Tuesday, November 23, 2010
Thursday, November 18, 2010
Digital Diagnosis Duo for DSM
I have found that turning ideas upside down often leads to truth. An example from my personal experience follows while another pokes fun at those who thrive (and even profit from) labeling any activity they deem excessive an addiction, then claim to offer treatment for it. (Nothing here should be interpreted as making fun of anyone who suffers from any psychiatric or substance use disorder or any professional or program intending to help such individuals.)
Digital Gaming Aversion Disorder (DGAD)
About two years ago, while sitting at my desk, I realized that there was really nothing I wanted to do. A friend had been playing solitaire on her computer, and that was all it took to get me going. Within a few days I was hooked. Almost every time I got done with whatever computer task I had been engaged in, I started playing solitaire. After a couple weeks I realized my skills were improving gradually. I began to develop winning strategies. Maybe I wasn't addicted yet, but I certainly might have been headed in that direction.
Then one day I noticed that some of the pleasure had gone. I almost had to force myself to finish a game. Next time I thought about starting another game I simply could not do it. I have not played solitaire since. When I see my friends playing, the screen looks totally two dimensional, unlike previously when it was as though I could see into the game. I cannot even imagine myself starting a game. The thought of how it works, the different suits, the different colors, the different numbers, all are blocked from my mind.
To be honest I cannot say this has interfered substantially with my social or occupational functioning. I cannot say that I am particularly distressed about this aversion to solitaire. However, should I want treatment, I have two approaches to propose, both probably requiring double blind studies to prove their effectiveness.
Psychotherapy of Digital Gaming Aversion Disorder
Cognitive behavior therapy will be the first line psychotherapy for this disorder. I believe a sufficient and appropriate reward will quickly overcome the aversion. I suggest rewarding the patient with $1000 for each game played to conclusion will rapidly reverse the aversion. I of course expect this to be covered by medical insurance.
Pharmacotherapy Of Digital Gaming Aversion Disorder
I believe a similar approach to that proposed for psychotherapy will lead to rapid resolution of this disorder using cocaine as the first line agent. A small dose after completing each solitaire game should lead to rapid resolution.
Digital Media Avoidance Disorder (DMAD)
For years now people have admonished those who, in their minds, use computers and/or the Internet "too much," calling these behaviors, like almost any other behavior they can label excessive, "addiction." It occurs to me, however, that those who engage in this "addiction addiction" simply want to deflect attention from their own dysfunction. This clever but pathological strategy, based on severe denial, has enabled them to avoid needed treatment, often for many years, for the condition I address below.
Today we must all face the fact that we can only experience true reality through digital media, using devices like computers, smart phones, and other devices, regularly, if not continually, connected to the Internet. Avoidance of this reality can be compared to intoxication with drugs or alcohol, which we all know provides an escape for the user who wants to avoid the realities of day-to-day life.
To address this problem first we must confront the denial, rejecting the notion that we can experience reality without digital media. This dangerous idea will certainly lead to impairment of social and occupational functioning and probably distress as well. In particular, avoidance of social media can lead to digital social isolation. A disturbing percentage of the population may have never communicated with another person via email or texting with resulting alienation from digitally connected friends and family!
Treatment of Digital Media Avoidance Disorder
Due to its similarity to chemical dependence, treatment requires admission to inpatient rehabilitation where a holistic approach involving staff of numerous disciplines will immerse the patient in (digital) reality with gradual elimination of escape into non-digital media euphoria. Cell phones with non-removable ear buds will start the detoxification process. Only in the first hours will staff allow patients gradually diminishing access to analogue devices such as harmonicas, nose whistles, and, for more severe cases, ukuleles to ease the transition. At first specially trained staff even engage in face to face conversations with them. Motivated patients will work the (binary) 1100 step program. They will gradually learn that ordinary feelings associated with life in the real digital world are normal and they they can tolerate them or even to appreciate them, that feeling them affirms life. They will learn to turn them over to Google (as they know it, their higher power). Patients who can tolerate tweeting and blogging while simultaneously listening to streamed audio, playing computer games and shopping on ebay will participate in a ritual upload to YouTube of a digital video showing their dysfunctional pre-digital escapest functioning followed by scenes showing them leading a fully sober digital life one virtual day at a time. They are ready for discharge. Most will continue working the binary 1100 steps in video-conference meetings for years after discharge, starting with 1001010 meetings in 1001010 days. After working the program for a year or more, some individuals can play World of Warcraft non-stop for 11000 hours without face-to-face contact with another human. Rarely do such individuals relapse.
Digital Gaming Aversion Disorder (DGAD)
About two years ago, while sitting at my desk, I realized that there was really nothing I wanted to do. A friend had been playing solitaire on her computer, and that was all it took to get me going. Within a few days I was hooked. Almost every time I got done with whatever computer task I had been engaged in, I started playing solitaire. After a couple weeks I realized my skills were improving gradually. I began to develop winning strategies. Maybe I wasn't addicted yet, but I certainly might have been headed in that direction.
Then one day I noticed that some of the pleasure had gone. I almost had to force myself to finish a game. Next time I thought about starting another game I simply could not do it. I have not played solitaire since. When I see my friends playing, the screen looks totally two dimensional, unlike previously when it was as though I could see into the game. I cannot even imagine myself starting a game. The thought of how it works, the different suits, the different colors, the different numbers, all are blocked from my mind.
To be honest I cannot say this has interfered substantially with my social or occupational functioning. I cannot say that I am particularly distressed about this aversion to solitaire. However, should I want treatment, I have two approaches to propose, both probably requiring double blind studies to prove their effectiveness.
Psychotherapy of Digital Gaming Aversion Disorder
Cognitive behavior therapy will be the first line psychotherapy for this disorder. I believe a sufficient and appropriate reward will quickly overcome the aversion. I suggest rewarding the patient with $1000 for each game played to conclusion will rapidly reverse the aversion. I of course expect this to be covered by medical insurance.
Pharmacotherapy Of Digital Gaming Aversion Disorder
I believe a similar approach to that proposed for psychotherapy will lead to rapid resolution of this disorder using cocaine as the first line agent. A small dose after completing each solitaire game should lead to rapid resolution.
Digital Media Avoidance Disorder (DMAD)
For years now people have admonished those who, in their minds, use computers and/or the Internet "too much," calling these behaviors, like almost any other behavior they can label excessive, "addiction." It occurs to me, however, that those who engage in this "addiction addiction" simply want to deflect attention from their own dysfunction. This clever but pathological strategy, based on severe denial, has enabled them to avoid needed treatment, often for many years, for the condition I address below.
Today we must all face the fact that we can only experience true reality through digital media, using devices like computers, smart phones, and other devices, regularly, if not continually, connected to the Internet. Avoidance of this reality can be compared to intoxication with drugs or alcohol, which we all know provides an escape for the user who wants to avoid the realities of day-to-day life.
To address this problem first we must confront the denial, rejecting the notion that we can experience reality without digital media. This dangerous idea will certainly lead to impairment of social and occupational functioning and probably distress as well. In particular, avoidance of social media can lead to digital social isolation. A disturbing percentage of the population may have never communicated with another person via email or texting with resulting alienation from digitally connected friends and family!
Treatment of Digital Media Avoidance Disorder
Due to its similarity to chemical dependence, treatment requires admission to inpatient rehabilitation where a holistic approach involving staff of numerous disciplines will immerse the patient in (digital) reality with gradual elimination of escape into non-digital media euphoria. Cell phones with non-removable ear buds will start the detoxification process. Only in the first hours will staff allow patients gradually diminishing access to analogue devices such as harmonicas, nose whistles, and, for more severe cases, ukuleles to ease the transition. At first specially trained staff even engage in face to face conversations with them. Motivated patients will work the (binary) 1100 step program. They will gradually learn that ordinary feelings associated with life in the real digital world are normal and they they can tolerate them or even to appreciate them, that feeling them affirms life. They will learn to turn them over to Google (as they know it, their higher power). Patients who can tolerate tweeting and blogging while simultaneously listening to streamed audio, playing computer games and shopping on ebay will participate in a ritual upload to YouTube of a digital video showing their dysfunctional pre-digital escapest functioning followed by scenes showing them leading a fully sober digital life one virtual day at a time. They are ready for discharge. Most will continue working the binary 1100 steps in video-conference meetings for years after discharge, starting with 1001010 meetings in 1001010 days. After working the program for a year or more, some individuals can play World of Warcraft non-stop for 11000 hours without face-to-face contact with another human. Rarely do such individuals relapse.
Thursday, November 11, 2010
Short Psychotherapy
No, not "short term," short, as in short sessions.
Who says psychotherapy requires 45-50 minute sessions and a formal commitment? Although I cannot claim to know the history I suspect the almost-an-hour session originated with psychoanalysis, and the 45' session allowed psychotherapists to pack more patients into a day, and make more money. Modern psychiatric visits started out as psychotherapy sessions. The medication management piece snuck in slowly and now threatens to take over entirely. Despite the numerous advantages of independent provision of medication management and formal psychotherapy a compromise model offers a few advantages that might quiet some of its critics.
Since I ostensibly stopped offering psychotherapy I have noticed that the patient and myself often wander off the subjects of symptoms, medications and side effects, and almost as often I yield to the temptation to offer a systemic intervention, even when I know the patient is "in" psychotherapy in the more formal sense with a non-physician professional.
When I reflect, I realize this is nothing new. My family systems perspective lends itself to this less rigid approach to psychotherapy. I have done this all along. There is no real contract. Patients appreciate it, possibly partly because it's one-stop shopping and I charge no more for the added time.
There's always that dilemma over whether to charge a flat fee whether the visit lasts only five minutes or requires twenty five. The payer, whether a third party or the patient herself, likes to know in advance how much any visit will cost. I don't like to have to worry about whether the patient can afford an extra ten minutes with me. Besides, my fee always covers much more than actual time with the patient: office rent, staff, billing services, postage, telephone calls, malpractice insurance, contacts with other treating professionals, writing medical records, copying medical records, reading some other provider's medical records, ordering prescriptions, etc, ad infinitum.
CBT, which can be directed at specific symptoms and disorders also may lend itself to this model. Read High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide
or the article in the October, 2010 issue of Psychiatric Times.
Pitfalls do exist:
Who says psychotherapy requires 45-50 minute sessions and a formal commitment? Although I cannot claim to know the history I suspect the almost-an-hour session originated with psychoanalysis, and the 45' session allowed psychotherapists to pack more patients into a day, and make more money. Modern psychiatric visits started out as psychotherapy sessions. The medication management piece snuck in slowly and now threatens to take over entirely. Despite the numerous advantages of independent provision of medication management and formal psychotherapy a compromise model offers a few advantages that might quiet some of its critics.
Since I ostensibly stopped offering psychotherapy I have noticed that the patient and myself often wander off the subjects of symptoms, medications and side effects, and almost as often I yield to the temptation to offer a systemic intervention, even when I know the patient is "in" psychotherapy in the more formal sense with a non-physician professional.
When I reflect, I realize this is nothing new. My family systems perspective lends itself to this less rigid approach to psychotherapy. I have done this all along. There is no real contract. Patients appreciate it, possibly partly because it's one-stop shopping and I charge no more for the added time.
There's always that dilemma over whether to charge a flat fee whether the visit lasts only five minutes or requires twenty five. The payer, whether a third party or the patient herself, likes to know in advance how much any visit will cost. I don't like to have to worry about whether the patient can afford an extra ten minutes with me. Besides, my fee always covers much more than actual time with the patient: office rent, staff, billing services, postage, telephone calls, malpractice insurance, contacts with other treating professionals, writing medical records, copying medical records, reading some other provider's medical records, ordering prescriptions, etc, ad infinitum.
CBT, which can be directed at specific symptoms and disorders also may lend itself to this model. Read High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide
or the article in the October, 2010 issue of Psychiatric Times.Pitfalls do exist:
- The psychiatrist risks working at cross purposes to the independent psychotherapist treating the patient formally.
- Without a contract patient expectations may exceed reality.
- It's a lot easier to say "time's up" when you both see the minute hand on ten. In this model you decide when to stop based on when you want to go home or how many patients are in the waiting room. There's no entitlement to the full 50'.
- Some patients may not feel permission to bring up a matter they want help with.
- That matter the patient wants your help with might require referral for formal psychotherapy. But you can figure that out with the patient and steer them in the right direction.
- Some interventions benefit from follow-up within a few weeks, but for medically stable patients the next regularly scheduled appointment may be months away.
The notion that psychotherapy must be an all or nothing proposition may prevent you from providing the best treatment to your patient. If you the psychiatrist include a psychotherapy intervention now and then, you may increase efficiency, cost-effectiveness, and your chances of success.
Wednesday, November 3, 2010
More Harassment from DEA
A few days after the audit I started getting voice mails (2) from a DEA auditor asking when I would like to meet to go over the "findings" growing out of The Audit. I ignored them and set Google Voice to block all numbers associated with the local DEA office. The auditor emailed me (He told me my number had been disconnected. Thanks for confirming the call blocking feature works!), this time asking if we could meet the next day (10.29). I faxed a terse letter to his boss that morning (last Friday) telling him he could send any comments or questions in writing.
That same Friday morning, as I waited for a new patient to finish her paperwork, my office manager informed me the auditor above and another male from DEA had just appeared in the waiting room.(They did not present a warrant.) Furious at this presumptuous invasion of my office I called the Seattle field office. Apparently they got the message that he was wasting his time (and our tax money). After they received a phone call they left.
I filed a formal complaint with the US Attorney. I attempted to have them charged with criminal trespass by local police, but the police refused to interfere with an ongoing "investigation." I have contacted the ACLU. I figure at a minimum DEA has violated my right to freedom from unreasonable search and seizure and the privacy rights of both myself and my patients, not to mention the patients of my office mates.
I don't recall that it was a requirement of DEA registration that I allow these thugs unrestricted access to my office, which I regard as my castle. If that's the case they can so inform me, and I will decide whether I might prefer to continue my practice without DEA registration. (Other than buprenorphine I only prescribe controlled substances to 4 patients, one with schizophrenia who takes clonazepam to prevent seizures related to clozapine, a couple of patients with ADD who take methylphenidate, and one buprenorphine patient who takes pregabalin (Has anyone heard of addiction/abuse associated with that drug?). Partly because most of my patients are usually recovering addicts/alcoholics I have convinced myself that I can handle almost any case without controlled substances. Hey, it could even help me market my practice.
I'm fed up with the harassment I apparently must endure to prescribe buprenorphine, and have allowed my buprenorphine practice to shrink since early this year anyway. I could retire. I would have time to picket in front of the local DEA office. At least one other physician I no of has said he will stop prescribing the drug because of DEA harassment.
My plan if another auditor shows up in my office without a warrant: Depending on whether patients are present I will call 911 or ignore them and maybe leave. I don't know whether my office mates have enough nerve to demand they leave if they present when I am not there.
When I spoke to the auditor at the field office while the two auditors were in my office I made her aware that I expect DEA to communicate with me in writing. She told me that's not the way they do things. Fine. If DEA wants to have a meeting, "their way," they can meet without me.
Five days have passed since I faxed my request for the findings from my audit in writing. So far I have received nothing, but this makes the third time DEA has ignored my letters. These are public servants?
That same Friday morning, as I waited for a new patient to finish her paperwork, my office manager informed me the auditor above and another male from DEA had just appeared in the waiting room.(They did not present a warrant.) Furious at this presumptuous invasion of my office I called the Seattle field office. Apparently they got the message that he was wasting his time (and our tax money). After they received a phone call they left.
I filed a formal complaint with the US Attorney. I attempted to have them charged with criminal trespass by local police, but the police refused to interfere with an ongoing "investigation." I have contacted the ACLU. I figure at a minimum DEA has violated my right to freedom from unreasonable search and seizure and the privacy rights of both myself and my patients, not to mention the patients of my office mates.
I don't recall that it was a requirement of DEA registration that I allow these thugs unrestricted access to my office, which I regard as my castle. If that's the case they can so inform me, and I will decide whether I might prefer to continue my practice without DEA registration. (Other than buprenorphine I only prescribe controlled substances to 4 patients, one with schizophrenia who takes clonazepam to prevent seizures related to clozapine, a couple of patients with ADD who take methylphenidate, and one buprenorphine patient who takes pregabalin (Has anyone heard of addiction/abuse associated with that drug?). Partly because most of my patients are usually recovering addicts/alcoholics I have convinced myself that I can handle almost any case without controlled substances. Hey, it could even help me market my practice.
I'm fed up with the harassment I apparently must endure to prescribe buprenorphine, and have allowed my buprenorphine practice to shrink since early this year anyway. I could retire. I would have time to picket in front of the local DEA office. At least one other physician I no of has said he will stop prescribing the drug because of DEA harassment.
My plan if another auditor shows up in my office without a warrant: Depending on whether patients are present I will call 911 or ignore them and maybe leave. I don't know whether my office mates have enough nerve to demand they leave if they present when I am not there.
When I spoke to the auditor at the field office while the two auditors were in my office I made her aware that I expect DEA to communicate with me in writing. She told me that's not the way they do things. Fine. If DEA wants to have a meeting, "their way," they can meet without me.
Five days have passed since I faxed my request for the findings from my audit in writing. So far I have received nothing, but this makes the third time DEA has ignored my letters. These are public servants?
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