All of us psychiatrists have had the experience of a raging borderline patient threatening to kill themselves unless they are admitted to the inpatient unit. They have a history of repeated, manipulative suicide attempts by cutting their wrists, and overdosing on small quantities of Tylenol, which once led to a prolonged ICU admission for liver failure. They also have a history of assaulting staff during prior admissions. One fellow psychiatrist sustained a disabling concussion during a particularly violent restraint which ultimately involved the state police. It was talked about for years by the staff psychiatrists. I am sure such a patient engenders many feelings in all of us who have gone through psychiatric training, including annoyance, anger, and possibly downright hatred. Some of us might be immobilized with fear, contemplating the thought of a successful lawsuit against them. Few of us would be able to respect and embrace such a patient. This provides an opportunity to assess our responses to such a patient.
In this case, the name of the patient is the US Government. We now face the “Sequester”, another one of those sequels to the first horror film, “The Debt Crisis”, released the summer of 2011 which resulted in a nomination for the “Borderline Prize of the Year” at the Insane Film Festival, held in a dysfunctional dystopia where the central players are unable to meet together and as a result seriously damage the environment for the townspeople. “A surreal psychological nightmare,” describes a leading East Coast newspaper. After such commercial misery, the sequel “Fiscal Cliff” was released, bringing back all of the familiar monsters, who had starred in “The Debt Crisis.” In this brilliantly staged nightmare, the monsters so hated each other that they decided in might be a good idea to destroy the villages of the people. The townspeople all reacted with fear, as the news spread. Many of the intelligent and successful townspeople warned of these monsters, pointing out the threat they created. Gates were raised at Sunday buffets, though the people sadly concluded houses would be lost, food would be taken away from the babies, and the old people might freeze or starve to death. Nonetheless, the townspeople were helpless, hoping it would all be ok. I won’t give away the ending though the latest sequel, “The Sequester,” represents the raging borderline at their best. It is amazing how the producers are able to bring back the same stars to play the monsters in each installment. In this latest freak out, not a good date movie at all, the monsters hatred towards each other so much creates a massive negative particle field which magically makes food, band aids, and teachers go away. Even some of the “taker carers of the land” are whisked away in the negative vortex. The townspeople will get to be exposed to the toxic particles, which will destroy some, possibly many of them. It is even possible that the townspeoples places of basic safety will be infected with the radioactive death particles, possibly hurting many of their basic needs. Sadly, the Scandinavian author of these stories committed suicide last spring, leaving the future growth of the trilogy in serious question.
What can we learn from these brilliant fictitious (or are they?) movies that can be directly applied to our professional lives and approaches to patient care? Cognitive approaches inform the importance of questioning underlying assumptions. Yesterday I was speaking with someone (not a patient) who may face imminent unemployment. They are well educated, successful, and in a stable relationship with middle and high school aged children. This person shared that they didn’t believe the sequester held any real threat to the economy but was somehow beneficial in reducing future debt. They also shared that personal efforts to find better employment were poor but when asked what the potential effect of adding thousands more people looking for jobs that are scarce – given the potential job cuts in ship manufacturing and defense related plants, a highly likely effect of the sequester - the response was to change the subject, instead clinging tenaciously to assumptions derived from an emotional response, disconnected from any basic economic theory. On a process level, the emotional response (they brought up the topic in initial disgust) seemed to impair a cognitive analysis of their underlying assumption sets. Dialectical approaches to this impasse might include efforts to reduce affective dysregulation and improve emotional responses, while also enhancing the parallel cognitive approaches.
Whatever the direct economic consequences of the potential sequester and later possible government shutdown, volatility and fear will continue to feed into the markets. Economic instability and volatility – enhanced beta without commensurate increase in alpha – damages many people. This country is continuing to improve from the financial calamity of 2008/2009 however many people, particularly older individuals without conventional pensions, are disproportionally effected by declining stock market values in their mutual funds. A low interest rate environment also forces them to live off more of their principal reflecting very low returns. Unemployment, though improved, remains a nightmare for many. Younger readers perusing this column may think none of this is relevant to them, though its proximate effect will be that they will need to save more and live on less. There is, and will continue to be, plenty of pain to go around. Demographic considerations must also be considered. Health care costs continue to rise, consuming a large share of all economic output. Approximately 10,000 Americans turn 65 each day and this will continue for at least the next 20 years. An average individual uses approximately 240,000 dollars more in health care costs than they contribute approximately into Medicare over their lifetime earnings. Additionally, intrinsic inflation in health care, like an education at a private college, has far outpaced aggregate inflation. It doesn’t take more than a calculator to see where this is going.
Given the multiple admissions and high utilization, a second opinion consultation for the patient initially presented is requested. As the consultant, you immediately find the presentation of the patient is confusing. Sensing the anxiety of your psychiatrist colleague/friend on the unit next door, you want to be thorough. You review the labs, noting marked hyperthyroidism with a virtually non-existent TSH. Cortisol levels are sky high, and the patient is a marked non-suppressor on the dexamethasone suppression test. You also notice a mention of idiopathic hirsuitism in a prior note of an endocrine consultant, who suggested the full battery of labs in the first place but whose locum tenens assignment ended. They also suggested an MRI, which you ordered and revealed a tumor extending into the right medial amygdala. Fortunately, it was successfully resected by neurosurgery with no evidence of malignancy or metastasis. It was only because of your calm, thorough, and rational approach that the clinical outcome was positive in this case. Maintaining an open, level, Socratic, and affectively modulated mind is the only way to win such cases. It seems there is much we can learn from our profession which can be applied to the Horror Movies around us.
Jeffrey S. Barkin MD, DFAPA
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