Category: Psychiatry

Svengoolie Movie Trilogy of Terror!

Last Saturday we watched the movie Trilogy of Terror on the Svengoolie show. Well, we tried anyway. There were a lot of interruptions from severe weather warnings. We didn’t mind them because you ignore them at your peril. It’s hard to forget the 2020 derecho in Iowa, which affected a lot of Iowans, including us.

Trilogy of Terror had some psychiatric aspects to it that reminded me how Hollywood frequently gets it wrong when portraying them in films—but sometimes hits the nail on the head.

Although we missed parts of the first and second parts of the movie, it wasn’t difficult to figure out the psychological angle. Both “Julie” and “Millicent and Therese” made me think of antisocial personality disorder (ASPD). The male college graduate student was a pretty good example of a predatory guy lacking any conscience and feeling no remorse for his bad behavior against his apparently meek and defenseless teacher, Julie.

But then the tables were turned and it was Julie who was actually the convincing, coldly calculating and remorseless psychopathic serial killer. She kept a scrapbook of the newspaper stories about her many victims.

One of my colleagues wrote the book about ASPD. Dr. Donald Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy). In it he recounts the story of serial killer John Gacy. He was diagnosed with ASPD at the University of Iowa. He collected a great deal of data about antisocial men and also acknowledges that women can be diagnosed with ASPD. He has also co-edited and published the Textbook of Antisocial Personality Disorder.

The “Millicent and Therese” part of the movie displayed how a woman can be diagnosed with ASPD. This was the character Therese—who was also Millicent, a very strait-laced alter personality, which makes this also a case of what you could call dissociative identity disorder (DID), which may be related to severe trauma. This used to be called multiple personality disorder. What was interesting about this part of the movie was that both identities were being managed somehow by a family physician, not a psychiatrist—which is not at all plausible.

The last part of Trilogy of Terror is “Amelia,” in which Amelia buys a Zuni fetish doll (named “He Who Kills”) which she intends to give to her boyfriend. However, she’s in a hostile, dependent relationship with her mother who controls her and interferes with every aspect of her life. Of course, the doll comes to life and tries to kill her.

The struggle between Amelia and the doll makes me think about her internal struggle with angry and probably murderous feelings about her controlling mother. Amelia finally internalizes the doll’s rage (actually her own) when he emerges from the oven where she shoved him in an apparently futile attempt to burn him to a crisp. What it looks like is that she inhaled the smoke, finally owning her own rage by internalizing the doll’s smoky remains. This transforms her into a vengeful killer (now grinning with the sharp teeth of the doll) who calls her mother to invite her over to her apartment with the obvious plan to cut her to pieces with a large knife.

This is probably not a movie for kids or sensitive adults, which Svengoolie acknowledges several times during the show. This is why I like the segment with Kerwyn, the dad joke telling chicken with teeth who is voiced by Rich Koz, who also plays Svengoolie. Usually during that segment he tells a series of jokes, repeating the lines a couple of times, seemingly in an effort to teach you how to tell dad jokes. There’s also a Kerwyn joke of the week event, in which he tells a joke submitted by a fan. The joke video takes a few seconds to load, so be patient.

The Dirty Dozen on Delirium in WordPress: A Shortcode Presentation

When I was a consultation-liaison psychiatrist I taught trainees in different ways. One of them was what I called the Dirty Dozen slide sets. They were on various basic topics that are important for psychistrists to know. I tried to put the most important points on only a dozen powerpoint slides.

After I started blogging about C-L Psychiatry around 13 years ago, the WordPress blogging platform started offering a way to post slide presentations using what is called shortcode. Presumably, you didn’t really have to know anything about coding language but the instructions weren’t very helpful.

I think I started trying to make slides using shortcode shortly after it was first introduced around 2013. I had to contact WordPress support because I couldn’t learn shortcode. A lot of bloggers had the same problem.

I think my main reason for getting interested in shortcode was so I could cut down on how many powerpoint slides I had to convert to images, which can take up a lot of space on a blog site after a while.

Anyway, in the past few days I tried to pick up the shortcode but couldn’t get the hang of it again. I finally found a WordPress help forum in which I found a blogger’s solution. She made it so clear.

Anyway, the Dirty Dozen on Delirium is below. 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. . When you click the URLs on the delirium websites, right click and open them in a new tab.

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Reminder: NAMIWalks May 4, 2024 in Iowa City

Don’t forget to register for the Johnson and Linn County NAMIWalks on May 4, 2024. See registration and location info below:

The University of Iowa Role in the Science Behind Psilocybin for Psychiatric Treatment

On April 9, 2024, the University of Iowa educational podcast, Rounding@Iowa presented a discussion about the study of the use of psilocybin in the treatment of psychiatric and addiction disorders. You can access the podcast below. The title is “Psilocybin Benefits and Risks.” The format involves an interview by Dr. Gerard Clancy, MD, Senior Associate Dean for External Affairs, Professor of Psychiatry and Emergency Medicine with distinguished University of Iowa faculty and clinician researchers.

In this presentation, the guest interviewees are Dr. Michael Flaum, MD, Professor Emeritus in Psychiatry, University of Iowa Carver College of Medicine, and Dr. Peggy Nopoulos, MD, Chair and Department Executive Officer for the University of Iowa Department of Psychiatry, Professor of Neurology, Pediatrics, and Psychiatry, University of Iowa Carver College of Medicine.

All three of these highly respected and accomplished faculty taught me when I was a trainee in the psychiatry department and afterward were esteemed colleagues.

87: New Treatment Options for Menopause – Rounding@IOWA

Join Dr. Clancy and his guests, Drs. Evelyn Ross-Shapiro, Sarah Shaffer, and Emily Walsh, as they discuss the complex set of symptoms and treatment options for those with significant symptoms from menopause.  CME Credit Available:  https://uiowa.cloud-cme.com/course/courseoverview?P=0&EID=81895  Host: Gerard Clancy, MD Senior Associate Dean for External Affairs Professor of Psychiatry and Emergency Medicine University of Iowa Carver College of Medicine Guests: Evelyn RossShapiro, MD, MPH Clinical Assistant Professor of Internal Medicine Clinic Director, LGBTQ Clinic University of Iowa Carver College of Medicine Sarah Shaffer, DO Clinical Associate Professor of Obstetrics and Gynecology Vice Chair for Education, Department of Obstetrics and Gynecology University of Iowa Carver College of Medicine Emily Walsh, PharmD, BCACP Clinical Pharmacy Specialist Iowa Health Care 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 1.00 ANCC contact hour. Physician: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this enduring material for a maximum of 1.00 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.) References/Resources:   
  1. 87: New Treatment Options for Menopause
  2. 86: Cancer Rates in Iowa
  3. 85: Solutions for Rural Health Workforce Shortages
  4. 84: When to Suspect Atypical Recreational Substances
  5. 83: Hidradenitis Suppurativa

The link icon adjacent to the title of the podcast takes you to the podcast website. The link to the article in Iowa Magazine about the psilocybin research at University of Iowa Health Care tells you more about Dr. Peggy Nopoulos and her role as principal investigator in the study.

There is also a link to the National Library of Medicine Clinical Trials web site where you can find out more details about the study design. You’ll notice a banner message which says: “The U.S. government does not review or approve the safety and science of all studies listed on the website” along with another link to a disclaimer with more details.

Cat-astrophizing About the Association Between Cats and Schizophrenia Risk

It seems like every few years there is a spate of news stories about the supposed risk of developing schizophrenia from having a pet cat. The bottom line is that there is no direct link, but you can’t tell a reporter that. I mentioned the issue in a blog post about a feral cat in our neighborhood last year.

The research about this often has limitations, some of which are pointed out in this web article. A Psychiatric News article published in 2017 presented a reasonable position which apparently no reporters have read.

I’m allergic to cat dander. On the other hand, some cats are important enough to be entrusted with carrying an entire galaxy around their belts, reported in the Men in Black documentary which is in large part about a cat named Orion.

The Changing Role of the Psychiatrist in Managing Depression with Medical Illness

This post is mainly a reminiscence about my days as a consultation-liaison psychiatrist. I often evaluated patients who had chronic hepatitis C. The liver disease itself and the treatment (interferon alfa) often led to patients struggling with depression.

The impetus for this came from noticing a couple of items. One is the recent l blog post about treatment of depression by George Dawson, MD (“Are Medication Trials for Depression Too Long in Duration?”). The other is a Psychiatric Times article about the Star-*D depression treatment study published in Psychiatric Times (“Star*D: It’s Time to Atone and Retract” by Nicolas Badre, MD and Jason Compton, MD).

Back in the day, I thought it made sense to use depression rating scales in my clinic practice. I use the term “clinic practice” reservedly because in actual practice I was too often running the hospital psychiatry consultation service to see outpatients regularly.

There has been a recent call to retract the Star*D study. I wasn’t involved in the study, of course. I was too busy running around the hospital responding to consultation requests. I noticed the criticism in the Psychiatric Times article by Badre and Compton of the specific depression rating scale, the QIDS-SR (which stands for Quick Inventory of Depressive Symptomatology (Self-Report).

I tried to integrate into my practice the QIDS-SR as well as the Clinically Useful Depression Outcome Scale (CUDOS). The latter was designed by psychiatrist Dr. Mark Zimmerman around 2008. I believed in the principle of measurement-based assessment of psychiatric symptoms and did my level best to integrate them into my practice.

It was very difficult to do. My patients were typically suffering from both medical and psychiatric illness. Often, they had physical symptoms that you could attribute to either the medical problem itself or “depression”—or both. This is a common challenge in consultation psychiatry.

Returning to my experience with patients who had chronic hepatitis C, in my early career, some of them who were on interferon alfa would not uncommonly develop depressive symptoms during treatment. Sometimes that meant stopping the treatment. Moreover, they sometimes had other side effects including thyroid function abnormalities, which can also cause mood disturbance.

There have been debates about whether to count physical symptoms in depression because of the overlapping symptoms: fatigue, appetite loss, trouble sleeping and the like. There’s also what has been called the “fallacy of good reasons.” Wouldn’t you be depressed too if you were sick and tired of being sick and tired? This could lead to undertreatment of depression. Some diagnostic models suggested counting all symptoms regardless of etiology.

Some randomized controlled trials of antidepressants in the past showed antidepressants were effective in the medically ill with depression. Others showed they were not better than placebo.

Nowadays there is a new pharmacologic approach to treating hepatitis C and those are in the category of direct-acting antivirals (DAA). According to fairly recent literature, the DAAs offer a better chance of cure of hepatitis C and less psychiatric side effects. That doesn’t mean psychiatrists are no longer needed. The common issues such as comorbid substance use and cognitive disorders, highlighting the ongoing need for collaborative care between medicine and psychiatry.

The FDA Announcement on Kratom

Just in case you missed it, the FDA posted an announcement about Kratom in February this year. According to the FDA:

“Kratom is a tropical tree (Mitragyna speciosa) that is native to Southeast Asia. Products prepared from kratom leaves are available in the U.S. through sales on the Internet and at brick-and-mortar stores. Kratom is often used to self-treat conditions such as pain, coughing, diarrhea, anxiety and depression, opioid use disorder, and opioid withdrawal.”

The other day as we were driving home on Highway 1 through Iowa City, I saw a sign advertising Kratom on a small store. I thought that might be illegal, but when I checked the Iowa Office of Drug Control and Policy, I found out it’s currently legal in the state.

Opinions vary about risks of using Kratom. The DEA tried to place in on the Schedule I, but the American Kratom Association and other supporters apparently prevented that simply by protesting it. The pharmacist who wrote the article (link above) raised a note of irony by questioning why marijuana is still regulated as a Schedule I drug.

The legality of Kratom also varies across the country. There is a very detailed review article about it that attempts to examine the use of Kratom from both the medical practitioner and patient points of view.

Picture Credit: By Psychonaught – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=8255742

Remember The Calling

I recommend Dr. George Dawson’s recent posts on seeing the practice of medicine as a calling and his passing a big milestone with 2 million reads on his blog.

I wrote a post entitled “Remembering Our Calling: MLK Day 2015.” It was republished in a local newspaper, the Iowa City Press-Citizen on January 19, 2015. And I reposted it in 2019 on this blog.

The trainees I taught also taught each other about psychiatry and medicine when they rotated on the consultation-liaison service at the hospital. We put them into the format of short presentations. I called mine the Dirty Dozen. The trainees and I also presented the Clinical Problems in Clinical Psychiatry (CPCP).

There were many of those meetings, which were necessarily short and to the point because the service was busy. We got called from all over the hospital. We answered those calls and learned something new every time.

I posted a lot of the trainees’ presentations in my previous blog, The Practical C-L Psychiatrist, which was replaced by this present blog. I haven’t posted the presentations partly because I wanted to give the younger teachers their due by naming them as they did on their title slides. But I would want to ask their permission first. They are long gone and far flung. Many are leaders now and have been for many years. I still have their slides. I’m very proud of their work. When they were called, they always showed up.

So, you’ll just have to put up with my work and my cornball jokes.  

The Good and the Not So Good About Mental Health Treatment

Sometimes I write “depressing” blog posts. On the other hand, I have both good and bad news today.

I found out that, according to the Treatment Advocacy Center, Iowa’s state psychiatric hospital bed availability is dismal according to 2023 figures. That’s actually not new. Although we rate last in the nation for this, we still get a Grade B overall. I’ll have more to say later about it. You can check your own state’s grade on the web site’s map graphic.

And a recently published article about antidepressant prescribing for young people is sort of depressing, there are ways to address the likelihood that adolescent females are being prescribed antidepressants more often than adolescent males.

I tend to agree with the author of another article on adopting a more nuanced perspective on what is often called “depression” in young people.  Not everybody who is distressed is depressed.

Even if we are depressed, there are healthy activities we can engage in to heal. We don’t all necessarily need antidepressants. That’s the point of a recent systematic review and meta-analysis on the role of exercise for managing depression. Exercise is effective either by itself or in addition to psychotherapy and antidepressant.

Iowa actually seems to be putting a lot of hard work in mental health outreach, such as Your Life Iowa. It’s funded by the Iowa Dept of Health and Human Services under the Division of Behavioral Health.

I’d say that’s pretty positive, overall.