Highlights From 2017 The National Psychiatric Convocation: ABC Journalist Shares Story of Strength and Inspiration

From Depths of Addiction to Triumph of Recovery: ABC Journalist Shares Story of Strength and Inspiration

Elizabeth Vargas , who delivered the 2017 William C. Menninger Memorial Award Lecture Monday evening, has traveled the world covering breaking news stories, reporting on in-depth investigations, and conducting interviews with high-profile newsmakers. She’s been credited by The New York Times for reinvigorating the newsmagazine format with her “intellectually brave” reporting.

“But in the past two years, I have become known for something else,” Vargas said. “I made headlines because I was forced to admit publicly that I am an alcoholic.”

The award-winning co-anchor of ABC’s “20/20” with David Muir delivered a candid address, describing the evolution of her alcoholism and its roots in a gripping anxiety she experienced since childhood. In September 2016, Vargas published the memoir Between Breaths: A Memoir of Panic and Addiction. The book details her struggles with anxiety and alcohol abuse and tells a powerful story of recovery and coping.

“My earliest memories are infused with anxiety,” Vargas said. “I’m an Army brat, and my father was a lifetime Army officer. When I was 6, we were stationed in Japan when my dad went to Vietnam. That’s when my anxiety moved in and took over my life.

“I began to have these panic attacks when I would cling to my mother’s skirts shrieking for her not to leave me. My mother didn’t know how to care for my anxiety, and I don’t judge her for that. We weren’t even paying attention then to soldiers returning from the war with PTSD, and we certainly weren’t paying attention to their children.”

She would also learn how to hide her distress. Vargas recalled a neighbor being recruited to look after her when her pregnant mother was in the hospital. The neighbor asked her incredulously when she had a panic attack, “What in the world is the matter with you?”

“That’s when I learned my panic and anxiety were shameful and were something I must hide,” Vargas said. “I literally white-knuckled my way through childhood and adolescence. Through it all I kept my anxiety a secret. I didn’t have a name for it. All I knew was that I seemed to be suffering in a way no one else was. I was singular in my struggle. That meant something must be wrong with me.”

It was years later, at her first job as a local television anchor, that Vargas said she learned of the “powerful seduction” of a glass of wine.

“It had a profound effect on my anxiety,” she said. “Suddenly the world seemed gentler. Those nightly glasses of wine became a routine for me. Over the decades I needed that wine to relax. By the time I made it to network, I was drinking wine every night. I needed that wine to ease my stress, and I failed to recognize its power.”

Over time the drinking escalated—“the nightly glass of wine morphed into a bottle of wine,” she said—and a familiar story ensued of alcoholic disintegration. “What I regret most about my disease was the life I missed out on, so many precious moments with my children,” she said. “I loved my children more than the universe, but I couldn’t stop drinking for them. When you are in the grip of this disease, you don’t see it.”

In time she bottomed out and sought help. Recovery wasn’t immediate—she would relapse and return to rehab—but today it has been years since she last had a drink.

Her presence at the rehab was leaked to the press, and Vargas’s plight was made public. Though that publicity was unsought, Vargas said that the 2012 memoir was a coming-clean.

“The response to my story has been extraordinary,” she said. “People have stopped me on the street to tell me I saved their life. I don’t know if that is true—it sounds rather grandiose to me. But the relief that I felt in writing this book and coming clean was enormous. I do know that if I convinced one other person to get help who needs it, or to reach out and share their experience with someone, and if my story can help reduce the stigma around addiction in even a small way, I will feel that I have contributed something.”

Community, Spirituality Important in Recovery, Says Vargas

“It’s so important for us as clinicians and researchers to hear your story,” Nora Volkow, M.D., director of the National Institute on Drug Abuse and internationally renowned expert on addiction, said during an on-stage interview of Vargas following her lecture. “We know that alcoholism is a disease of the brain, but every story of addiction is different.”

Volkow remarked on how prominent was the theme of stigma and shame in her story. “It’s true,” Vargas said. “I am sure if I had cancer, I would feel terribly upset about those missed parts of my children’s lives, but I wouldn’t feel that I had done something wrong. To know that addiction is a disease of the brain is one thing, but to really embrace it is something else.”

When Volkow asked what psychiatrists should know about addiction and recovery, the journalist urged clinicians to pay attention to the value of community and spirituality in recovery. “It’s so encouraging to simply know there is a place to go where people understand your addiction,” she said. “As physicians, you know all about the brain and the body, but I think the role of community is so important too.”

Author Cahalan Tells a Tale of the Art and Science of Clinical Care

“I know what it is like to lose your grip,” said author Susannah Cahalan. “I have come back intact, and I hope I can share with you the perspective of a patient. I want to offer you a view from the inside of psychosis, hallucinations, and delusions.”

The author of Brain on Fire spoke at the Opening Session on Sunday in which she described her experience with anti-NMDA receptor encephalitis, a rare autoimmune condition that mimics the symptoms of psychosis and other mental disorders.

“At the most basic level,” Cahalan said, “I hope I can make you aware of this diagnosis since the vast majority of patients with this disorder will see a psychiatrist before they see another physician.”

Her story is harrowing. In 2009, Cahalan was living the life of an on-the-go young reporter for the New York Post when she fell—actually, “nosedived” might be a better word—into an illness that physicians could not readily identify, though it mimicked in some ways the symptoms of psychosis. After a month in the hospital and a dizzying array of tests that turned up nothing, neurologist Souhel Najjar, M.D. (who is chair of the Department of Neurology at Hofstra University), made the right diagnosis—anti-NMDA receptor encephalitis.

The disorder had been identified only in 2007. A December 7, 2008, report in Lancet Neurology by Josep Dalmau, M.D., and colleagues reported a case series of 100 patients with the disorder. They described it as “a severe form of encephalitis associated with antibodies against NR1–NR2 heteromers of NMDA.” Patients who were treated rapidly with immunotherapy survived.

Cahalan told her story with a writer’s flair and the verve of someone who had come back from a dark place that few have visited. Using videos of herself in the hospital and audio transcripts of conversations with her boyfriend (now husband) who witnessed her disintegration, Cahalan illustrated her descent into florid psychosis.

It began insidiously with odd, eccentric thoughts—an obsession with bedbugs—that progressed into more ominous delusions and erratic behavior (rifling through her boyfriend’s possessions) and finally devolving while in the hospital to a state that mirrored catatonic psychosis.

A review in the New York Times of Cahalan’s 2012 book said “Brain on Fire is at its most captivating when describing the torturous process of how doctors arrived at that diagnosis.” When neurologist Najjar, who was familiar with the 2008 Lancet Neurology article, came to assess Cahalan, he asked her to draw a clock, she said. The image she drew—which she reproduced for the audience—showed a circle with all 12 numbers crowded into one quadrant. That and other clues suggested to the neurologist that she might have the rare autoimmune disorder described by Dalmau.

Najjar would provide the title to Cahalan’s book when he told the author’s anxious family, “Her brain is on fire. Her brain is under attack from her own body.” After rapid treatment with immunotherapy, Cahalan recovered.

Though her baffling condition was bound to be uncovered by a neurologist, Cahalan said her story testifies to the value of clinical skills familiar to psychiatrists. “I believe my story is a triumph of clinical care,” Cahalan said. “It highlights the science but also the art—the art of listening to patients and asking the right questions. Those are the tenets of any great physician.”

To Google or Not to Google: How Much Do You Want to Know About Your Patient?

Are you Googling your patients’ names?

You may not be alone. According to a pilot survey of attending and resident physicians at a large academic medical center, 93 percent of attendees who responded to the survey (n=40) said they had ever Googled a patient’s name, and 94.1 percent of responding residents (n=32) said they had done so. Meanwhile, 89.6 percent of attendees said they had ever considered Googling a patient, and 100 percent of residents said they had done so.

The survey was reported by Liliya Gershengoren, M.D., M.P.H., at an Annual Meeting symposium titled, “Patient Targeted Googling: Oh! What a Tangled Web We Weave, When We First Practice to Deceive.”

The practice of Googling a patient’s name may be too easy to resist and may seem innocuous. But a panel of experts at yesterday’s session said Googling and other forms of collecting collateral information about a patient online raise a host of questions, ethical and clinical, about how that information may affect the physician-patient relationship and clinical care.

Glen O. Gabbard, M.D., discussed the impact of the Internet on the doctor-patient relationship and potential boundary violations. Paul Appelbaum, M.D. (pictured above), explored the ethical and legal implications of using a patient’s “digital phenotype”—which refers to the entirety of an individual’s online presence—as well as emerging technologies that may be used to track patients online in real time. Robert Boland, M.D., discussed the work of the American Association of Directors of Psychiatric Residency Training Task Force on Professionalism and the Internet. John Luo, M.D., an expert on psychiatry and informatics, concluded the session by Googling the name of a volunteer from the audience to show how revealing the Internet may be, for better or worse.

Experts agreed that the ease and availability of online information raises questions that are better addressed than ignored. Quoting an iconic line from the 1999 movie “Cruel Intentions,” Gershengoren said, “Everybody does it; it’s just that nobody talks about it.” She added, “Hopefully, today’s talk has given us a way to talk about it.”

Pediatric Psychosomatic Physician Talks About Special Considerations for Young, Medically Ill

Psychosomatic medicine—the psychological care of people with physical illnesses—is a relatively new medical specialty field, having been recognized only in 2003 as an official subspecialty in which psychiatrists can earn board certification. While most people think of psychosomatic medicine as a field that treats adult patients with cancer, HIV/AIDS, or other serious illnesses, there is a vibrant and emerging community of pediatric psychosomatic doctors.

One such physician, Maryland Pao, M.D., the clinical and deputy scientific director at the National Institute of Mental Health, put her field in the limelight at this year’s Annual Meeting with her talk “Pediatric Psychosomatic Medicine: A Field in Development.”

The last word has double meaning, for while pediatric psychosomatic medicine is still changing and evolving, it also reflects the importance of being sensitive to childhood developmental trajectories in clinical practice.

“Our job is to maximize children’s health-related quality of life, and there is a greater focus on facilitating coping and adjustment and not just assessing psychopathology,” she said. Another difference for pediatric psychosomatic specialists is that given the time course of when mental illnesses manifest, there are also more opportunities for prevention in the younger population.

Pao provided two examples of recent accomplishments that highlight some of the nuanced differences between pediatric psychosomatic medicine and the adult counterpart.

The first involved the decade-long journey of developing a screening tool for pediatric suicide. There are many templates available as a starting point, including the gold-standard Suicidal Ideation Questionnaire (SIQ), but adapting SIQ queries to children required some careful considerations.

Some issues involved simple word choice, such as whether children would understand terms like “unbearable.” There are also changes based on children’s role in family, so rather than ask about a child’s individual burden, it might be more appropriate to ask, Have you felt your family would be better off if you were dead?

After a couple iterations, Pao was glad to report that a team of which she was a part managed to find a set of four questions that could identify suicide risk in children with both psychiatric and other medical disorders in an emergency department setting. Researchers are currently validating theask suicide-screening questions (asq) in other settings.

The other advance also deals with mortality—how to approach end-of-life questions and decision making in children with a chronic condition like cancer or a congenital heart defect. Life expectancy for children with such disorders is greatly improved, but they still claim many lives. Until recently, the issue of how children want to plan for end of life was not really considered, since legally the parents have all the rights.

But through focus groups, Pao and her colleagues found that children are very interested in their potential end-of-life choices, but more so in how they would like to be personally treated (as opposed to medically treated) and how they wanted to be remembered by family and friends.

Pao and colleagues then adapted an adult advanced care planning tool known as My Five Wishes and created another tool called voicing my choices.

“What makes this tool very powerful is that not only does it empower children and express their desires, but it also helps parents make more informed decisions on behalf of their children,” Pao said.

Pao noted another important consideration in her field is that there are special considerations in relation to children, as well as to pediatric nurses and other providers. “A lot of the subjects we deal with, like suicide and end-of-life care, are still considered taboo in some circles, so we have to make sure that the language we use can be delivered in a thoughtful and appropriate manner,” she said.

Lessons Learned From Studying Mental Health Outcomes of U.S., U.K. Soldiers

The most traumatic national experience for Great Britain in the 20th century was World War I, whose centenary the nation is now observing, said Sir Simon Wessely, the Regius Professor of Psychiatry and co-director of the King’s Centre for Military Health Research at King’s College London, at APA’s Annual Meeting. A century later, the mental health legacy of that war continues today for troops of both the United Kingdom and the United States.

In fact, 2017 also marks the centenary of the birth of modern psychiatry, a birth midwifed by the treatment of soldiers devastated by combat in the trenches, said Wessely, who is also president of the Royal College of Psychiatrists. Charles Myers, M.D., of the Royal Medical Corps had published a description of what he termed “shell shock” two years earlier. For a while, traumatized soldiers were simply sent home, but by 1917, the army had lost so many men that another approach was needed. Myers instituted what today is known as “forward psychiatry.” Soldiers were to be treated close to the front, as soon as possible, and with an expectation of recovery.

The United States joined the war that same year, and the two countries have been military allies ever since. That alliance offered an unusual chance for cross-national research on mental health as they fought wars in Afghanistan and Iraq over the last 16 years.

“We have seen similar experiences of war but also some different outcomes,” said Wessely. For instance, U.S. troops had higher rates of posttraumatic stress disorder (PTSD) from baseline following deployment to Afghanistan and Iraq, while the British saw no increase from baseline. Rates of mild traumatic brain injury ran about 15 percent to 22 percent among American forces, but were just 3.6 percent among the British. At the same time, rates of mental problems rose among British troops if their tours of duty were extended without notice, while they were deployed in combat. The British also faced greater problems with alcohol misuse.

Screening returning troops to detect symptoms of mental illness is a “seductive idea,” said Wessely, yet little is known about its value. So he and his colleagues conducted the first randomized, controlled study of the effects of mental health screening. The screened group received immediate feedback about any problems, while the control group just got general mental health advice. The results were not so seductive.

“Screening made no significant difference in mental health outcomes,” said Wessely. “It didn’t get people better or even connect them with help.”

Apparently, soldiers thought interventions were likely to be ineffective, or thought they could manage on their own, or they simply lacked confidence in the health system.

If there is a lesson to be learned, it may be a return to Charles Myers’ dedication to recovery.

“Military psychiatry has made an enormous contribution to the field of mental health,” said Wessely, “but the mental health of armed forces follows the same principles that apply to everyone else—that is, a combination of biological, physical, and social factors that affect the individual.”

By | 2017-05-24T14:35:04+00:00 May 24th, 2017|We Know Psychiatry|0 Comments

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