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A Spo-fan asked me the other day (or was it a few weeks ago?) please write out my thoughts on the topic of Introversion vs. Extroversion. I was about to write a most-fascinating entry about the drainpipes but this topic topic sounds more vital. There is a lot of rubbish about on I. vs. E. and perhaps I can banish some ignorance.

If you get one thing out of reading this, it is the following: the difference is “where do you go to get recharged?” [1] When you feel drained do you prefer to be to yourself or do you prefer doing something with others?  That’s it. That’s all that matters. That’s the difference.

Jung wrote a lot on the topic. He saw the two modes of operation as how does one process the world, internally (introversion) or externally (extroversion). His goal for mental well-being is always to get one’s psyche in balance as much as possible. One finds out which is your ‘major’ and go to work on the other.

It is nonsense to see these two terms as black and white, or it’s one or the other. “I’m an introvert!” I hear someone say in a bar or at a party. I have to hold my tongue to respond so what are you doing here.

Urs Truly has a predominate introverted psyche. There is nothing so pleasing to me as spending a day to myself reading and doing chores only to realize I haven’t spoken to anyone all day. Some friends find my statement hard to believe, seeing me mingle and interacting well with others in social settings. After all, I am in the blogging community for pete’s sake – that’s a very extroverted endeavor. Introverts do not lack social skills, nor do they hate socializing etc. It’s just if given a choice between happy hour or staying home with a good book they find more ‘charge’ in the latter.

People who predominately relate to the world through extroversion [2] often  find the other kind a bit bewildering. Es are more likely to encourage/push Is “out the door’ as it were. [3]  However even Extroverts see value in ‘down time’ and peace and quiet – at least the more balanced ones.

There is no war between the two types.

One is not ‘born one way’ and one is not destined to be just one way or the other.

Do not try to put yourself as one or the other.

Goal of learning this: balance out as much as possible while keeping an eye on what recharges your battery – a book or a telephone call.

ExInFI-e1451914524243

I thought I would put up one cliche summary picture.

Get the gist and now discard. 

 

[1] If you like more fancy words: in what setting does The Ego find replenishment for spent Libido (viz. psychic energy).

[2] I purposely don’t use the words Extrovert and Introvert as they enhance labels. Nevertheless it is hard to avoid the lexicon.

[3] Thems mostly introverted seldom bother to try to make extroverted types stay more at home.  It’s an iniquitous arrangement.

Office

I get to work around 7AM although the first patient is not scheduled until eight. 7-8AM is a pleasant time and at this time of the year the rising sun shines on my side as I sit at my desk; it feels as pleasant as a cat in a sunbeam. I get a lot done in these serene sixty minutes. Best yet, I can write out a blog entry while having a nice hot cup of morning tea. There are no interruptions or phone calls to mar my meditation. It is a lovely way to start the day.

It’s Wednesday, which have been christened ‘Wacky Wednesday” for most of the week’s shenanigans happen on today. I get more calls/reminders and fires to extinguish than on any other day.**

I’ve just learned today’s pharm representative has called to cancel lunch. I have some backup protein drinks which will do me no harm. I worry I am scaring the reps away. I don’t think I am ‘mean’ to them but I do not buy their song and dance at face value but ask questions for which they often don’t know or exposes jiggery-pokery. Oh well. I never was happy having them.  Pharmaceutical representatives are only doing their job of course, but as a group they come across as rug salesmen trying to sell me something I already have or don’t want.  They move around like Bedouins: one day Sally Sue is working for “A” and next week she’s with “B”.  It is hard to get them straight as who does what.

I’ve scanned my day’s roster and did not have any “Frau Blucher” responses to the drama personae on my dance card. It’s nearly starting time. I can hear some mild commotion coming from the lobby. Mr. 8PM has arrived; it sounds like he is not in a good mood and having his crisis de jour. It looks to be a long day, as is the wont on Wednesday.

Happy Hump-day to Spo-fans far and wide. Don’t stick no beans of your nose. And always ask who was excluded in the double-blind trial of your medication.

 

**I may be at ease now but I won’t be so jolly by 3PM. Happily, my track record for getting through Wednesday’s Woebegones is so far 100%.

Office

Not long ago I had a patient with symptoms that occurred only in the middle of the night. He would wake with chest tightness and a sense of foreboding. A creeping sensation took over him and develop into partial paralysis. His theory was not depression or panic attacks but the house was bewitched. He tried to exorcise the alleged ghost(s) with some sort of cleansing ritual but no luck: the symptoms continued. His PCP sent him on the possibility he was off his rocker. I didn’t think him ‘crazy’ but I wasn’t going with his hypothesis of spooks. I got him to have his place checked for black mold and the like. It turns out carbon monoxide was seeping in to his room from the near by garage. I thought the man would be grateful but he wasn’t. He was downright disappointed the explanation wasn’t supernatural. You’re welcome. People believe in a lot of mumbo-jumbo about illness and treatment. Because of my training in Jungian psychology patients expect me to be full of dungeons and dragons and they are dismayed when I cut through their rubbishy theories about every little fiddle-faddle. They want me to agree with their beliefs and take umbrage when I don’t

On the other hand I’ve learned if a patient is gung-ho about something for their treatment I go with it so long as their modest proposal does no harm. The placebo effect is a strong and useful medicine. If their way works, great; if it doesn’t, then next time it is my way.  It is important to be neutral about these things. A patient recently returned after a year of trying a myriad of non-pharmaceutical means to alleviate her depression, only to sheepishly admit (with a touch of rancor) only the zoloft works and would I please give her another prescription. OK is the answer, not I told you so you silly person.

Patients with paranoid delusions are particularly tough nuts to crack. I’ve learned not to butt heads yes it’s true no it’s not but to go with the affect.  “Gee, that must make you (angry/scared/frustrated) to have that happen to you” not only does this mirror the affect but it dodges the debate about the truth of it all.

I see Thursday’s roster has “Joe” coming in. He doesn’t want treatment per se but seems to be showing up solely to wear me out through attrition and get me admit I am wrong and affirm his belief about the supposed nightly break-ins. My two comments  a) how the hell can I know for sure and b) it sounds not likely and give it a rest neither appease or cause him to dismiss me as a quack and go elsewhere. He is determined to get me to confess yes he’s right. It’s all rather tedious. I am half-tempted to tell him his house is bewitched. It may actually raise his low opinion of me.

Office

The Other Doctor called in sick today and The Wonder Receptionist is taking time off for a family matter, so things are a bit quiet here at the office. I sense the former’s absence will create ‘cover’ work, while the absence of the latter will mean the phone calls won’t get through. Today’s pharmaceutical lunch may be canceled due to lack of attendance. I will have to run out in mid-day traffic to find something to eat as quickly as possible between noon and 1230 in time to get back to the helm. For all my wool-gathering, I am never asleep at the switch.

The clinic has lost another potential new prescriber. For some time the bosses have been trying to get a 3rd doctor but no such luck. A physician or RN gets oh-so-close and then they bail. I am told this last one went a little off the deep end just before starting. Apparently she was appalled to learn part of the job of working with anxious or ADHD patients means sometimes prescribing controlled substance Rx. Worse, she has to cover her patient’s phone calls. It was probably good to find this out prior to her being on board.

I am clearing out my files of ‘clippings of interest’ and ‘patient resources’. In my field things come and go so quickly; last year’s research and recommendations may already be outdated. While it is exciting to be an ever-growing branch of Medicine, it is rawther difficult to keep up. Sometimes it is easier just to go to Youtube than read JAMA, which I read mainly for the lovely art history articles that illustrates the front covers.

I am practicing my Spanish lessons on the clerical staff. They are too polite to tell me my Spanish is god-awful, so getting feedback is faulty. My formal grammar is politely corrected to everyday vernacular, which I appreciate. I can’t seem to remember the who/what/where/why words but the swear words have landed safely into my lexicon. Cabron is my new favorite, probably because it isn’t clear to me what it means exactly.  For all I know I am getting the Spanish version of “The dirty Hungarian translation book”.

 

Ok Spo-fans, here is a blog entry derived from the medical conference. Last weekend I was pow-wowing with my fellow wizards when Albus Dumbledore, M.D. gave out THE “prescription” for mental health and well being. This balsam is based on the following principles:

It gets formidable results.

It has data to support its efficacy. These may seem like ‘no-brainers’ but it is important for me to recommend things evidence-based.

It addresses the mind/body connections using the simplest of interactions

It is measurable. You can record and monitor your adherence.

What you need to do doesn’t cost money, and it doesn’t take too much time in a day.

There are 5 elements:

Mindfulness

Exercise

Nutrition

Sleep

Social Connection.yellow_five_star_90.jpg

You need do all five elements, like the tips of a five-pointed star. You ‘take your medicine’ daily for thirty days to assess the benefits.

These elements works upon the immune system, your physical well-being, and the brain’s neurochemistry. These systems act as a three-way towards diminishing mental and physical illnesses.

Here is the prescription for what you do daily x 30 days:

Mindfulness – 10 minutes of something (relaxation, yoga, meditation, or sitting with nothing going on).

Exercise – 30 minutes of moderate intensity. If you can’t do this, try walking.

Nutrition – log what you eat every day x 30 days on the guideline of the MIND diet (the MIND diet is best correlated to well-being)

Sleep – practice sleep hygiene techniques for 30 days.

Social Connection – visit and interact with a friend or family member each day for thirty days. Or text or call someone.

A study of patients with depression, anxiety, or pain showed the following after 30 days:

In the mental illness patients: depression improved by 43%; anxiety by 40%; sleep by 29%; general wellness (measured by WHO-5) improved by 60%.

In the pain patients: depression went down by 43%; anxiety by 39%; sleep improved by 29%, and wellness improved by 57%.

These percentages beat anything prescription medications can do. They have less adverse reactions and they address multiple systems/general well-being.

So there is it. Nothing fancy or trendy, but it has the data.

Satyrs

A Spo-fan recently e-mailed me a question. Now that he’s reached ‘a certain age’ he is seen and pursued by younger lads as a ‘daddy’ figure.* He wonders – and worries – if these younger men lusting for ‘daddy’ is a sign of neurosis or – worse – some sort of sexually acting out of having  been sexually abused.  He turns to me for my sagacity on the subject. Is this a realistic concern or this merely a proclivity like an apricity for feet or suits or doing it to disco music?

Good question.

I can assure him and any Spo-fans interested in this topic there is no good evidence being attracted to an older person is correlated to a history of sexual abuse. Somewhere Freud is cackling as I write this for sexual longing for an older parent is the basis of his Oedipal complex. Younger to older sexual attraction has the spice of  the ultimate taboo: having sex with your parent (or counterpart). At one point (goes the theory) we all long to possess the older parent. This desire later gets sublimated into ‘normal’ sexual attraction and activity.

The Jungian theory is more cosmic and less sexual: the erotic element is merely part of the desire to unite with Wisdom as demonstrated by an older person. My an archetypal point of view, Age is Wisdom is Power – all attractive.

A more prosaic interpretation: older men generally have money than younger ones.In the West we equivocate money with sexual potency. You can be as ugly as a hedgehog but if you have money you and others see you as sexy.

Apart from all the psychobabble there are biological and evolutionary components for younger folks attracted to oldsters. Girls achieve sexual and mental maturity earlier  than their male counterparts; pubescent girls want sexually compatible partners. This means going for men 5-10 years older than they. In eons past, an older cave-man was more ‘successful’ at staying alive to reproduce, shaping the gene pool for youngsters to want someone older for protection etc.

Having had twenty five year experience at head-shrinking (and some personal research in the field) many lads tell me its just jolly good fun to be with an older man who has more experience who can take charge, be confident, and has his act together. Men generally admire men who have strength, which is often not yet present in youngsters.

The dirty secret of human sexual psychology is no one really knows why people like what they like. “There is no accounting for taste’ one of my teachers said.  Bottom line (pun intended):  many young gay man love the company and pleasure of an older man for nurturance and guidance – and to get a good tumble.

The idea this desire is based on aberrations from childhood derives from the old prejudice any sexual activity that isn’t same-age-monogamous-heterosexual is a perversion.

In conclusion, the Spo-fan’s question made me recall a scene from the “Cabaret”. In the film a woman asks Liza Minelli (with her history of “many screwings”) if her longing for a man is love or mere infatuation of the body. Liza replies:

“Does it really matter as long as you’re having fun?”

 

 

*Being called ‘daddy” is sometimes a turnoff; it is the older gay men’s equivalence to women being called ma’am.

Office

Throughout the year a plethora of people have asked me to comment on Mr. Trump’s mentality. What they really want to know is do I think he is crazy. They inquire what is his psychiatric diagnosis.

It reminds me of “The Goldwater Rule”:

Mr. Barry Goldwater ran for president in 1964. A magazine polled all the shrinks of the land whether or not they thought him mentally fit to be president. Of the ~2,500 docs who responded, 1189 said no, he was not fit. They diagnosed him as mentally deranged, unstable, possibly psychotic; many diagnosed him with a personality disorder. The magazine published this in an article saying “1189 psychiatrists think Goldwater a Loon” – or words to that effect. He lost to Mr. Johnson. After the election Mr. Goldwater sued the magazine for defamation, stating none of these psychiatrists had examined him and they didn’t have his permission to give out their professional opinions. While I am no fan of Mr. Goldwater, he was right.  In response The APA made “The Goldwater Rule”. This law means my fellow wizards and I are not supposed to give pat diagnosis to people we haven’t personally examined or haven’t received permission, especially sue-happy Mr. Trump.

There are many aspects of Mr. Trump I find deplorable  but I say this as a citizen giving his first amendment protected opinion based on his nasty statements and actions.  I think him a nawful person, but I shan’t go so far as to publicly say he’s crazy as an outhouse rat.*

This doesn’t satisfy Spo-fans and patients; they want me to state I believe he has a narcissistic personality disorder.  I have probity; I shan’t give out my professional opinion on his mentality lest The APA Secret Police or Trump’s lackeys suddenly appear and beat me up.**

So – I mind my Ps and Qs and merely voice my disapproval of his nasty ways and statements and of the Laestrygonians who follow him around.

The other day a patient came in for his/her appointment execrating Mrs. Clinton while extolling the so-called virtues of Mr. Trump, but the patient had paranoid schizophrenia, not merely racist views. I upped the dose of his/her medication to curtail the psychosis so hopefully he/she will soon come to his/her senses but I don’t think the Latuda will cause him/her to vote Democrat.

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*This is not an official diagnosis in DSM-5.

**I shudder to imagaine which group would be more truculent.

Office

My best friend from med school and I like to rib each we can’t fathom how the other does the job.  She does OB-GYN; she sits between women’s legs sometimes for hours birthing babies doing so at all hours of the week. I can’t imagine doing that. On the hour hand she wonders how on earth I put up with “all those people’ viz. the angry and the out of control types. Indeed. Sometimes I wonder how I do it.

Back when I was in analysis my analyst had hanging on his office wall a print of The Buddha sitting serenely in the lotus position. He is surrounded by an azul circle resembling a clear night sky. Around this, in a fiery ring, was a wreath of gyrating demons. They are fighting among themselves and/or trying to reach out towards The Buddha, who looks to be the eye of a hurricane.  Sometimes when I am in the presence of anger, anxiety, or agitation, I recall this print and try to emulate it. Buddha-like I stay centered and calm.  In turn this sometimes helps the other to become calm. Regardless of the outcome it helps me not to succumb to their fiery emotions. Doing so does them and me no good.

In chakra energy, chakra #3 (located in the belly I believe) is associated with well being. It is our ‘happy place’. When I encounter a person with no manifest positive qualities I need to quickly find something, anything, positive in them to latch onto if I am to have any hope of connection and empathy, which is prerequisite for doing the person any good. This unconscious connection is hard to describe. I get in touch with my third chakra, emulate positivity, and reach out mentally to whatever I can find in the other and link to it. It may be as simple as feeling their anguish, fear, or pain. This mitigates enough to ‘get in’.

The other day I was referred a man I was warned ahead of time as very angry, highly skeptical, and already hostile to psychiatry – but he really needed my help.  He had burned through a series of counselors and I was his last hope. I wondered how on earth was I to make a rapport. My third chakra reached out and I became instantly aware he was highly intelligent. I like bright people. I latched onto that. Without directly saying so, I talked to his brilliance. He sensed – consciously? –  I was not going to be another condescending ‘me professional, you patient’ type. By the end of the appointment he conveyed relief and rapport – and a willingness to accept and do recommendations.

These two maneuvers have helped me through a lot over the decades, whether with  patients or with the man on the street. It is neither devious nor extraordinary; with practice anyone can do so.

I used to try hard to find a copy of the Buddha print to hang in my office, but I don’t need it now. I have incorporated it within me, in the third chakra as it were.

Discourtesy is unspeakably ugly to me.”  ― The Silence of the Lambs

Mark Twain said “I differ from George Washington that George could not tell a lie. I can, but I won’t. ” It is the same for Urs Truly and Hannibal Lector. Our knowledge base and psychological training are identical and I do enjoy a nice Chianti. The difference is I use my knowledge of mind games to heal while he uses his to eat people. Sometimes it is useful and necessary to get in touch with my inner-Hannibal and release the Kraken as it were. And no, I don’t bite people in the face.

I have to deal with insurance companies, particularly when they demand that most irksome  of forms: the ‘prior-authorization’.  The Wonder Receptionist tells me with gravitas “You have to write that letter”. What she means is I need to compose the infamous-diabolically inspired “letter of persuasion”.  I compose this marvel while possessed by the good Doctor Lector.  At times not only is it necessary but jolly good fun.

As Professor McGonagall says in “Harry Potter” when she conjures up battle guards: “ I’ve always wanted to use that spell!”

Patient confidentiality (and modesty) forbids me to show you an actual example of such a correspondence, but I will do my best to describe it.  In the letter I am never threatening, nor use imprecations. The HL letter follows a format. I start with a solemn statement of sadness for their decision, followed by a polite request they reconsider their rash decision based on some ominous facts of which they may not be aware. Otherwise why would the have made such a fatalistic error? I go on to scribble how the patient will soon be without their prescription, hinting they will soon go off the deep end; the howl of their withdrawal will resemble an orchestra of scorched cats. Then I write a series of ‘what ifs’ and we are off. It is a bit Professor Harold Hill and GOP fear-mongering. If you don’t approve this patient’s medication (I write in my best Anthony Hopkins voice) he/she will degenerate (if all goes well) into murders and suicide. The next thing The Insurance Company will hear about this poor unfortunate soul is he/she is now the lead on the news having just mowed down in gun fire a group of kittens and white people. Your denial letter will be right next to the subpoena in the crazed dead patient’s chart. The horror, the horror.

Or words to that effect.

I am never direct or blunt; I write (thanks, Hannibal!) an exquisite prose using indirect speech acts that say all of the above without actually having it written out. I imagine the recipient bean-counter upon reading “The Letter” goes running to the computer in a fright to authorize the medication and apologize for a mistake.

It seldom fails.

Hannibal_Lecter.jpg

Every physician (except pathologists) experiences death. The death of patients often reflects the speciality. For example, cardiologists usually lose patients from heart attacks while oncologists see they patients die from cancer.  When a psychiatrist loses a patient so it is often from suicide.

Today the office of the county coroner faxed over a request for chart notes on X. X is dead. The request doesn’t say how X died. The cause may be a car accident, or a murder, or a heart attack.  Given the patients I treat the main reason is usually suicide.

I don’t know what is the usual emotional response when a doctor loses a patient through suicide but I become very sad by the tragedy. Why didn’t X reach out to someone or call me? I go through the chart of the deceased trying to get answers.  Sometimes a patient is at high risk for suicide and it if happens it is ’understandable’ but this provides no comfort. In today’s case of X, my last note indicates X was doing well, in good mood, and looking forward to things. X recently had a break up. X felt sad by this but empowered as it was right thing to do (X was the one who broke it off). Is this why X committed suicide? Perhaps X did not share with me all the story. Had X been plotting death all along or  did something horrible happen since our last appointment that made X believe death was the only way out?

Patient suicides often have no meaning and no closure. Because of this – and doctors being ‘good people’ – it is all too easy to start doubting oneself and one’s worth as a physician. “What did I do wrong?” and “What could I have done differently/“ are two questions we all consider when someone dies or commits suicide.

Along with sorrow of the loss of a life doctors develop fear of legal retaliation. Will I be sued for this we all ask ourselves? It is almost grim humor death is often considered a sort of negligence. If a patient dies something must have gone wrong and it is someone’s fault it happened.

The sad truth is if a person decides to kill his or herself no one can stop them.  Treatment plans, contracts, 24 hour call centers etc. can not guarantee life or prevent death.

As X didn’t have a spouse or children I can’t call someone to offer condolences and find out what happened. I may find out ‘how’ via the coroner’s report but that is of little value for closure. I want to know ‘why’ rather. It leaves you with a sense of failure even when you know you did not err or deviate from standard of care.

It’s the hardest part of being a physician.

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