Sometimes I envy scientists and physicians from 100 years ago who took credit for the easy discoveries, sometimes even attaching their names to them. The Bernoulli Principle, for example, describes how the pressure of an inviscid material decreases as the flow of the material increases, and why the disgusting shower drape in cheap motels is pulled toward the person in the shower. I’m sure that I noticed that effect when I was about six years old, and had it not been already figured out, I know I would have come up with it eventually! But the days of simply thinking real, real, hard and coming up with a ‘discovery’ are long gone.
Or are they? I have a good one, I think… and with the right presentation and help from readers I might become famous. Or not. Either way, it’s worth a shot…. So I’d like to introduce Junig’s Warm Coat Theory of Psychotropic Prescribing. (I know—the title needs work)
Back when I was an anesthesiologist, surgeons sometimes used the phrase ‘better is the enemy of good.’ The point was that in some surgeries the best approach was to remove the infected or diseased tissue, stop the bleeding, close up ASAP and get the patient back to the ICU. Spending another 4 hours picking at the tissue to make everything pretty risked a drop in the patient’s body temperature, a decrease in clotting and immune function, and an increased stress response, all in turn increasing the odds of a bad surgical outcome. I have to give credit where credit is due, and note that the warm coat theory is similar in some ways to the ‘enemy of good’ phrase that I have heard recited over the years. In fact, it is entirely possible that the unconscious parts of my mind stole the phrase and adapted it to psychiatry. If that is the case, I’m sorry for the actions of my unconscious—and I plead ignorance to the entire affair!
When prescribing medication for psychiatric conditions– for example ADD or anxiety– the patient might note positive effects initially but then at some point ask ‘maybe I’d do better with a higher dose—should we try a little more?’ With any medication for any condition, there is a balance between positive effects of the medication and risks or side effects from the medication. Serotonin medications work well for depression and anxiety, but as their doses are increased they will eventually cause sexual side effects. At still higher doses they may cause drowsiness or nausea. The positive effects of a medication go up with dose, but the side effects increase as well. The goal for the patient and physician is to find the proper balance is between positive effects and negative side effects. If the patient has no interest in sex (and doesn’t WANT an interest in sex), sexual side effects should not limit the dose. Nausea or sedation on the other hand may be barriers to dose increases. Different people have different concerns about risks and side effects, and different people have different needs for higher doses of medication. These differences, by the way, are why I maintain that psychiatrists should spend more time with patients than they do—but that’s another topic for another day.
A warm coat in Wisconsin
When us Wisconsin folks go outside in January, we take a look at the Weather Channel and dress accordingly. But we don’t dress for 14 degrees F; we dress for ‘pretty darn cold.’ If I’m going to a Packer game, I’ll put on my long-johns (too much information?), jeans, and the snow-suit from Fleet Farm (that changed my life when I finally bought it, after suffering a few football seasons without it). I’ll also wear a stocking cap and maybe even a face mask, and of course a thick pair of gloves. At some point during the game, if the drunken guys squeezed in way-too-close on each side of me take off their shirts so their body heat radiates toward me and warms me up, I’ll take off my face mask and maybe my cap. By the end of the game I might even have my own shirt off if the sun is out. Of course the guys next to me might have enough of the game at some point and spend the rest of the game at the bar, just as the sun disappears behind a thick layer of clouds. Then I’ll put the heavy stuff back on, and maybe rub my hands together or do some jumping around to raise my body heat. If I get cold enough, I’ll go inside and warm up for a few possessions. The point is that I don’t bring along a spring jacket to change into when I’m warm, and I don’t bring extra coats for when I’m cold. Instead I change my activity, my location, or make minor adjustments to my wardrobe.
According to the warm coat approach, I suggest that patients think of their psychiatric medications in a way similar to how I think of dressing for a Packer game in January. At the time the person wonders about a higher dose, he/she is getting a good response from the medication, usually with a low amount of side effects. At this point, ‘better’ may be the enemy of ‘good.’ The person is essentially wearing a warm coat in January. There is no need to run home and pick up a few more coats; the better action is to change behavior to fine-tune the degree of symptom relief. If the target symptoms are attention problems and the current dose of stimulant has taken the person 85% of the way, the correct action is to adjust behavior. Find a quiet location for studying. Get enough sleep. Come up with reminders and plan ahead, to avoid time crunches that interfere with performance. These are better approaches than increasing the dose of stimulant, which might raise blood pressure or lead to addictive problems. If the target symptoms are anxiety-related, work on positive self-talk and try to gain insight into why the anxiety is there in the first place. Learn to relax using deep breaths or by taking a walk to get away from the stressful environment.
The medication should be like a warm coat in January; a way to make symptoms ‘good.’ Use behavioral or therapeutic interventions– approaches that don’t increase risks or side effects– to make things ‘better.’
If Junig’s Warm Coat Approach becomes big, some day you’ll be telling your grandchildren about the day you first read it, before anyone was talking about it. They’ll look up at you with big eyes and say ‘Wow!’
Or not. Either way, I for one think the idea has legs!
{ 6 comments… read them below or add one }
“If the patient has no interest in sex (and doesn’t WANT an interest in sex)….”
As a fellow doctor – if only in organic chemistry and pharmaceutical science – that must also seek constant psychiatric intervention, it astounds me how many medical doctors/therapists I’ve seen that dismiss such sentiment out-of-hand, or believe it indicative of a greater issue, or a diagnosis in-and-of itself. It did reach the point of refusing to mention such a sentiment, such as refusing to mention use of medication-assisted recovery in the twelve-steps, which, ironically, in both cases, hinders the treatment, because in both psychotherapy, psychopharmacotherapy, and the twelve-steps, “absolute honesty” is required. Although, a little more so in psychotherapy – so the clinician knows what to look at, from what angle – and psychopharmacotherapy – so the clinician knows what medications to throw at a condition, etc. It doesn’t help anyone if a counsellor believes you are a manic-depressive when you really are an opioid addict (one of several trials and tribulations with the mental health system I have had), because (1) a mood stabilizer’s not going to help, and (2) the cause of the most immediate symptoms is continuing to degenerate in to a worse state: no wonder there is no therapeutic response!
Dr. Junig, I thank you, and salute you, for acknowledging what very few doctors will, in that short sentence. Too many doctors, upon learning that I have no desire to have any desire to engage in any sexual activity, full stop, pathologize it, attempt to treat it, or attempt to define a physical or psychosocial etiology for it (and then treat it) instead of accepting it as a non-pathological variation: indeed, a variation that leaves a man much more free to pursue constructive activities in life without being drawn down by the most base, instinctual desires, and seeking pleasure as a drug addict seeks a fix. No one can argue convincingly that sexual activity serves anything other than an evolutionary purpose, to propagate life (and if you believe the Eastern mantra of something like “life is suffering,” which, in the broadest sense, life always contains suffering, check out “Better Never to Have Been,” David Benatar; I adhere strictly to the anti-natalist viewpoint, so sex becomes, to such a person, an instrument of repression and terror, much like a nuclear weapon, but lacking even the beauty of man’s ingenuity that can make such a devastating device amazing). The “other side of the coin” – people who do see a problem in losing sexual desire due to a chemotherapeutic substance that is improving every other measure of their life – those are the ones who should be pathologized, as such intent – let alone behavior – interrupts the peaceful progression of meaningful activities in a person’s life. If it does bother a person, they can’t let it go – just like an unrepentant drug addict still using. In this way, sexual activity is just like drug-abuse: it keeps one from climbing the ladder of Maslow’s hierarchy.
We, as a collective society, are undergoing what seems to be an intense “medicalization” – and in such a society, any behavior or mind-set that is not a majority behavior or mind-set becomes pathologized, such as the arguably superior functional state a person with no desire for sexual activity lives in.
“It is not a measure of health to be well-adjusted to a profoundly sick society.”
By the way, as a psychopharmacologist – albeit, an unrepentant and irredeemably insane one – I don’t put any stock in psychotherapy as a treatment for diseases with a physical etiology. Even if it is not yet defined, mental illnesses are diseases of the brain, and can not be treated by willpower or talk therapy – it would be as easy to offer therapy to turn one in to a telekineticist as it would to control mental illness with one. Yes, for replacing defective thought-processes, it seems to help, though I do not know how, as all emotional and psychological states are reflections of physical states (whether “thought” is a deterministic [classical] or probabilities-based [quantum] process, I do not know), and, it is, to my mind, such a conundrum as “To make a key, turn on the car,” to be able to treat a physical condition with anything other than physical (i.e. chemotherapeutic agents) therapy. This is why neuroleptics are used – talk therapy can not correct the etiology that is the cause of a hallucination. I’m a believer in the “medication, medication, and more medication, to treat any condition, physical or mental” school of thought (I don’t believe in the Eastern quackery, nor in the “spirit” or “soul” – such are designs to bilk desperate people out of a few quid; Western, approved medicine with a theory behind it, a proposed mechanism of action, and empirical evidence is real medicine – the other “treatments” range from placebo to worse than placebo [twelve-step programs anyone?]) although much of this likely comes from my own education and worldview, and likely has only what would be called a “moderate” statistical relation to reality.. probably around 0.42
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I’ll shut up before the writing – originally planned as a few sentences praising Dr. Junig for acknowledging the legitimacy of non-sexuality – turns from a novellum to a novel. I think, if the six degrees of separation holds true, if I continue speaking, I will come full circle.
L Marchese Ph.D. D.Pharm.Sci.
Thanks for your comments! I appreciate your sense of humor– I’m sitting here chuckling inside over your comments about telekinesis and a ‘moderate’ statistical relation to reality!
As for the ‘sexuality thing,’ there is such a disconnect between the way people are portrayed in sitcoms and in the media in general, vs. what I hear from people– who in person are much less sex-centered than someone in Hollywood seems to think.
Thanks again for writing– always keep in mind that you very well might be more sane than your therapist. I’d place those odds at well above 50:50!
JJ
Very interesting and thought-provoking post. I like the analogy of a warm coat – it’s nicely illustrative of the principle it represents.
Question: is Junig’s Warm Coat Approach specific to dosage levels, or does it/could it pertain also to the number of medications prescribed to a given patient?
Thanks– sure, I suppose it could be to the number of meds as well as the dose. I think of people on antidepressants who are doing pretty well, but who feel that they just aren’t feeling well enough– emphasis on ‘enough.’ I certainly don’t want to make light of incomplete resolution of depression, but at the same time, the more medications that are added, the higher chance of side effects or toxicity. After all, the human body was designed to work pretty much ‘as is;’ medications often are necessary, but they always add something negative as well.
It’s always adding something negative, whether the patient realizes it or not. I hold the belief that we can learn to cope with anything our brain throws at us if we give it our best shot, and taking medication to patch behavior is “taking the easy way out” and only makes things harder for us in the long run.
The best method of usage I’ve seen for brain medication was described by a bipolar schizophrenic. He said that medicine can help us stabilize ourselves and teach us what it means to cope with our feelings – to use it only as a tool to teach ourselves how to function without any medication at all.
I like to believe the above. I’ve taken both a stimulant and an antidepressant, and honestly, they’ve only served to scramble my own self-understanding. I’m more confused now than I’ve ever been in my life, and that’s no way to live. Those who rely on and swear by stimulants are only becoming more delusional and dependent – and as more time passes, they will find they aren’t only having to learn to cope with their actions and behaviors, they’ll find they have to cope with the actions and behaviors of two separate people – one the stimulant, and off the stimulant. This is addiction.
I am less fond of medication than some psychiatrists, but I cannot agree with your comment to a significant extent. And I think you would change your opinion as well, if you were to spend time with those who are truly significantly mentally ill.
I don’t know about your patient with ‘bipolar schizophrenia’– which would actually be a condition called schizoaffective disorder, if you are talking about someone with schizophrenia who also has a mood disorder. That diagnosis is thrown around too often; I saw it placed on Black inmates at the prisons I’ve worked at, simply because, in my opinion, the physician or evaluator was afraid of the inmate! But true schizophrenia is a horrible disease that destroys a person; without medication, many patients with schizophrenia or other psychotic disorders have no way to differentiate between what is real and what is not. For people who REALLY have those diagnoses, there is simply no way to learn to treat themselves.
Even ADD is essentially a brain disorder; we have more and more evidence that the brains of those wiith ADD are different. My point is not that people should remain untreated– but that treatment should be used to eliminate MOST of the trouble symptoms, and then the person should learn to do the best he/she can with the remaining symptoms. Sometimes, of course, the symptoms are SO bad that a person must keep looking for better symptoms control– but I was speaking to those who make ‘just a little better’ a mantra that guarantees a lifetime of disappointment.