Between Flag Day & Father’s Day

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There are many different kinds of fathers, many kinds of courage.  This is dedicated to my own father, as well as the many other warriors & fathers I have loved…

As a psychiatrist and a physician, this is the protocol for presenting a patient, an initial psychiatric evaluation.  To maintain confidentiality, details have been altered to protect the patient.

Identification: Mr. Klein is a 27 year-old computer programmer with a recent history of worsening depressive and anxiety symptoms, presenting for evaluation of possible Posttraumatic Stress Disorder.

Chief Complaint: “I am not sleeping and my family says I am not myself anymore”

History of Present Illness: Tim states that his sleep keeps getting worse.  He is now sleeping 3-4 hours a night on a “good night”.  He sleeps 10-12 hours once every couple of weeks.  His mind races and he can’t sleep without some noise or a light on.  This has been going on for about 2 years.  He does not feel rested.  He does not take naps.  Energy is low.  He has tried taking over-the-counter sleeping pills, which make him feel hungover and still not rested.  He is having nightmares 2-3 times/week.

Tim’s mood is labile, he switches from happy to angry almost instantly This can happen multiple times a day. He states that he is snapping at people all the time. Appetite is low, he eats about once a day, because his wife makes him, otherwise, he forgets or doesn’t care.  He has lost 10 pounds in the last several months.  He has decreased motivation and some difficulty with focus and concentration, is having to write things down more.  He used to enjoy hunting, fishing, riding his dirt bike, working out and being with his family, but has not been able to enjoy any activities lately.  He continues to function at work, however he does snap at coworkers more than usual and can’t always explain why.

He did have one experience of extreme hopelessness and sat looking at his gun about 6 months ago, and occasionally feels like there is not a point to living, but states suicide is not an option for him because he could not do that to his family and also feels like his dog needs him.  He still sleeps with his gun.

Tim endorses trauma in Iraq but is hesitant to describe it, only saying he cleaned up dead bodies.  He endorses re-experiencing symptoms and describes these as repeated, disturbing, uncontrollable memories of the trauma, nightmares of the same, and having physical symptoms of shortness of breath, chest tightness, sweating triggered by babies crying, large groups of people.  These episodes occur a couple times a month, lasting 15-20 minutes.  He has difficulty turning generalized worry thoughts off.

He describes avoidance symptoms as an inability to discuss events of deployment with anyone, inability to go to Wal-Mart or movies; feels distant and cut off from people, occasionally loses track of time.  He describes hyperarousal as extreme difficulty falling asleep, jumping when someone comes up behind him, almost hitting people that tap him on shoulder, has to sit in the corner facing out at restaurants.

He denies manic/hypomanic symptoms, including hyperverbosity, euphoria, excessive impulsivity such as gambling/spending sprees, pressured speech, increased energy, decreased need for sleep.

He denies auditory hallucinations, but describes seeing shadows out of the corner of his eye occasionally.  Denies paranoia per se, but also worries excessively about being judged by others in general.  Denies reading others’ thoughts or concern for others inserting or reading his mind.

Past Psychiatric History: none

Past Medical History: history of ACL repair several years ago, otherwise healthy; no head injuries.

Medications: none, occasional multivitamin

Allergies: no known drug allergies

Family History: Father with coronary artery disease, died of myocardial infarction in his 40’s; Mother is healthy with possible anxiety, never treated.

Social History: Tim grew up in Salt Lake City.  Describes childhood as “okay”.  Is oldest of 4, with 2 brothers and one sister.  Father died when he was a teenager.  Father was authoritative, strict, occasionally spanked the kids.  Mother was quiet & loving, but devastated by loss of patient’s father.  She struggled to raise the kids.  Mother remarried x 2.  Once when pt was young and again more recently.  Happily married now.  Patient left home at early age and worked several jobs.  Is still close with mother and siblings. Had several relationships with women, but married when his current wife got pregnant.  Has been married 5 years and has two children, ages 5 and 3.  Wife is supportive and works as bank teller.  Patient graduated high school and has some community college, would like to return to school.  He currently works as programmer.  He denies sexual/physical abuse.

Military History: joined Marines at age 18 to “get life straightened out”, liked the people and the structure, was a combat lifesaver, deployed in 2003, 2006, 2007; honorable discharge, highest rank of sergeant.

Substance Abuse History: First drink of alcohol at age 17, “partied” a couple of times in high school, socially in military and since discharge, recently increasing over last couple of months to a 6-pack a night, most nights of the week and occasionally drinking to get drunk on weekends.  History of blackouts on 2-3 occasions.  Denies ever having withdrawal symptoms or DUI.  Smoking tobacco since combat training, one-half pack per day.  Remote marijuana experimentation, none recent.  No other illicit.  No misuse of prescription medications.  Rare caffeine.

Legal: none

Mental Status Exam:  Tim appears stated age.  He is well-groomed, with good hygiene, in professional clothing.  He had normal eye contact and was polite, appropriate.  He was cooperative.  He appeared mildly anxious throughout exam, with some foot tapping and hand-wringing.  He was alert, oriented x 4, was able to attend.  His speech was of normal volume, pace and pressure, with mildly shaky intonation at times.  His mood was described as “irritable”.  His affect mildly dysphoric and mildly anxious.  His form of thought was linear.  Content of thought was normal, no circumstantiality/tangentiality, perseveration, delusions or current suicidal or homicidal ideation.  His perceptions appeared normal with intact judgment and insight.  No gross cognitive or memory impairments observed.

Normally this is the point in the evaluation where the assessment, diagnosis and treatment plan would be in the outlined.  Instead, here is more of the story.  What is written thus far is how I see and formulate the patient after 50 minutes, but Tim grows and fills out over the months and years that he comes to me for follow-up medication management and talk therapy.  Although parts of the story will circle around again and I hear them repeated, either he will add something new, deeper or I will ask a magic question and get more.  We develop a relationship.  He trusts me and lets me in. He gets to know me, in that I truly care about him, there is nothing that he can tell me that will make me turn away from him.

It is in his telling, testing, trusting that he begins to allow himself the peeling away of the layers.

Tim was the good son.  The boy who had had the perfect life, hunting, fishing, camping with his father – idyllic, reliable.  His father strict and authoritative, Tim always knew where he stood, how to succeed and exactly when and how he failed.  He also knew his father loved him.  He had something he could count on.  After his father died suddenly of a heart attack, in Tim’s adolescence, he had to learn as a kid, a junior in high school, how to be his own man.  His mother, so lost in her grief, she could barely care for the young ones, and Tim concerned that he was a burden to his mother, he left home at an early age and worked to support himself.  He lost not only his father, but his mother and his home.  He spent many years taking pride in the fact that he cared for himself and only now, many years later begins to sidle up to the sadness of it.  The emptiness and loneliness of it.

Struggling to make his way, he supported himself.  But also lost years to parties, girls and occasional drugs.  He met an older man at one of his menial jobs, who, like a father, encouraged him to get his life back on track and consider the military.  Tim loved the military.  Once again he had something he could count on.  The military replaced the father, mother and family he no longer had.  He didn’t have to wonder what his job or purpose was, what was expected of him, how to succeed. He was a good and strong worker and rose in the ranks.  Happy, satisfied and motivated.  He was able to support his family and give his kids what he lost as a child.  He was a good dad, he took care of them, they could count on him and he ran a tight ship.

Then, he was deployed to Iraq.  Not once.  Not twice.  But three times over the course of several years.  The things he saw and did were so terrible he could not speak them to me until he knew me almost a year.  They are not things a young man, with the world by the balls, should have to see, do, or say.  These are the things he can not confess to his wife.  He wouldn’t be able to bear shocking, disgusting or horrifying her.  Or worse, receive a blank stare.  Not getting it, instead with the now you are home, you can get over it, hold your child, move on.  In his protecting himself, protecting her, protecting his kids, he becomes more isolated, alone, irritable, angry.  More distant from who he was before he left.  Which gets further and further away from him.  He becomes panicked.

He wakes up kicking and screaming.  He wife begins to fear him.  Already used to being alone, because she was without him during his multiple deployments.  She had to learn to be the mom and the dad while he was gone, so she continues to live independently and doesn’t really need him, come to think of it.  She manages the house, the kids.  They live like roommates.  Tim is no help to her.  He feels more broken.  Tim unable to comfort his children when they cry, soothe or hold them because of what it reminds him of, he usually escapes the house.  He abandons his family and yet feels grossly abandoned by them.  But he only does what he has always done.  What he did to stay alive at 16 and again in the “sandbox” and ever since.

What he is left with is memories.  They haunt him in waking and in sleeping.  They chase and terrify him.  Trick him into thinking he is dying and in the most public of places, a Smiths or Wal-Mart.  He becomes the monster he imagines he must be.  Alone and lost in his head, his brain continues to play tricks on him.  He tries to solve the puzzle but can’t.  He used to be able to plug in A to get B, now just gets him cra-Z.

I know.  Not because I have been there, done that.  But because I have inhabited these stories, over and over again.  Not just Tim’s story. But the Vietnam war vet, the Iraq or Afghanistan veteran, even a Korean War vet.  I sit with them.  I hold the space.  I hold on to myself.  They need not be anyone for me.  I do not judge them, hurt them, abandon them.  I understand that walking through that door of the clinic, that first time we meet takes more courage than stepping off a plane into Fallujah.  Admitting he needs help, terrified he may be crazy, sitting still in the chair across from me, may be the harder of things Tim has done lately.  But it is often at the point when they are getting closest to nothing-to-lose that they risk it.  And then, that act alone may give him the confidence to keep moving through.  Which is what I keep asking him to do.

Tim, like all the soldiers, were good, strong boys, if not mildly damaged, hurt before they found the military or the military rescued them.  And he, like most, was a very good soldier.  He survived didn’t he?  Or part of him did.  His hyper-alert senses helped him stay alive. His compartmentalizing, keeping his family tucked safely away.  To keep them too close might distract him from his mission, as would emotions, his humanness, tucked away too.  His strong, taking-care keeps him from asking for help, admitting weakness.  So even when the plane brings him back to safety, his well-trained, well-behaved soldier does not turn off like a switch.  Iraq may not have made sense in his head or in reality, but ironically, the chaos of his life now is what makes him feel crazy.  There is no logic.  No structure.  His strong betrays him.  Around him are insanely petty problems.  Gossip.  Intensely stupid drivers in traffic.  His wife nagging at him or worse, ignoring him.  All confuse him further.  He loses track even more.  Becomes more angry, let down, feels betrayed constantly.  Lost.  And touching on a lifetime of loss: dad, the three boys in his unit he watched get blown to bits by an IED, his wife, his kids, himself, his sanity, his strength and his “surviving”.  Confused.  About what he did, gave, and got in return.  Trapped between worlds.  Between here and there.  Between who he was and who he may become. Between avoiding grief and getting to the other side of it.

I listen to the stories.  Witness.  Inhabit.  Keep them close.  Keep them safe.  The medications I offer may turn down the fight or flight, get him sleeping, keep him off the bottle, help him stay married or keep his job or keep him out of a bar fight.  But it is what I do with his story, which will help him come home, help him find his way back to himself and hope.  Help him make sense of the senseless, understand the completely illogical.  Speaking the all of it, aloud, layer by layer, and bravely.  And then held preciously.

Moving through it, and not-alone, helps him grieve, get unstuck, out of the in-between.  And for me, it is a deep and abiding honor.

Post-Prozac

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Dr. Siddharta Mukherjee – author of the wonderful book, Emperor of Maladies, a biography of cancer – has written a compelling article in the New York Times Magazine (dated April 22, 2012), Post-Prozac Nation.

What I enjoyed most about this article are the important questions he brings up, his position of curiosity and hope, as well as the fair and even way he describes a complex and nuanced subject with color, depth and breadth.  Similar to his cancer tome, he brings his medical understanding, clinical experience, together with history and personal story to present a literary tale about a topic that may otherwise be technical or dry: psychopharmacology.

He moves the dialogue forward from the evangelism of the early days of SSRI’s, ala Wurtzel’s Prozac Nation and Kramer’s Listening to Prozac, beyond the later/latter days (and backlash) ala Healy’s Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression.  

Addressing the serotonin/chemical imbalance theory which has developed in the vacuum of ignorance around how exactly these medications work, and is now looking like a (over-simplistic) fail, Mukherjee quotes Jonathan Rottenberg (Psychology Today), reminding us: “… the nature of science is ultimately to be self-correcting. Ideas must yield before evidence”.  He goes further to say that “Science may be self-correcting, but occasionally it overcorrects – discarding theories that instead need to be rejuvenated”, he then rejuvenates by showing us some of the new evidence, and in light of the past and what we have seen so far, NOT throwing out the “baby with the bath water” so to speak.  Taking a broad and curious view.  Which leaves so many more exciting questions.

Mukherjee reviews the history of the discovery of the “exultation” of Prozac, starting with the 1950′s use of isoniazid and Raudixin, inserting the poetic and literary understanding of depression, the “flaw of love”, and uses a personal clinical case to both broaden and personalize this story.  He uses the metaphor of heart disease and a common pathway theory to broaden the view of how depression may work in the brain, comparing the SSRI to how aspirin is used today in heart disease.  Different fascinating results are presented from a multitude of neuropsych research studies in order to invite us to step back and see one more piece, to not-know, with a wider lens, as a starting place for more questions, instead of zooming in to see one single study as “the” answer to an obviously giant complex puzzle.

He bravely brings up the SSRI vs Placebo question and addresses whether SSRIs help at all.  Short answer, they do.  He gives good argument.  An important part of this whole argument, in my mind, and perhaps implied by this article, is the difference in the conversation if the goal is “cure” or if the goal is “symptom relief” or as the author describes, the return of “vitality”.  An important differentiation and perspective for an individual living with chronic and debilitating depression, where improved quality of life may feel huge, in a world where there may be no cure.

Mukherjee brings in the fascinating discovery of neuro-plasticity, still relatively infant, beginning in the 1980′s.  And how this seemingly peripheral development may relate to this SSRI discussion and an ongoing exploration of depression understanding and treatment.  Prozac causing neuronal growth?!  Awesome.

Just as moving the goal of treatment from cure to healing, or “vitality”, the author moves the chemical hypothesis conversation from a static, signal-strengthener view to a discussion of “process”, with serotonin still central but in a much more dynamic (and fascinating) story.  He even ventures out into the territory of the SSRI changing behavior and the behavior affecting mood.  Stretch the mystery.  Might as well.

Mukherjee wraps all these wonderful stories and questions up, quoting John Gribbin, a historian of science (like Mukherjee) saying that “seminal scientific discoveries are inevitably preceded by technological inventions”, mentioning the telescope and astronomy, microscopes and the cell, and ends with a beautiful metaphor: “Our current antidepressants will owe a deep intellectual debt to our thinking about serotonin in the brain. Our current antidepressants are thus best conceived not as medical breakthroughs but as technological breakthroughs.”

I am grateful to Dr. Mukherjee for his wise, compassionate and nuanced attention to this medical history, diving into the controversy with an openness and fascination with the mystery, his courage and creativity in asking brave questions of us and the future and all with a lovely, lyrical storytelling quality.

Prozac may not be the savior we once hoped or for all.  But it is neither the devil or great disappointment.  And thus, we do the best we can on the ground, in the clinic, in the mean time.  With each other and what we know and have right now, believing and hoping that the future will continue to bring the picture into brighter, sharper focus.  We can do what works, reflect on our history and individual story, accept the mystery and stay open, wondering, curious.

Wild Geese

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You do not have to be good.
You do not have to walk on your knees
for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body
love what it loves.
Tell me about despair, yours, and I will tell you mine.
Meanwhile the world goes on.
Meanwhile the sun and the clear pebbles of the rain
are moving across the landscapes,
over the prairies and the deep trees,
the mountains and the rivers.
Meanwhile the wild geese, high in the clean blue air,
are heading home again.
Whoever you are, no matter how lonely,
the world offers itself to your imagination,
calls to you like the wild geese, harsh and exciting–
over and over announcing your place
in the family of things.
– Mary Oliver