Psychiatry as a profession in crisis.

Recently on NPR, Dr. Daniel Carlat discussed his new book, Unhinged: The Trouble with Psychiatry, in which he takes his profession to task for its increasing focus on prescribing medications for mental ailments and de-emphasis on engaging patients in talk therapy.

Carlat's is not an anti-psychiatry screed (you can learn about one of those here) -- he believes that psychiatric medications and therapy can both be efficacious -- but as the following excerpt from the book makes clear, he's quite critical of himself and his peers:

Carol told me that she had been in the car with her father, who was driving. They came over a rise in the road, and another car was just pulling out of a driveway in front of them. Her father tried to swerve, but it was too late. They collided with the other car, and her father, who was not wearing a seat belt, was killed instantly. Miraculously, Carol was not seriously injured.

Since then, she said, she had recurrent dreams about the accident, and couldn't prevent herself from replaying the scene during the day. The events would unreel themselves like a movie in front of her, and often she would start sobbing uncontrollably. I recognized these experiences — nightmares and flashbacks — as typical symptoms of post-traumatic stress disorder, or PTSD. I asked her a series of questions about other symptoms, such as poor concentra­tion, insomnia, being easily startled, and the need to avoid situations reminding her of the crash, all of which are commonly associated with PTSD.

She said she was experiencing all of them. Her life was constricting inward. She drove rarely, avoiding especially the road where the accident had occurred....

"The worst thing," she said, "is how guilty I feel."

"Why guilty?" I asked.

"It was my fault that we crashed. I got him upset."

Her eyes began to well up. "I was telling him that he shouldn't be drinking."

"He was drinking and driving?"

She nodded. "I told him I could smell it on his breath and that he shouldn't be driving. He got mad, started yelling at me. And then he floored the gas pedal, said something like 'Am I driving good enough now?' That's when it happened."

I could see that this was more than a simple case of PTSD. She would have complicated feelings about her father to wrestle with — grief, regret, and eventually a good deal of anger....

"I'd like to give you some medication to help you through this," I said. I wrote out prescriptions for the antidepressant Zoloft and for the tranquilizer Klonopin. Then I reached into my file cabinet, and handed her a business card. "And this is a good therapist who I often work with. I recommend that you give her a call and set up an appointment. The medication works better when you are also seeing a counselor."

She looked confused. "Aren't you my therapist?"

I shook my head. "Unfortunately, I don't have time in my practice to do therapy. I usually refer patients to psychotherapists whom I trust."

"So . . . am I going to see you again?"

"Yes, we'll schedule another appointment in about a month, to see how the medications are working. But in the meantime, I hope you'll have had a couple of sessions with this other doctor."

Carol still didn't look at all happy with this.

"But aren't there any psychiatrists that do therapy?"

"There are a few," I said, "but not many. They're hard to find these days."

This has been my experience with psychiatrists, too. Has it been yours?

Now THIS is a reason to be afraid.

Fascinating tale here, of a woman stalked and attacked by a mountain lion. The piece, an excerpt from a book called Extreme Fear, by Jeff Wise, reviews the four stages of fear: freeze, flight, fright, and fight. From the article:

As she locked eyes with it, the mountain lion moved forward, descending the shrubby bank and heading straight toward her.

Yellowtail waded back across the three-foot-deep stream, back toward her truck. To be prudent, she thought, she had better keep the width of the icy stream between herself and the animal. As she made it to the far side, the big cat quietly slipped into the water.

A former biology major, Yellowtail had studied predator behavior. She knew that if she began climbing the steep bank up toward her truck, she would expose her back, and she guessed that the moment of vulnerability might spur the mountain lion to attack. Instead she moved quickly down the edge of the stream and crossed again, feeling her way over the slick cobbles underfoot. Looking behind her, she expected to see the animal climb the far bank and disappear. But no: It followed her path along the water’s edge and again started swimming after her.

“I’m in trouble,” Yellowtail thought. “This is serious.” There was no doubting the mountain lion’s intention now. Trapped between the stream’s steep narrow banks, she couldn’t think of any way to keep the animal away. She was holding a microcassette recorder that she kept for taking notes, and she threw it at the cat. It just kept coming.

Yellowtail retreated down the riverbank, shouting and throwing rocks and chunks of ice. Somehow she managed to keep herself from running. She crossed the stream, worked farther down the bank, and crossed again. The cat followed, relentlessly closing the distance. Even as she felt panic building, Yellowtail had enough presence of mind to understand that what she was seeing was a classic example of predator behavior. Running would only stoke the animal’s attack instinct. She had to fight the urge.

The mountain lion was close now, near enough to pounce. As she splashed once more across the stream, the need to run surged over her like a shiver. She bolted, splashing madly through the shallow water, her legs churning over the rough, slippery cobbles of the streambed.

She ran with everything she had.

Next time someone who doesn't know better asks you what a panic attack is like, tell 'em it's like this, only without the mountain lion. It might not clue them in as to how it can be that someone can panic without an objective object of danger -- send 'em to these PANIC! posts for that -- but it will certainly bring home the chilling sense of fear they bring.