Monday, January 26, 2009

Guest entry: Suicide, psychiatry, and fiction

posted by Antigone Kostas, MD (psychiatry resident)

It's been insidious. Having been on vacation from psychiatry residency for a week with more time to peruse fiction selections, I have noticed a change.

At one point in a story I was reading the narrator noted that he and another guy "just ended up" peeing together behind a tree. He mentioned this detail in passing, as a segue to the conversation they had while peeing, but whoa! How does something like that happen? What happened to personal space and the fact that a whole field (without a mention of a paucity of trees) does not necessarily situate these urinals naturally next to each other? Suddenly, a major red flag appears. Details I would have normally glossed over, I now can't.

Way too much Freud.

In addition, since working in the psychiatric ER, I have learned not to dismiss things. I have learned to ask very specific questions and not to leave things to vague feelings. At first, I admit, I didn't see the point ("They're suicidal, they swallowed a bottle of pills, for god's sake hospitalize them!!"), but we can't hospitalize all the suicidal patients

1, especially those with borderline personality disorder2 when the events were just an acting out.

People with borderline personality disorder don't have a strong sense of 'wholeness.' Much of what they feel internally comes from what is going on externally, and as a result they cannot regulate their own emotions very well. They don't tolerate frustration well so they may jump from the extremes of being very angry to being okay. While they were in the throes of a very strong emotion when they tried to commit suicide, they just don't feel that way anymore. Borderlines often have multiple suicide attempts in their history and some actually do die, usually because they misjudged the lethality of their attempt, but more often the attempts are a cry for help or an acting out.

In the course of examining suicide attempts, innumerable questions arise. How serious was the attempt? How many pills did they take? What was it? For example, Benadryl is less serious. Did they take it in front of someone in a melodramatic gesture? Who found them? How were they found? Did they leave a note? A note is more serious and suggests they were not just acting in the heat of the moment. Have they attempted suicide before? What were their other suicide attempts like? Are they repetitive incidences of acting out or are they all serious attempts? Can they keep it together now in the psychiatric ER?

In the ER, as psychiatrists, we have to probe the patients' motivations at each step, study their current affect and decide whether we think they're serious about making another attempt. It can be tricky (and there's no guarantee that someone might not act unpredictably and try suicide again...), which is why we really have to make sure we probe every detail and make sure we don't miss something the patients are trying to hide.

This is the reason why now, reading fiction, if I read an odd description and the author does not explain the context or motivations of the characters, I feel like I am being duped. I cannot easily go on, gloss over for the sake of fiction, because the whole premise is false. It would never happen! There needs to be context... Instead of location location location, it's now context context context!


1We can't hospitalize all the suicidal patients in part because there are too many of them.

2Borderline personality disorder is a complex syndrome and includes some of the following diagnostic criteria:

"– dramatic efforts to avoid being alone
– a pattern of intense unstable relationships
– disturbances of self-image
– self-damaging acts
– suicidal threats or gestures
– marked emotional instability
– persistent feelings of emptiness
– difficulties with controlling anger
– thoughts of persecution or episodes of dissociation”

(Robinson, David, J. Disordered personalities. Rapid Psychler Press, Michigan: 2005)

Sunday, January 11, 2009

Reaction to Article: "Communicating Medical News -- Pitfalls of Health Care Journalism"

Communicating Medical News -- Pitfalls of Health Care Journalism by Susan Dentzer (New England Journal of Medicine; January 1, 2009)

The article above, printed in the “Perspectives” column in a recent issue of The New England Journal of Medicine, reviews the failings of heath care news and challenges journalists to offer a more complete picture and resist the urge to sensationalize and oversimplify the news. I recommend that every consumer of health care news read the article as it provides an important perspective.

The article will also give readers a better appreciation for the frustration that doctors experience reading health care news in the lay press, realizing the misinformation that readers digest, and knowing the time and energy they then must spend attempting to correct mistaken notions.

The bottom line: read health care news with a good degree of skepticism. (Despite journalism's best intentions, the media industry is ultimately in the business of making money. Health care news, whether fully accurate or not, sells and increased sales bring more money.)

Thursday, January 1, 2009

Turns out our mothers were right: why we should eat slowly and fully chew our food

In talking with gastroenterologist friends about being on call this holiday season, they humorously note the number of times they inevitably are called by the Emergency Room to see patients in whom food has become lodged in their esophagus.


In the normal act of eating, after chewing our food, a bolus is transferred from the back of our mouth to our pharynx and then to our esophagus. Once in our esophagus the food is pushed along to our stomach by peristalsis, organized contractions of the muscles of the esophagus. (a graphic illustration of the swallowing process,

Holiday hiccups

In our holiday zeal on seeing all the delicious, prepared goodies (after starving all day in anticipation), we inhale our holiday meals, but several unlucky individuals among us will get a large piece of food stuck in their esophagus (the size of the food bolus overwhelming the muscles of the esophagus) and be found by a gasroenterologist uncomfortable, lying on a stretcher in the ER in search of relief.

The remedy

The patients are brought to the Endoscopy Suite where the gastroenterologist passes a flexible tube with a camera at its end (an endoscope) through the mouth and down the esophagus to where the food is lodged. Once there, typically, the gastroenterologist simply pushes the food through the rest of the esophagus to the stomach where digestion will aid it's transit through the remainder of the digestive tract...

Not always a laughing matter

On a more serious note the procedure, an esophagogastroduodenoscopy (EGD), like any other procedure has its own risks, including the potential for rupture of the esophagus – a steep price to pay for time otherwise spent eating slowly and enjoying a meal.