I (along with my friends) have made progress through the five pounds of fortune cookies; I now have about two pounds of cookies left. I am collecting all of the fortunes in a clear sandwich bag. Most of the fortunes are fluffy and light:
- You will hear from an old friend.
- You will find fame and fortune.
- You will develop a new interest.
Some of them do not explicitly forecast good fortunes:
- A career change may be in your future (… because your skills are outdated. You are the weakest link—good-bye!).
- You will be admired for your internal beauty (… because there’s nothing to admire about your physical appearance).
- Your curiosity may mean success (… or not).
One fortune was particularly striking:
- You will never know hunger.
What a fantastic fortune, right? To know that a basic human need will always be met? That, even if I do not “meet a new friend”, “find a small fortune”, or “soon follow [my] heart’s desire”, I will never know hunger?
It’s an accurate fortune; people who are acquainted with hunger likely will never eat fortune cookies—you need money to acquire these trifling treats.
This is a humbling fortune. I only wish that it could be true for everyone, everywhere.
19 Feb 2007 | 3 comments.
The Question of Bipolar Disorder in Kids.
It’s no wonder that people think psychiatrists are a bunch of hacks.
Rebecca Riley was a four year-old girl, diagnosed with bipolar disorder at the age of 2.5 (!!!), who was found dead in Hull, Massachusetts, presumably due to
“intoxication due to the combined effects” of the drugs clonidine, valproic acid (Depakote), dextromethorphan, and chlorpheniramine….
For reference, clonidine is a blood pressure medication that is sedating (and thus has been used to promote sleep and reduce (aggression in kids).
Valproic acid is a mood stabilizer and anticonvulsant (prevents seizures) that is commonly used in the treatment of bipolar disorder. Frequent side effects include weight gain and sedation. (Then there’s the minor details of possible liver inflammation and pancreatitis (inflammation of the pancreas).)
Dextromethorphan is an “antitussive” (prevents coughing). You can also get high off of it—if you consume enough of the stuff.
Micromedex tells me that chlorpheniramine (which I’ve never heard of before) is used for allergies—like Benadryl.
According to news reports, she also received quetiapine (tradename: Seroquel), an antipsychotic medication, from her psychiatrist. The major side effects of quetiapine include weight gain and sedation. It can also cause blood pressure to drop, such that people feel light-headed.
Prior to her death, school administrators had noted that she had been “a little too quiet”. Probably because she was “a little too sedated”.
There does not exist any criteria that are clearly valid or reliable for the diagnosis of bipolar disorder in children (1). The assumption is that criteria for adult bipolar disorder can be applied to kids, though researchers in that area simultaneously agree that adjustments are necessary for this diagnosis in kids. It’s kinda like saying, “It’s basically the same thing, but only different.”
The criteria that some researchers (2) use to diagnose bipolar disorder in kids include:
Elated mood:
- “… it can be very misleading to see a happy child laughing in the office in the context of a miserable history (e.g., school suspensions, family fights).”
Grandiose delusions:
- “A common presentation for bipolar children is to harass teachers about how to teach a class; this harassment is often so intense that teachers telephone parents, begging them to ask their children to desist.”
- “Another common grandiose manifestation in children as young as seven is to steal expensive items and be impervious to police officers who attempt to make them understand that what they have done is wrong and illegal.”
- “Common adolescent grandiose delusions include are that they will achieve a prominent profession (e.g., lawyer) even though they are failing at school, i.e., the belief that they can have a high attainment when they have failing school grades bypasses the laws of logic.”
High activity level:
- “Manic adolescents will wait until their parents are asleep and then go out “partying”….
Pressured speech, racing thoughts:
- “… children state that they are not able to get anything done because their thoughts keep interrupting.”
Hypersexuality:
- “Children may masturbate frequently, initially openly, and then when told not to do it publicly will simply make frequent trips to the bathroom to continue the stimulation.”
- “Adolescents develop romantic fantasies and delusions about teachers.”
Risk taking:
“Interest in money appears in young children when they start their own businesses in school and when they begin to order multiple items, trips, and plane tickets….”
What?
These criteria significantly overlap with the range of normal. Should every kid who is experiencing difficult social stressors never laugh? Can’t kids be obnoxious and tell off the teacher? Are kids “mentally ill” for possessing dreams and aspirations? Do kids who disobey their parents have a condition that is only treatable with medications? Is distractibility a marker of pathology?
And, for the love of God, KIDS MASTURBATE. That’s part of normal—yes, normal—development. It happens. And shouldn’t we congratulate kids for changing their behavior after receiving admonitions (kindly or otherwise) and conducting their business in private? After all, at least they’re not telling their teachers how to masturbate properly.
And what kid hasn’t had a crush on a teacher? And where do kids get the idea that money is an important facet of life? Isn’t that cultural in nature?
The article that cites these criteria does list them as if they are valid and reliable—which they’re totally not. We cannot rely on these criteria for diagnosis and since diagnosis guides treatment, the treatment (medications) is faulty due to the weakness of the evidence.
And no one is jumping up to conduct a randomized, placebo-controlled, double-blinded study on kids and medications because of all the ethical issues involved (although I recall reading somewhere that Harvard had done something like that… though I can’t find the citation now). Would you want your kid (baby sister/brother/cousin/et al.) to receive medications at uncertain doses with uncertain effects with uncertain outcomes? Do we even know how quetiapine or valproic acid or whatever affects neuronal (read: brain) development? Particularly at the age of TWO? Or, heck, even FOUR? The brain is a miraculous organ that changes dramatically well through adolescence. Just what are we doing to the neurochemistry of the brain through the introduction of these substances?
We don’t even know how valproic acid works in the treatment of bipolar disorder in adults.
The only argument I can come up with as to how these researchers justify diagnosis and subsequent treatment of bipolar disorder in kids is one that is frequently used with pregnant women: “The effects of the disease may be more harmful than the effects of the medications.” (For example, non-depressed, non-anxious pregnant women get better prenatal care, have more optimized nutritional status, smoke less, use fewer drugs, and drink less alcohol (3). Suicide is also the third most common cause of maternal death in the U.S. (4) One can thus argue that the benefits of antidepressant use outweigh the risks to the fetus.) If, however, we can’t even offer valid and reliable definitions for the disease, how can we possibly argue that treatment of this amorphous disease has any benefit?
Another facet of this is that there are some adults with bipolar disorder who state that they believe they developed this condition when they were children (1). (Side note: Using the above criteria, more than 10% of kids meet those criteria for bipolar disorder… and in adults, the prevalence is closer to 1%. This means that (a) the child and adolescent criteria for diagnosis are inaccurate, (b) the condition “burns out”, or (c) we’re measuring the wrong things.) Are we invalidating these adults by stating that bipolar disorder just doesn’t exist in kids? (Of course, who is going to remember that they had symptoms when they were two years old?)
One last aspect I’d like to address is how psychiatric training varies by region. The rumor mill tells me that child and adolescent psychiatry in Washington State is arguably the most conservative in the country; “play therapy” (where the thought is kids “play out” their issues under the watchful eyes of the therapist) is considered irrelevant and is generally not practiced here. Although there are certainly child and adolescent psychiatrists here who prescribe many, many medications to kids, the general push is to remove as many medications as possible and use behavioral interventions, structure, etc. in treatment. This is apparently in significant contrast to the East Coast, where apparently many more psychiatrists believe in the “bipolar child” paradigm—and as one moves out West, skepticism tramples this belief underfoot. The major proponents for bipolar disorder in kids (including the author of the above criteria) are all located East of the Mississippi River.
The case of Rebecca Riley is tragic on many different levels—it cries for reform throughout the system on many levels, particularly in the realm of education. We need to learn more about valid and reliable diagnosis for psychiatric disorders, both in kids and adults. We need to learn more about appropriate treatments—and not just in the realm of pharmacology—for these conditions. We need to provide this information—all of it, not just the parts that sound benign—to patients and their families. We also need to facilitate discussion with patients and families such that they feel comfortable asking questions about their care; this results in more thorough coverage of risks and benefits, encourages collaboration (e.g. increased frequency in follow-up, etc.), and improves the therapeutic relationship. We need to stop labeling behavior as pathological just because it causes us inconvenience. We also need to stop using diagnoses as means of absolving us of our responsibilities (”it was the bipolar that made me say those mean things to you; it wasn’t me”). We, as providers, need to stop colluding in these goals: We need to stop the belief that a pill will always cure everything.
That is all.
(1) Harris, J. Child & Adolescent Psychiatry: The Increased Diagnosis of “Juvenile Bipolar Disorder”: What Are We Treating? Psychiatr Serv 56:529-531, May 2005
(2) Geller B, Luby J: Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 36:1168–1176, 1997
(3) Wisner KL, Zarin DA, Holmboe ES, Appelbaum PS, Gelenberg AJ, Leonard HL, Frank E. Risk-benefit decision making for treatment of depression during pregnancy. Am J Psychiatry. 2000 Dec;157(12):1933-40.
(4) Appleby L. Suicide during pregnancy and in the first postnatal year. BMJ. 1991 Jan 19;302(6769):137-40.
17 Feb 2007 | 45 comments.
Unfortunate Fortune Cookies.
On 8th Avenue South, between South King and South Weller Streets, is a non-descript warehouse. One can easily overlook the flour spilled on the wet sidewalk outside, the corrugated aluminum garage door, and the various materials that comprise the same wall on 8th Avenue: brick, (faux?) marble, and plaster. The corporate front office is located at South Weller Street, where the words “Tsue Chong” jut out from the (faux?) marble wall in large, brass letters. Miniature blinds shade the windows and the door swings in both directions to let people in or out.
The fragrance of sugary dough hovers over the entire block.
The northern portions of the warehouse are constructed of brick. Behind the glass plate windows facing South King Street are evenly spaced, rusting bars that imprison the confections inside. Peering through the flour-dusted windows one can see a refrigerated case holding bottles decorated with bright colors, a drab, off-white counter upon which sits a tired cash register, and several shelves holding large, clear bags of thin, circular objects that resemble cookies.
(You can guess what caught my attention.)
An eight- by eleven-inch sheet of paper is taped above the shelves and, in Times New Roman font, reads “Unfortunate Fortune Cookies”. Underneath, in simple and neat handwritten print, is the phrase “5 pounds for $6.00″. There is no further explanation.
A small sign reads “PUSH” on the glass door (which, incidentally, also has a skeleton of iron bars). Upon closer inspection of the bags, one sees that each bag contains malformed fortune cookies. Most are folded, but not in the characteristic shape: Some are twisted; some feature an overly acute angle; some are missing one half of their form; many are cracked. Most of them contain the slips of paper that foretell the future; many of these cookies seem to be sticking out their thin paper tongues at passers-by. On top of these unfortunate fortune cookies are the cookies that failed to fold at all; they are instead grapefruit-sized circles.
Five pounds (2.3 kilograms) of fortune cookies occupy the entire volume of a standard plastic shopping bag.
They’re delicious, but there are way too many cookies. (I don’t know what I was thinking.) I am sharing the wealth—and the fortunes.
The fortunes, each adorned with an ornate black rose, I have thus far collected:
- Good news is coming soon.
- You will receive constructive advice today.
- The time is right to buy yourself something nice.
- All the troubles you have will pass quickly.
- You will meet a new friend.
- The future will bring romance.
- Something special is coming your way.
- Good opportunity awaits.
- You will go far, but be sure to come back.
As with many things, it’s what’s inside that counts.
15 Feb 2007 | 8 comments.
Emily Dickinson Would Be Proud.
His wound was spurting red
His skin was turning blue
He took his last breath
Before he could say, “I love you.”
(For warmer, less morose, yet still clinically relevant Valentine’s greetings, visit The Blog That Ate Manhattan.)
14 Feb 2007 | 4 comments.
CAG-CAG-CAG…
He lurched forward in the chair, nearly folding himself in half at the waist before throwing himself back again. His left leg kicked forward when his shoulders touched the chair. Though he turned his head up, the tears continued to trickle down his face.
“The reason they fired me is because they didn’t like me—I know this is true. There is no other way to explain it. They just don’t like me—I worked all of those years and this is how they thank me,” he said, his right hand tightly clutching several sheets of letterhead with “Microsoft” monogrammed across the top. Before I could read the lines of handwriting traveling across the page, his arm jerked away. The motion of his elbow tossed his wrist into the air like a slingshot launching a stone.
“Can I see the papers?” I asked, leaning against the frame of the door.
As he extended his right arm forward, his left arm shot out away from his body, as if he was flinging a gigantic cockroach from his hand.
He saw me flinch. The papers in his hand were trembling and the whispers of the rustling pages filled the room.
Before taking them, I gingerly asked him, “Are you getting angry?” I felt the muscles in my legs tighten to prepare for any sprints in my immediate future.
“NO!” he shouted, dropping his arm as his torso sharply twisted to the right. “I’m not getting angry! I just talk like this! Okay, yes, I am angry, but I’m not angry at you! I’m angry because this is happening to me and I was unfairly fired and my family is far away and—and—”
His sobs matched the uncoordinated jerking of his limbs; they were choking staccatos that sounded more mechanical than mournful.
“I’m sorry,” he mumbled, his arms still jerking at the shoulders and elbows. “I’m sorry.”
He again raised his arm—still trembling—and I took the papers from his hand. It was difficult to look at him and register his suffering; I was grateful that I could distract myself with another sight.
Scribbled across the pages were fragments of phrases, impassioned sentences, and rows of numbers, some interrupted with dashes:
4698 Harrison Drive 469 Harrison Drive 46 Harrison Drive Harrison Drive Harrison Drive Drive Drive
I speak only the truth. I tell no lies. They speak falsehoods.
425-425-425425 Microsoft Windows login pass login pass login pass login
The truth only. That is what matters. Only the truth. I know the truth. They know the lies. I know the truth. The truth. Truth. Truth. True.
“They told lies, that is why they fired me, they told lies,” he said, getting out of the chair. His body wobbled, as if his torso was not under his control. His left arm jerked out away from his body again as he reached for a sheet of paper in my hand.
I nodded, unsure of what to say. I knew he had recently learned of his diagnosis; saying “sorry” seemed empty and useless.
“Did they fire you before or after you learned you have Huntington’s Disease?” I asked.
“I was fired months and months ago, but my body was already starting to do all of this,” he answered, tossing himself back into the chair. His limbs did not rest when the rest of his body settled; they continued to move about as if controlled by a novice puppeteer. He sloppily wiped his eyes with the back of a hand before continuing, “No one in my family had this; I don’t understand why this is happening to me. No one—no one! I’ve never even heard of Huntington’s Disease! And now everyone is holding it against me—Microsoft, my family, my friends—but they all tell lies, they all tell lies. I speak only the truth. Only the truth.”
I breathed in sharply—I wanted to look away.
“I don’t understand what is happening to me,” he said, his voice becoming quiet. “I never wrote things like this before in the past—I was good at what I did. I’m changing. I never did this before—I worry that it will never go away.”
Oh God… he knows he’s losing his mind. He has insight.
“You have to help me,” he said, his right arm still twitching in his lap. My mind’s eye saw the strand of excess genetic material swirling off of his fourth chromosome, as if it was the animated tail of an exuberant kite. “I can’t go out there; people are going to think I’m a freak because I can’t stop moving; I’m going to get beat up and my stuff will get stolen and people will continue to lie about it all. I can’t do this anymore by myself.”
I tried to capture everything in that moment in my memory because I knew that, in a few months, his condition would likely be much worse. And I wanted at least one of us to remember him before he deteriorated further.
12 Feb 2007 | 11 comments.