ARTISS SYMPOSIUM 2016 Understanding the Patients’ Experiences: Beyond Diagnostic Labels SPONSORED BY Department of Psychiatry, Walter Reed National Military Medical Center Center for the Study of Traumatic Stress Department of Psychiatry, Uniformed Services University ARTISS SYMPOSIUM 2016 Understanding the Patients’ Experiences: Beyond Diagnostic Labels SPONSORED BY Department of Psychiatry, Walter Reed National Military Medical Center Center for the Study of Traumatic Stress Department of Psychiatry, Uniformed Services University From the Conference Series: ARTISS SYMPOSIUM Understanding the Patients’ Experiences: Beyond Diagnostic Labels Editor’s Note: This transcript has been edited, however, as in most transcripts some errors may have been missed. The editors are responsible for any errors of content or editing that remain. IPD 2016 by Center for the Study of Traumatic Stress Department of Psychiatry Uniformed Services University 4301 Jones Bridge Road Bethesda, MD 20814-4799 First Edition Mary Lee Dichtel, RN Senior Medical Editor Educational Support Management Services, LLC [email protected] Contents List of Speakers ....................................................................................................i Introduction ........................................................................................................1 Harold J. Wain, PhD Listening Beyond the Diagnosis.......................................................................5 Russell B. Carr, MD Trauma and Dissociation: Understanding and Treating the Person(s) Behind the Diagnosis.......................................................................................11 David Spiegel, MD Uncertain Footing: Practicing Beyond the Evidence Base .........................29 Stephen J. Cozza, MD Why Isn’t a Diagnosis Deep Enough? A Perspective from Internal Medicine ............................................................................................................39 Louis N. Pangaro, MD Transgender Care: Beyond the Diagnosis and Defining Best Practices ....51 Babette C. Glister, MD Beyond the Diagnosis: A Psychodynamic Perspective on Treatment Resistant Depression ........................................................................................61 Eric M. Plakun, MD Speaker Biographies ........................................................................................ 77 History of the Artiss Symposium Kenneth L. Artiss (1913–2001), the namesake of this symposium, was an Army officer, a research psychiatrist and instructor at Walter Reed Army Medical Center. Dr. Artiss, who served for 21 years in the Army Medical Corps retired in 1964 as a Lieutenant Colonel. He was Chief of the Depart- ment of Psychiatry in the Division of Neuropsychiatry at Walter Reed’s In- stitute of Research. His work included development of treatment methods for combatants with severe psychiatric disorders. After his retirement from the Army, Dr. Artiss was a senior consultant for many years to Walter Reed’s psychiatric residency training program. Dr. Artiss created an award in 1983 to spur military psychiatry residents to con- duct high quality research. This award still exists today and was presented at the conclusion of this symposium. i Speakers Harold J. Wain, PhD Chief, Psychiatry Consultation Liaison Service Walter Reed National Military Medical Center Russell B. Carr, MD CDR, MC, USN Chief, Department of Psychiatry Walter Reed National Military Medical Center David Spiegel, MD Deputy Chair, Department of Psychiatry Stanford University School of Medicine Stephen J. Cozza, MD Professor, Department of Psychiatry Associate Director, Center for the Study of Traumatic Stress Uniformed Services University Louis N. Pangaro, MD Professor and Chair Department of Medicine Uniformed Services University Babette C. Glister, MD LTC, MC, USA Program Director, NCC Endocrinology and Metabolism Fellowship Walter Reed National Military Medical Center Eric M. Plakun, MD Associate Medical Director Director of Admissions The Austen Riggs Center ii 2016 Conference Organizing Committee Harold J. Wain, PhD, Chairman Robert J. Ursano, MD Aniceto Navarro, MD Shannon Ford, MD Miguel Alampay, MD Russell B. Carr, MD Joseph Wise, MD Patcho Santiago, MD Mary Lee Dichtel, RN 1 Introduction: Beyond the Diagnosis Harold J. Wain, PhD Why did we choose the topic, Beyond the Diagnosis? Why do people re- spond differently to a diagnosis? We want to ask that question. Why is an al- gorithmic approach not efficacious for all? Why is non-compliance so read- ily observed in our patients, and what do we do with it? Recently, I heard a story from one of my grandchild’s classes that illus- trates an important point. The teacher asked each child to draw a picture, and the teacher walked by and asked, “Who are you drawing a picture of?” The child looked up and said, “I’m drawing a picture of God.” The teacher looked at him and said, “You know, that’s strange. Nobody knows what God looks like.” And without blinking an eye, the child looked up and said, “At the end of this picture, everyone will know what God looks like.” I am hoping by the end of this seminar that all of us will know why a diagnosis by itself is not sufficient because we need to look beyond the diag- nosis. We want to go beyond what the obvious looks like in terms of trying to understand another person. How do we make an effective intervention with complex patients that both the patient and other clinicians understand? The answer to that question is a major goal. What is a diagnosis? It is a shorthand attempt to communicate informa- tion from one clinician to another. When a diagnosis is used, it can simply be an abstraction. And if used by itself, rather than with an understanding of the patient, to plan an intervention, it is like planning a construction project using a map without taking into account what was used in surveying the actual ground. Evidence-based interventions frequently go awry because the unique fac- tors of the individual were either disregarded, not seen, or not heard. When treatment fails, the patient is labeled refractory or resistant. We never look at ourselves. It becomes the patient’s fault. It is easy. We can blame everybody but ourselves for not going deeper. What is the purpose of symptoms? Frederick Toews taught us that the 2 Artiss Symposium 2016 — Understanding the Patients’ Experiences symptoms of disease are marked by purpose, and the purpose is beneficial. The processes of disease aim not at the destruction of life, but to save it. It is a very interesting comment because we develop a symptom as a protection. When we have pain, the pain leads us to seek help. When we have a fever it is a warning sign that something wrong. When that symptom is a cluster of behaviors, it serves to prevent internal annihilation. Why do people think about suicide? What are they running from inter- nally? What is the conflict going on internally and why does that impulsive decision occur? What do we have to do with it? A patient on the ward right now was admitted with suicidal ideation, got leave on a pass and came back with a knife. What was his thinking about his behavior? Why does he want to run from the fact that he cannot reach his narcissistic goal? What is it about his relationship with his new wife that is causing the problem? Why does he promise everyone that he is safe to leave when he is not safe? What might the symptoms be masking? What is the suicide attempt masking? That is what we want to find out. Carl Jung coined the term “persona” and I like this word for describing what we all deal with. Persona is the appearance we present to the world. There is a character we assume through it and a way we relate to others. Persona includes our various roles, the kind of clothes we wear, individual styles, and how we express ourselves, both in health and in sickness. Why does somebody play a sick role? Why does somebody assume the depressed role or the anxious role? What are they doing with that? What is the mask we wear? We have learned by many games of charades and by the models in modern technology. We model after the roles actors portray in movies and after some of the characters in the video games that children play today. If this were an internal medicine group instead of a group primarily of psychiatrists, I would ask you this question, “When is shoulder pain only shoulder pain?” Pain in the right shoulder may suggest gallbladder issues. Pain in the left shoulder may reflect coronary thrombosis. The function of much of psychopathology is to distort or deny either internal or external conflict. I believe it is a way of coping with internalized conflict. Why do individuals respond differently? Some of you may remember the fascinating paper that George Murray wrote on limbic music; the paper was discussed in the late 70s and early 80s. It described how Murray saw the limbic system and how the amygdala was involved. We are talking about biological entities and how these entities operate in terms of determining behavior. What about cultural backgrounds? What about the previous history of the patient? What about going through developmental milestones and mod- els people have? Many of you throw out the term “unconscious.” I do not. I still look at the Freudian concepts and the Jungian conceptualization of Harold J. Wain, PhD 3 what the unconscious really means. Is there a collective unconscious? What about the patient’s assets? How do we encourage our amputees or our wounded to bind to their assets so they can overcome their adversities? I heard an interesting story this weekend from one of our peer visitors. This man lost his leg in Vietnam and afterwards he was in a body cast. He was sent to Japan where, unfortunately, he got gangrenous. He was at the old Walter Reed for a year. He was an athlete in college, and he said to himself, “I’ll never run again. I’ll never be able to do anything again.” About a month later, he heard a voice within himself, and the voice said, “Jack, you were nev- er a good athlete anyway, so what’s the big deal?” He recognized that he had other things to do and that he could do other things.