Across and Inside my Universe

About My Psychiatrist/Patient Relationship

My last appointment was almost two weeks ago, with the psychiatrist.

She's decided to keep me on 150mg Lamictal, though I told her I wasn't sure how effective it was. She said I need to modify my behavior, implying that I'm expecting the medication to take care of the problem.

You know, I can understand that and that's fine, I work hard on modifying my behavior anyway even if it often seems to be futile and frustrating.

The thing is, when I came back to her last November after not seeing her since July, and told her about my mania and the most troubling behavioral symptoms of it, she was all, "OH! We need to get you on some medication right away so you don't ruin your life!"

So, I feel like she's being a bit of a hypocrite; actually, what she's telling me now with, "Oh, modify your behavior," it seems the exact opposite of what she told me last November!!!

Now, regardless of whether a behavior is influenced by or triggered by my mania, I believe a person should work as hard as they can to modify/change that behavior. BUT . . . when the mania is pushing you, urging you, sometimes overwhelming you . . . . that makes it so difficult it feels impossible at times to just manage it yourself.

Another thing: If I only engage in the behavior when I'm manic, whilst other times I have enough self-control to keep from engaging in the behavior, as well as at these other non-manic times I don't have any desire or wish to engage in the behavior, well that to me says there's a biological factor influenceing and/or triggering the behavior. Meaning in order for me to deal with this, medication would be more than helpful.

I am frustrated though that so many medications have not worked out for me, but I can remember how moderately well the Risperdal worked, as opposed to how moderately poorly the Lamictal is working at 150mg. When I was on 200mg Lamictal, it felt like it was closer to the effectiveness of the Risperdal, but I can't go that high on Lamictal. We had actually been shooting for 300mg even.

I'd say the Lamictal is taking about 24% to 30% off the edge of my mania, while the Risperdal was more like roughly 55% or so. This is academic however since I can't go back on Risperdal.

I am also rather afraid of Lithium, given its high side effect profile (not sure if I'm phrasing that right.)

I think besides Lithium and Zyprexa, the only other medication might be Seroquel, which we tried last year for depression and it didn't work well for that; I wonder how it would do for the mania, though. We stopped the Seroquel (it was 300-400mg, I forget) about two months before the mania hit big-time. I will NOT take Zyprexa, after the Depakote caused me to gain weight; I can't deal with the diabetes risk. I've heard that PCOS (polycystic ovarian syndrome) is a pre-diabetic condition anyway, but I have no idea.

As far as I know, we've run through almost all of the bipolar medication options. Then again, I don't know much lol.

I'm frustrated with my psychiatrist for acting like a hypocrite though. I do realize that 25% to 30% off my mania is better than nothing. I did not put it in terms of a percentage to her, however, I just came up with that as I was writing this post.

Another frustration is that I'd heard Lamictal and birth control pills can affect each other; I've heard that either one makes the other less effective, or that both make each other less effective.

So I asked her, and she said that, if anything, the Lamictal makes the birth control less effective (I had mostly heard it was the other way around.) So I had my husband ask the pharmacist when he went to pick up my pills, and he confirmed what my psychiatrist said.

This angers me, because neither the pharmacist nor the psychiatrist told me of this side effect with potentially huge consequences. Granted, I wasn't on the birth control pills when I started the Lamictal, but when I did start the birth control pills, I emailed the psychiatrist, as well as discussed them and the reasons for them as opposed to the permanent solution to birth control I am working on getting comfortable with. So during this whole discussion about my fertility and deciding to end it, and why I'm taking birth control pills instead of doing something else right now, she never mentioned this important side effect. And neither did the pharmacist, though I thought drug interactions were part of their main concern.

I know no one is perfect, though. It just could have huge consequences . . . . this is the first time I feel my psychiatrist has not been on the ball, really sharp mentally, extremely knowledgeable, about medications and the issues related to them. So she can't remember everything, all the time, I'm telling myself, trying to not expect perfectiong. Still, of all the side effects to forget, this one is a doozy.

I REALLY don't want to do something permanent to my body, ie, the uterine ablation or whatever it's called when they freeze the lining in there, until I'm comfortable with it, until I've come to terms with how I feel about ending my fertility (what little there might be with PCOS).

I'm also frustrated with my psychiatrist for not wanting to deal with my depression; we haven't tried anything for it since the Seroquel last year. Perhaps she wanted to get the mania under control, first, but it seems she's decided it's as under control as it's going to be . . . so why not address the depression?

I think there may be a couple of reasons for that. One, anti-depressants can set off mania, and we don't want to make that worse. Two, her practice has been getting busier and busier; it was six weeks between the last two appointments, and now it's two months until the next one. While I'm kinda happy not to see her as soon, on the other hand I wonder if she's getting too busy. Although it could be that since she feels I'm as good as I can be on the Lamictal, she wants it to float that way for awhile, and see in two months how I am . . .

I keep reading back and seeing I say, I think she may have these reasons, or she may feel this way, etc., and I wince, because shouldn't she and I be DISCUSSING these things? Then again I AM afraid of her, and we've discussed what I've thought of to discuss in recent appointments; it's been less of her forced "Let's talk about whatever comes out of your mouth first" contrived technique.

Do I think my fear of her may be part of the reason I "forget" important stuff to talk about? Perhaps. I'm certainly not gonna be near as critical of her in appointment as I am on this blog. There's a difference between being critical and asking genuine questions that may sound as if I'm questioning her reasons for what she's prescribing and why; I can see why I might be afraid to ask her such questions, but in a good doctor/patient relationship the doctor should feel or act threatened by a patient wondering about these things. Our relationship is not a good one, however, and after typing this post which is helping me think through these issues, I wonder how harmful to my health IS this doctor/patient relationship becoming, if I can't ask her the questions I feel are necessary for the best care . . . .

When The Doctor/Patient Relationship Becomes Heated

I don't pretend to be an expert on this, or that what I have to say is, in fact, all that earth-shattering on this or any matter.

Still, ever since the Shrink Rappers announced a "heated" or "hot" theme for the upcoming Grand Rounds to be hosted on their blog very soon, I have NOT been able to get the above-titled topic out of my head . . . and so, I will get it out of my head and onto my blog, no matter any reservations I have about being so forward as to submit something for Grand Rounds . . .

I have had two different heated exchanges (actually, they were alot more one-sided than exchanges, with the heat all coming from the doc) with doctors, both of them psychiatrists. One male, and my first psychiatrist, and the other female, and my third and current psychiatrist.

I think it is a negative thing for ANY doctor to yell at or harangue/browbeat their patients, but I feel that with psychiatrists, even when seeing them just for medication management, that since it is usually expected that psychiatrists be sensitive to one's feelings etc., that when they act disrespectful and "heatedly", it's even a bit MORE jarring than it would be from another medical profession.

Now, doctors are human. They are not perfect; they have feelings and good days and bad days and life crises all happening just like the rest of us. I can understand this, and, in fact, in one of the two cases I mention above, it really helped me deal with the episode. The other episode, with my current, female psychiatrist, is harder for me to deal with, and in fact it still bothers me a great deal.

Before I get into specifics, let me say that as a patient, when you are sitting there on the receiving end of some "heat", or ire, or intense aggravation, or anger, even, it is shocking, bewildering, and causes you to wonder what is wrong with you or what you did wrong, as the patient, to deserve what is happening. You are shocked because, if you've had enough dealings with this doctor (about a year, in my first psychiatrist's case, when this happened) you know that he normally conducts himself much more professionally; to see and FEEL such unfettered, intense, unpleasant emotion, directed at YOU . . . well to say it is bothersome is an understatement.

It directly impinges on trust; you wonder, as you get past some of the shock, if you can trust this professional with the most intimate things that you think and feel, things that are necessary for them to diagnose and treat you correctly. If you HAVEN'T had enough dealings with the doctor to know that they usually act more professionally, OR if some of your dealings with them have been laced with discomfort from feeling they are forcing their agenda down your throat, then as you sit there feeling the "heat" you may also end up in "survival mode", doing your best to survive what feels like a verbal assault, trying to get through it as best you can. In my case with my current psychiatrist, this "survival mode" kicked in without conscious thought, and I didn't identify it until later that day or the next day.

I guess I'm trying to say that perhaps some of the difference in how I feel about, and how I handled, the two different incidents, is based, in part, how my usual interactions with that doctor go; how much a partner in my treatment I feel I am with each particular practitioner, and perhaps partly based on my past history, in the female's case, with a dominant, physically abusive woman.

So, here's what happened. With my first psychiatrist, well, he's definitely a Type A personality as they say; very strong, very opinionated, but rather intelligent, always acting in a professional manner, even though he frequently had things to say to me that were difficult to hear. I didn't always agree with those things, but the times I did, were very profound. I don't believe the times I didn't meant he was right, I was wrong, and just wouldn't see it. I really felt that sometimes he didn't listen to me and would come to his conclusion before hearing everything he needed to to come to the most informed conclusion.

This became the basis for his going off on me, one day . . . he spent 25 minutes in angry discourse at me about how I go on too much and waste his time by taking up so much time. After getting over some of the shock, I thought, wait, isn't this the pot calling the kettle black? Who is taking up a bunch of time now? Wouldn't this time be better spent working out our apparent communication problem?

Basically, I sat there and quietly listened until he was done. The appointment ended very soon thereafter, and I was rather upset, although in some ways not . . . . because it was SO UNLIKE him. I also had reason to think that he might be personally going through some emotional difficulties, because the previous summer he'd been suspended by the, whatever the Psychiatric Board or authority is that disciplines psychiatrists. I believe it was an unfounded charge, based on a random meeting long after he'd stopped treating someone, but then, he COULD be rather aggressive in his opinions and ways of interacting (nothing inappropriate, just very assertive) and someone could easily resent that and want to punish him for it.

Regardless, after I went home that day I wondered if he was still dealing with the fallout from his suspension; I imagine it's not easy to get a substitute to cover your practice for 3 months, nor would it be easy to deal with the opinions of your colleagues once they found out you'd been suspended, and even harder, dealing with your patients' feelings about it. So that is what I suspected was going on, so I had an easier time dealing with this.

Still, at the next appointment he apologized for his behavior, saying something about he'd been going through something at the time. I accepted his apology and we moved on, though I did still continue to have problems with him not listening to me enough (yes, I could keep appointments to the 15 minutes, I didn't always go over.)

Eventually, he decided to close his private practice and become a consultant-liason psychiatrist at a local hospital; the timing of this decision was such that I knew he had to have been mulling it over that fall when he ripped me a new one. The deed was done less than 6 months after the harangue.

The second, more troubling to me incident, happened in January of this year with my third, and first female, psychiatrist. I'd been seeing her since the previous March, with a break at the end of summer into late fall. She has a very different philosophy, is an "integrative" psychiatrist, is Buddhist, and is a strong, dominant female personality. At various times I've felt like she's trying to shove some random agenda of hers down my throat . . .

In January, I had finally decided to tell her I was afraid of her. This is a good thing, no? Then the doctor can understand why I seem hesitant or other things . . . Well, apparently my "mistake" was in the type of insight that had led me to realize this; I had realized that because my mother used to physically abuse me, I was afraid of my psychiatrist since she was a strong female, with dominating characteristics. To me, the connection of the two seemed like a no-brainer . . . if one woman in your life beats you and tries to dominate you (there were reasons behind the hitting), then it may make you wary and even afraid of other strong, dominating women.

BIG mistake on my part. I told her straight out, "I'm afraid of you because my mother used to hit me.", figuring that psychiatrists are extremely familiar with the concept of transference . . . . She was instantly OUTRAGED upon hearing this and so angry it took her a few moments to be able to speak and then she assaulted me with angry questions about things like, was she my mother, what does one thing have to do with the other, and eventually she asked me if she was being scary right now . . . . by this point I had unconsciously retreated into "survival mode" and really could not identify ANYTHING I was feeling at that time; I tried, and couldn't feel anything, so I said "No.".

Well, HELL YEAH she was scaring me! Once I'd had some time and space between her and I, oh boy could I identify my feelings . . . . she was proving how RIGHT I was to be scared of her. She FORCED me to answer every question, in a way that made me feel stupid and insignificant, staring me down until I answered. "Do I LOOK like your mother?" "No . . . " "AM I your mother?" "No . . . " and she asked me some other things but honestly I was too traumatized to remember it all. I just remember feeling so verbally assaulted . . . .

In thinking about it now, I feel that she really missed an important opportunity, as a doctor, to connect with her patient and deal with an issue that would interfere with the doctor/patient relationship if left unaddressed. EVEN if she couldn't recognize the validity of the transference principle as something that could fit with her very strange and different philosophies, why throw the baby out with the bathwater and not stop to consider that I said I was scared of her? If she could have set aside the philosophy she couldn't stand, and seen the very real issue between us, then she would have done what was best for her patient, in that situation, in my opinion.

But, as I say, doctors are human too, and when one REALLY objects to a particular school of thought or psychiatric philosophy, perhaps that invalidated to her everything else that was attached to it in the statement I had made. I've often wondered if I had just said, "I am afraid of you", if the reaction would have been much different.

Perhaps, but perhaps not. I suspect she would've assaulted me with questions like, "Do I look frightening?" "Am I scary?" "What, specifically, scares you about me?" and when I couldn't come up with an answer, she'd satisfactorily verbally beat me down with the fact that I couldn't possibly be scared of her, just like she did this last January. But I may be being unfair; perhaps it really WAS the "unacceptable to her" psych concept of transference that was the basis for her going off on me. Perhaps she WOULD have listened if I'd put it differently, but you see, she's the doctor, and I'm the patient, and no matter what "could have" or "should have" been done differently by me, she acted unprofessionally and unacceptably towards me.

Why do I find her behavior so much less acceptable than my first psychiatrist's? Perhaps it is because she had a history of forcing her way on me . . . but then I think, didn't Psychiatrist Number One also have a strong way about him, where he tried to get me to think along his lines of thinking? Yes, he did . . . Then again, he'd never given me an ultimatum, like she had. He'd never tried ramming wierd goals for me down my throat, like she had . . .

In the end I think I can safely say that part of the difference in how I reacted to the two incidents is, indeed, related to my fear of strong, dominant women based on how my mother treated me. Part of it, though, I think is that I had more a feeling of being a partner in my treatment with the male psychiatrist; I wouldn't hesitate to stand up to him, which was saying ALOT for me, because I usually shrink from such things, and he had VERY strong opinions. Still, since I really wanted him to understand me, I knew I had to press for standing up for my view, or my experience, or my thought process that I wanted him to UNDERSTAND before coming to a conclusion.

I guess, after writing that last paragraph, it's easy for me to see now that my mother IS a big part of it; I could stand up to HIM, but not to HER.

Six months down the line from the "heat" I received from my current shrink, and I am still having trust issues, and definitely fear issues. I finally may be getting up the courage to bring up the issue with her again (sans mother), but I am not sure if I have the courage. I do hope that if she gets angry again I can tell her what I think of her unprofessional behavior . . . and lack of insight into the issues that can interfere with a good doctor/patient relationship.