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February 07, 2006

Worst psychiatrist ever

Twisty points to a very disturbing article in this month's Prospect about Nia, a gorgeous 17-year-old schizophrenic--"Psychiatric drugs restored Nia's sanity and destroyed her beauty, and she doesn't mind"!

The article is written from the perspective of a young male psychiatry resident who is devastated when the only medication that relieves Nia's psychosis also causes major weight gain. What really weirds him out, though, is the fact Nia herself isn't bothered.

For a while the young psychiatrist worried about the consequences of the choices they had made in treating her. They had removed a stigma of the mind and replaced it with a stigma of the body. It struck him as strange that the patient had been the only one not to worry about a loss that the team around her found so tragic. Perhaps it didn’t matter. Perhaps, in fact, this was a merciful side-effect of medication, or even of the disorder itself; one that liberated Nia from the need to live up to the standards of an image-obsessed world.

The patient seems much better-adjusted than her psychiatrist. The medication relieved her unremitting torments, and she's not too broken up about gaining weight. Her doctor, on the other hand, suspects that her equanimity is a symptom or a side effect. It doesn't sound as if he kept existential horror to himself, either. I hope he didn't relieve Nia's schizophrenia only to shame her into non-compliance and/or an eating disorder.

More on our psych resident's touching first person account of the pain of objectification (when your object just isn't abject enough!) from Zuzu and Amanda

Now, if you'd like to read some really good medical writing, check out this week's Grand Rounds, chez coturnix.


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How utterly disheartening. What's wrong with her? Sacrificing the transcendant actualization of being skinny for the vainglorious superficiality of non-psychosis! Iatrogenesis run amok.

Without knowing more about this girl's case history I'm a little reluctant to pass judgment on the doctors. However, my gut instinct agrees with you, Lindsay.

Even if these doctors are all huge fuck-ups I still know that none of them is the worst psychiatrist ever. This man is: Radovan Karadzic.

"But was it really a blessing that Nia seemed to have no conception of what she had lost?"

From the description of the patient, it sounded like a big part of her psychosis was thinking that people were looking at her and talking about her. So I can see that it would be an enormous relief to her NOT to be the center of attention anymore.

And that was not only a bad doctor, but a bad hospital. One of the male patients is found in bed with her and she "MYSTERIOUSLY" gets worse? Sheesh.

You know, I think I've survived blogginess for quite some time without typing the next sentence, so I hope it carries some weight.

That is the fuckind stupidest thing I have ever read in my life.

Been there done that. Pillow over the head for weeks. In the 70s it was large doses of halperidol. The tardive dyskinesia wasn't so bad alleviated with anti-Parkinson drugs, creating a secondary side effect of dryness and tremors(don't ask me).

But I felt I had lost thirty IQ points. Thinking real slow and real shallow. Couldn't read the good stuff, couldn't multi-task at work, descended to menial labor. Felt real mellow, but something missing. I consider myself lucky to value things higher than happiness. So I quit the drugs and developed life-management strategies. I was never dangerous to others, tho often a major annoyance to associates. Still am, sometimes. Eventually with age the schizophrenia or borderline or whatever diminished.

You are all projecting. The shrink is right to be concerned, and all he was was concerned. He never took her off the prescription. Lindsay, would you give up thirty IQ points for perfect happiness? I doubt it. Physical beauty not comparable to intelligence? Don't know, never been beautiful.

A good shrink, the really good ones, and I have known a bunch, don't see their jobs as making people content or productive but making people free. I don't know if this girl is free, the drugs are in the way.

Would I give up thirty IQ points for perfect happiness? Probably not. I wouldn't give up thirty IQ points to have a model's physique, either. But on the other hand, I'd rather die than be as depressed as I was as a teenager. And as much as I love my skinny-girl privileges, I certainly I can't say I'd rather be dead than fat.

I know a obese woman who not only has been long unhappy, but is losing her knees and ankles at age 40. Constant pain, can't do stairs, cant walk the length of a football field. Needs replacements. Hips are in jeopardy. Obesity will kill you.

Are you sure you aren't throwing your own political agenda in here? We would prefer looks don't matter, but they do. Would we prefer intelligence or social skills don't matter, or other useful traits? And no offense, but you are attractive, and perhaps not the best judge as to whether a life of ugliness is not painful. The ugly ones don't talk about it much.

Bob, you're being ridiculous.

Go ask that obese woman you know whether she'd rather be losing her knees or losing her mind. Ask her whether if she could be magically transformed into a spectacularly attractive woman who couldn't function, hold a job, leave the house, or read a book, would she do it?

Really, there's nothing inherently wrong with being beautiful. But Nia couldn't even function enough to enjoy being beautiful (and a lot of beautiful people will say it's not even alway enjoyable). The people around her enjoyed her beauty, and in the end the *psychiatrist* is wondering whether the enjoyment of the people around her of the decorative element that she brings to the world is more important than her own mental health and pursuit of happiness?

Not to mention you're being ridiculous, as in, if she was slender to start with, adding 40 pounds or even 100 pounds will *not* make her dangerously fat, if there is even such a thing as dangerously fat...

Good grief, what did the worst shrink ever actually do? He regretted he did not have a better solution on offer, after attempting to do the best job he could. He ruined her self-image forever? Trust me, he will have plenty of help as she goes thru life.

If the choice was dysfunctional madness or obesity, of course the best choice was made. And he did indeed make that choice. But are we claiming this was an unqualified success? That no sadness is appropriate?

Look, anorexia, bulimia, pressure by society to look like a supermodel are bad. But we take this way too far if we extend that to saying 100 pounds of excess weight have no reasonable bad consequences. I am not making a moral judgement of the obese, but have enough actual experience with them to not replace actual compassion with political correctness.

I suspect what I am hearing is women who have a justifiable rage at the pressure over 10-30 pounds utterly misunderstanding what being 100 pounds overweight means.

I'm reacting to the structure of the essay as a whole. The psychiatrist is obsessed with Nia's appearance. "She was too pretty to be in a mental institution..." He tells the story of Nia's weight gain as if it were a huge metaphysical tragedy, not so much for her, but for him.

No question, medication side effects suck. Weight gain is an especially problematic side effect because of the social stigma.

But the doc loses all perspective. The medication freed Nia from unremitting torment and probably saved her life. If his description is accurate, she's probably still conventionally attractive, even if she's no longer skinny.

The doc invests Nia's appearance way more metaphorical significance that it deserves.

Should van Gogh have been given Prozac? Probably. But it is likely we would not have "Starry Night" then. We'd have a little more sanity and a little less beauty. It would certainly be selfish of the world to prefer a painting to a man's sanity.

So we are willing to let van Gogh have his happy pill, and he decides to quit painting altogether. He is thrilled about becoming an accountant for the Dutch East India company. He doesn't even miss painting a bit. Is it wrong for us to feel regret? I don't think so. It would be wrong to leave oils and canvasses conveniently littered around his house, but it would not be wrong to regret.

I would rather have the paintings. "Million Dollar Baby" deals with this theme a little, according to my reading that her style of boxing made some tragedy inevitable.

But this girl was apparently not as functional as Van Gogh, and my uninformed opinion is that physical beauty is not so valuable to its possessor without some other skills and/or talents. This story is far from a tragedy, perhaps not even a misfortune, maybe a mixed blessing?

As to whether the extreme cases of individual physical beauty have a value to society beyond their value to the possessor I wouldn't know where to start. With a comparison to intelligence and other talents, I suppose.

There's nothing wrong with regretting. Side effects are regrettable by definition. But lost thinness is trivial compared to lost genius.

It's not even clear that Nia has lost anything permanently. The girl is probably still very pretty. If she wants, she can diet or exercise later. Besides, it's not a foregone conclusion that she'll need this medication for the rest of her life. One third of schizophrenics can go off the meds for good after the first episode. New drugs are being developed all the time. Nia might eventually be able to switch her meds around.

It's the doctor's attitude that's troubling. He literally says that Nia is a different person now that she's no longer beautiful (in his eyes). Her family is weeping because the meds have restored their daughter to her old self, but the doc is convinced that he's transformed the girl into a fundamentally different being just because she doesn't look like an ethereal waif anymore.

Beauty is great. It would be perfectly reasonable for Nia to feel bad about losing some of her conventional attractiveness. For whatever reason, it's not a big deal for her. It's strange and condescending that the doctor is assumes that her indifference is inherently pathological. He cares a lot, so he concludes that there's something wrong with her if she doesn't care as much as he does.

I also react to this sentance:

But was it really a blessing that Nia seemed to have no conception of what she had lost?

It is the structure, the focus, the assumption of the essay that being model thin and beautiful is so important, equally important to sanity. And as for who made the decision, I don't see here that the doctor discussed this with Nina. What does Nina say about it? Does she have a conception about it? Did she have her whole life set on being a fashion model, or not? Does she have no conception of 'what she lost'?

As for importing political agendas, no, I think those of us being horrified are horrified not that thin is considered good as much as we are horrified that the doctor has his own agenda for the patient that doesn't seem to be validated by anything the patient says.

All of us might make different choices. I know that depression has some positive impact on my creativity and I'll take a little depression to get it, but not life threatening depression. But that is MY choice, others might select a different tradeoff.

But what this shows - again - is another example of the medical profession assuming control over patients it shouldn't be entitled to. Being sick does not mean that the meaning of my life is now for the doctor to decide for me. Help me with, point out issues, ask me questions, etc. But the only one here who seems to have lost is that the doctor has one less pretty girl to eye.

Sorry for the failure to close the quote above. And I know HTML....

You do, do you?

John, I think you do get at part of what I found disgusting and terrifying as well - the fact that the article implies that it's a pretty close tradeoff, despite the fact that it's clear that the patient suffered from severe, dangerous schizophrenia.

Even creepier to me, though, was the distressing interest the psychiatrist even took in how attractive the patient was by his standards. Of course weight gain from psychiatric medication is something to be worried about, both if it may be healthy and if it leads to further emotional problems. But if the patient doesn't give a shit, the response is not to be concerned. The response is that that's great fucking news. Obviously, the patient valued her sanity over meeting her doctor's personal beauty standards. That's the reaction you'd want the patient to have in this situation.

It's also a very logical reaction on the patient's part. She gained some weight, which might lead her to expect that fewer people found her attractive. But prior to medication, she actively believed that a vast network of strangers was saying terrible things about her all the time. Her self-perceived standing in the eyes of others went up, not down. Why would she worry?

I think it is a good response on the therapist's part that he is concerned about any change that happens to his patient as a result of his work. Would you rather he blithely shrug off all side effects as necessary evils? I cannot fault him his scruples.

Italics off.

That's a false dichotomy, perianwyr. Obviously, doctors should be concerned about side effects, including some side effects their patients don't mind in the short term. The doc from The Prospect went way beyond professional concern, and even beyond paternalism. Judging by the article, he lacks insight into how his own emotions are warping his clinical judgement and potentially his therapeutic effectiveness. He could have said, "It's too bad my patient put on a lot of weight. On the other hand, my reaction is disproportionate. I should be looking out for side effects. But is the intensity of my reaction to the change in her appearance really motivated by dispassionate clinical concerns? And if not, what does that say about me as a doctor?"

" But if the patient doesn't give a shit, the response is not to be concerned."

I don't agree completely. True, if the patient is comfortable with the side effects, it is not the doctor's place to make the value judgements about them. However, if the patient shows no sign whatsoever of caring about the side effects, there is a possibility that there is a problem. If the apathy is extreme, there may be unforseen side effects in play, or undiagnosed problems previously overshadowed by the schizophrenia. It may be that the patient doesn't care about physical beauty today, and doesn't care about the color of traffic lights tommorrow.

Admittedly, that is not the jist of the doctor's concern, but I like to argue.

Actually, the most objectionable thing in the article is this :

" He felt himself giving her more time than usual... ".

It implies that he is shortchanging his other patients because of her attractiveness. I've come to expect that from bartenders. I suppose it isn't that surprising that psychiatrists do it too.

Njorl: you are right. The psychiatrist should be generally concerned about any reaction and what it could implicate. I should have been more specific and said that the appropriate response was not to be concerned in the way described.

"It's too bad my patient put on a lot of weight. On the other hand, my reaction is disproportionate. I should be looking out for side effects. But is the intensity of my reaction to the change in her appearance really motivated by dispassionate clinical concerns? And if not, what does that say about me as a doctor?"

A reasonable reworking, but people close to me have had enough experiences with therapists acting like bad mechanics (hey, yer wipers are fixed, them headlights gettin dimmer weren't what ya asked me about, now were they?) that I am at least happy that he is concerned in the holistic sense.

I'd rather have my therapist attentive than unconcerned.

I'd rather have my therapist not obsessed with how hot I am when I'm 17 fucking years old.

Would the article have been written this way if Nia was Neal? I don't think so.

Also, HOW obese? I'm not sure if I would rather be insane or 370 lbs (I'm 175 now, and could afford to lose 10). I KNOW that if the choice were sanity or 250 I'd smack the shit out of my psychiatrist for "worrying".

Also, what's up with psychiatrists, lawyers, etc all breaching their confidences for the press? I still don't get this. I took ethics, and I don't buy it.

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