Taking a break from technology is a fine idea, but we don’t need a pseudoscientific new name for it: dopamine fasting.  Launched with viral Silicon Valley memes, online reports, and articles in the New York Times and elsewhere, dopamine fasting is now a thing.  Basically, the idea is to temporarily deprive oneself of the usual stimulations of life — largely ...

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It was 2013. High-tech entrepreneurs were excitedly “disrupting” industries, bringing goods and services closer to users. Uber replaced cabs, Kickstarter replaced investors, and telehealth companies offered convenient, at-home medical care over smartphone video. Why waste time going to an office or clinic, especially if you’re not feeling well? Why spend so much money? The physician’s physical examination had been oversold. It wasn’t really needed. Psychotherapy never required a physical exam in ...

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When a mental health clinic, online referral service, or private practice offers “evidence-based” psychotherapy, that certainly sounds like a selling point.  It suggests solid science supports the therapy offered -- and that competing services lack this support.  But what does this phrase really mean? “Evidence-based medicine” first appeared in the medical literature in 1991.  It cast doubt on physicians’ clinical intuition and anecdotal experience, reminding them that science should guide medical ...

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“Complementary and alternative medicine” (CAM) is a category that includes all the methods of physical or mental healing that do not fall under the umbrella of western medicine. Examples include comprehensive healing traditions from other cultures, such as Chinese or Ayurvedic (Indian) medicine; herbal remedies; and a wide variety of mind-body treatments, such as meditation and yoga. CAM treatments are popular everywhere, including here in the U.S. ...

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Two cars arrive at a stop sign at the same time.  Both start into the intersection.  One driver speeds through, while the other jams on the brakes, avoiding a collision.  This driver feels insulted, offended, diminished.  Who the hell does that other driver think he is?  He nearly killed me! This scenario, and countless others involving merge lanes, contested parking spaces, and aggressive rush hour traffic, are set-ups for road rage. ...

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It has become a sign of legitimacy to call a personal problem “medical.”  This aims to distinguish the problem from those of morality or character.  It implies both that the problem is serious, and that it is unbidden and largely out of the sufferer’s control.  Unfortunately, it isn’t clear what exactly qualifies as “medical,” so this label serves more as a rhetorical device than a scientific finding. Alcoholism is ...

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In Toronto on April 23, 2018, Alek Minassian intentionally drove a rented van into pedestrians, killing ten and injuring at least 15. Later the same day, Constable Ken Lam of the Toronto Police Service arrested Minassian after a brief, tense standoff. As seen in a widely circulated video, Minassian dared the officer to shoot, and feigned drawing a gun, most likely to commit “suicide by cop.” Constable Lam, however, ...

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In her recent New Yorker article, “The Sorrow and the Shame of the Accidental Killer,” author Alice Gregory claims there are no self-help books for anyone who has accidentally killed another person.  Nor published research, therapeutic protocols, publicly listed support groups, nor therapists who specialize in their treatment.  She profiles several such tormented souls who bear their burdens largely alone. Yet dealing with guilt, shame, and regret is a mainstay of ...

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A woman recently requested a medication evaluation at the suggestion of her psychotherapist.  The caller told me her diagnosis was borderline personality disorder. She hoped medication might ease her anxiety.  She also admitted that two other psychiatrists refused to see her because she was too “high risk.”  I asked if she was suicidal.  Yes, thoughts crossed her mind. However, she never acted on them, and was not suicidal currently.  I ...

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In a world of diverse mental health treatments and treatment settings, psychoanalysis and psychodynamic psychotherapy have lost their former prominence.  Only a small fraction of patients have the time, money, and interest to engage in long-term, open-ended mental exploration -- even if doing so would get to the root of their problems and lead to lasting improvement. More commonly, emotional distress is dealt with in emergency departments, in crisis clinics, on the medical and surgical floors of hospitals, in ...

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On January 31, 2017, the Psychology Today editorial staff published a well-balanced summary of the debate over whether to declare President Trump mentally ill. While the debate focuses on mental health professionals such as psychiatrists and psychologists who are credentialed to make such diagnoses, the question clearly goes further. Public commentary following this and other articles expresses outrage -- not only at the behaviors and policies of Trump himself, but also at any suggestion ...

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Opioid painkillers, such as Vicodin (hydrocodone) and OxyContin (oxycodone), are crucial medical tools that are addictive and widely abused. Tranquilizers and sleeping pills of the benzodiazepine class, like Xanax (alprazolam), Ativan (lorazepam) and Klonopin (clonazepam), are safe and effective in limited, short-term use, but are often taken too freely, leading to drug tolerance and withdrawal risks. Stimulants such as Ritalin (methylphenidate) and Adderall (amphetamine) ease the burden of ADHD but ...

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Prior to the release of DSM-5 in 2013, I referred at times to the pocket copy of DSM-IV parked in my office bookcase.  The main reason was to enter the right diagnostic codes on insurance forms.  I also sometimes quoted DSM criteria to show a patient that ADHD can’t arise in adulthood, that daily mood swings are not characteristic of bipolar disorder, or that six months of sobriety is still “
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A primary care physician named Ashley Maltz recently discussed advantages and disadvantages of a cash-based practice. I appreciate her evenhanded tone: She prefers this model yet expressed concern for patients who can’t use it. In the comments section, several physicians extolled the virtues of cash-pay, but patients were mixed. It’s attractive for those who can afford it, while it worries, and maybe angers, those who can’t. I enjoy the personal and patient benefits of a mostly cash-pay psychiatric practice (I ...

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Again and again in therapy I find myself emphasizing the distinction between feeling an emotion and acting on it. Many patients, and non-patients too, take undue responsibility for their emotions, as though feelings were volitional behaviors, the result of a choice.  Often there is a stated or implied should: “I should feel this, not that.”  Note how commonly people blame themselves for feeling, or not feeling, a certain emotion: “I should be more grateful after all she’s done for me.” “It’s wrong of ...

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Some maladies that attract psychiatric attention are unequivocally brain diseases.  Huntington’s disease.  Brain tumors.  Lead poisoning.  However, these are not psychiatric diseases.  Huntington’s is a genetic abnormality diagnosed and treated by neurologists.  Brain tumors are managed by neurosurgeons and oncologists.  Lead toxicity is treated by internal medicine.  Indeed, a long list of medical and surgical diseases include psychiatric features: stroke, anoxic brain injury, meningitis, lupus, diabetic ketoacidosis, and febrile delirium to name a few.  One important ...

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As we grow into adulthood, each of us develops a personal comfort zone located on the continuum between paranoia and gullibility.  A few of us are highly suspicious by nature, a few are unwitting dupes; most of us are in between.  Mental health professionals are no exception, and it shows in our work.  Is a request for tranquilizers or stimulants legitimate, or are we abetting a substance abuser? When told of horrific past abuse, do we believe every word, ...

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Two of the most commented posts on my blog are about charging patients for missed sessions and how psychotherapies end.  As there is no single correct approach to either of these, there’s plenty of room for practices legitimately to vary, and plenty of room for patients, i.e., most of my commenters, to express their likes and dislikes.  By my reading, many commenters assume that cancelation and termination policies mainly feed their therapists’ wallets; they ...

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The history of American medicine is the story of the rise and fall of a professional guild.  In the 19th and early 20th centuries, physicians distinguished themselves from other healers by banding together to form professional associations dedicated to science-based practice.  Even more important, medical ethics put the patient first, above considerations of personal gain or even collective social goods.  The medical guild may have been insular, self-protectively territorial and ...

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shutterstock_202325860 The current state of telemedicine -- that is, teleconferencing with a physician over one’s smartphone -- worries many critics because it assumes patients can be evaluated without a physical exam.  The critics are right that those with a financial interest in “disrupting” health care typically minimize the trade-offs.  Convenience and lower cost are trumpeted, while risks of misdiagnosis and mismanagement are waved off.  The concerns of practicing physicians are dismissed ...

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