumes that modifying dysfunctional thinking improves or resolves symptoms
–Modifying dysfunctional beliefs that underlie dysfunctional thinking produces more sustainable change
Overview
–Pragmatic, action-oriented treatment approach
–Initially developed for depression and anxiety
–Empirically validated brief psychotherapy shown effective in over 350 outcome studies
–Effective in treatment of many medical and psychiatric conditions
Examples of Automatic Thoughts
–I should be doing better in life
–I’ve let him/her down
–I can’t handle it
–I feel like giving up
–Something bad is sure to happen
–I’ll never be able to get this done
Examples of Maladaptive Schemas
–I must be perfect to be accepted
–I’m a fake
–I’m unlovable
–I must always be in control
–Other people will take advantage of me I’m stupid
Key Behavioral Concepts
–Depressive behavior can be modified with behavioral techniques
–Exposure therapy and related methods can be effective interventions for anxiety disorders
–Behavioral interventions can be useful for helping patients improve coping, social, and problem-solving skills
Principles of CBT
–Overall goal is to help achieve remission of disorder by solving problems and relieving symptoms.
–Achieved through collaborative empiricism
–Approach which teaches patients to view reality more clearly by examining their distorted cognitions
–Correcting faulty ideas leads to improvement in mood and function
–CBT is educative in nature; it teaches patients to be their own therapists. CBT is goal oriented.
CBT Methods
–Socratic questioning
–Stimulate curiosity to engage in learning, less didacticIdentifying cognitive errors
–Thought change record
–Guided discovery-series of inductive questions to reveal unhelpful thought patterns
–Examining the evidence
–Generating rational alternatives
–Role play and rehearsal
Behavioral Methods Used in CBT
–Activity and pleasant event scheduling
–Graded task assignments
–Exposure and response prevention
–Relaxation training
–Breathing training
–Coping cards;example: suicide safety plans
References
–Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
–Garland, A., R. Fox, et al. (2002). “Overcoming reduced activity and avoidance: a Five Areas approach.” Advances in Psychiatric Treatment 8(6): 453-462.
–Temple, S., PhD, and S. Stuart, MD (2010). Psychotherapy for the hospitalized medically ill patient. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 242-248.
References cont.
–Whitfield, G. and C. Williams (2003). “The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings.” Advances in Psychiatric Treatment 9(1): 21-30.
–Williams, C. and A. Garland (2002). “A cognitive–behavioural therapy assessment model for use in everyday clinical practice.” Advances in Psychiatric Treatment 8(3): 172-179.
–Williams, C. and A. Garland (2002). “Identifying and challenging unhelpful thinking.” Advances in Psychiatric Treatment 8(5): 377-386.
We saw the movie House of Frankenstein last Saturday night and, spoiler alert, everybody dies!
Anyway, the main impulse we had when listening to Boris Karloff (who played Dr. Gustav Niemann) was to think of something I’m not even sure I can say on this blog due to the strict copyright laws governing even the utterance what I’m going to call NAME. I’m using only the word NAME because I’m afraid Dr. Sues Enterprises will track me down and sue me for copyright infringement if I actually say NAME.
Yes, Dr. Sues Enterprises is intentionally spelled that way because I’m not even sure I can say their name without getting slapped with a lawsuit.
No kidding (and this is no joke by the way), I read a lot of scary stuff on line about how NAME is not in the public domain and what can happen to you if you even say it out loud.
I think I can get away with saying that Boris Karloff was 79 years old when he voiced NAME in the movie which I guess will have to remain nameless.
There are people who get away with it, though. Maybe it’s because they pay for the privilege of uttering NAME.
Here’s an interesting thing. Pixabay has a lot of pictures that are royalty-free. You want to guess what I found there? Pictures of NAME! I don’t know how they get away with it. OK, so maybe it’s because they don’t charge a fee for use.
On the other hand, there’s this guy who wrote in to some kind of ask-a-lawyer website that he sells a tee shirt that has NAME printed on it. He got a copyright infringement notice and asks why he can’t get away with it. All the lawyers who answered said he can’t sell shirts with NAME on it because Dr. Sues Enterprises has a federal trademark registration on NAME.
Anyway, that’s the most interesting part about the movie House of Frankenstein.
I found out that the Centers for Medicare and Medicaid Services (CMS) is planning to reclassify the diagnosis code for delirium, making it less serious than encephalopathy. Many clinicians are challenging it and organizations of consultation-liaison psychiatrists and the like, including me, don’t understand or agree with the plan.
Even though I’m a retired C-L psychiatrist, I put my two cents in as a comment. I told them what I used to tell others who were either my colleagues or my trainees—that delirium is a medical emergency. I support classifying delirium as a major complication or comorbidity (MCC).
Since CMS asked for supporting documents, I included a pdf of Oldham’s article:
Oldham MA, Flanagan NM, Khan A, Boukrina O, Marcantonio ER. Responding to Ten Common Delirium Misconceptions With Best Evidence: An Educational Review for Clinicians. J Neuropsychiatry Clin Neurosci. 2018 Winter;30(1):51-57. doi: 10.1176/appi.neuropsych.17030065. Epub 2017 Sep 6. PMID: 28876970.
As the authors say, “Delirium always has a physiological cause.”
I want to give a shout out to the Big Mo Pod Show Subverting Expectations that aired on May 11, 2024 following the Friday Big Mo Blues Show on May 10, 2024.
What impressed me most and puzzled me a lot was the tune that Big Mo didn’t talk about on the podcast. The tune was a dazzling guitar performance called “Hot Fingers” by a duo called Lonnie Johnson and Blind Willie Dunn. Big Mo said it was recorded in the 1920s.
I looked for a video of it and could find several with the picture of what looked like a Caucasian guitarist and nobody else. I also saw one picture with the Caucasian guitarist and what looked like a cut-and-pasted photo of a black guitarist.
Because I couldn’t tell who was who, I googled their names. It turns out that Lonnie Johnson was a well-known blues guitarist. He was black. Lonnie Johnson recorded “Hot Fingers” with another famous jazz guitarist named Eddie Lang, who was white. Eddie Lang used the alias of Blind Willie Dunn in order to hide his race while performing with Lonnie Johnson. I’m not sure how Eddie Lang could pass for black, an interesting twist in the late 1920s. I’m not saying either was racist. Why would they have performed together if they were? And why would Eddie Lang have adopted the black-sounding pseudonym?
So that brings me back to the title of the Big Mo Pod Show which was Subverting Expectations. The expectation that gets subverted had to do with a tune I don’t remember hearing on Friday night. It was “That Lovin’ Thang,” by the group Tas Cru, with which I’m unfamiliar. Big Mo remarked that you could listen to the blues as played by Tas Cru with an expectation that they were going to make mistakes in their performance—which never happened, attesting to their talent.
On the other hand, it strikes me that the story behind Lonnie Johnson and Blind Willie Dunn (Eddie Lang) does create its own sort of subverted expectation, in a different sense. I know Blues music experts already knew that, but it was news to me.
Go Retire Psychiatrist 