Monthly Archives: March 2015

Mar 31 2015

Personality Disorders

I’m going to continue to talk about the #Germanwings case since someone on CNN has brought up the possibility that Andreas Lubitz had some sort of personality disorder. I’ll talk about the specific personality disorders in later posts.

Personality disorders are long-term, pervasive ways of relating to the world. There are a variety which include Anti-Social, Borderline, Narcissistic, Paranoid, Histrionic, and others. All are different. Note that: all are different. A Histrionic person will seem very different from the person with Paranoid Personality Disorder. Personality disorders are also more difficult to diagnose in many cases. They can underlie the more acute mental illnesses most of us think of when we talk about mental health problems. Or they can stand alone and the person with the personality disorder may never suffer from any other acute mental illness.

Nothing I’ve heard so far leads me to think that Lubitz suffered from a personality disorder. He may have or he may have not. I can’t tell from what’s been in the media. Yes, some people with a personality disorder may kill others. But not all. And not all killers have a personality disorder. To assume a personality disorder just because this individual killed 149 other people is not professional.

Back when I was in graduate school, my class was discussing the issue of insanity. During the break, the professor and a couple of us were sitting at a table talking about crime and mental illness. It was mentioned that anyone who could kill others had to be mentally ill. I mean, it just made sense. We all nodded our heads, but the professor cautioned us. We can’t diagnose by one action and insanity was a legal issue (as I’ve mentioned in a prior post).

Just a quick note: a person with Anti-social Personality Disorder (which includes psychopaths) rarely suffers from depression. The exception being when they get caught. So, in this case, Lubitz’s history of depression and anxiety argue AGAINST him suffering from Anit-Social Personality Disorder. Could he have suffered from a different personality disorder? Of course, but we just don’t have the information at this point. A person with Borderline Personality Disorder or Narcissistic Personality Disorder or Paranoid Personality Disorder could all commit murder, even mass murder.

For writers: if you decide you want your character to have a personality disorder, be sure to show the full picture. If you have a character saying, based on extremely limited information, “He’s got a personality disorder”, please have someone call that character out as an idiot who doesn’t know what he’s talking about.

Mar 30 2015

Antipsychotic Medication and Flying

Okay, folks, let’s talk about antipsychotic meds. Remember, I’m a psychologist and not a psychiatrist. However, many of my clients over the years have taken these medications, so I think I have more than a passing knowledge of them.

Antipsychotic medications are primarily used to treat psychotic disorders. Makes sense, eh? Specifically, these medications help with the hallucinations and delusions experienced during many psychoses. I have sent patients to psychiatrists when it’s clear they’re suffering from a psychotic disorder. There are two basic types: the older “typical” antipsychotics and the newer “atypical” antipsychotics. The typical antipsychotic include Chlorpromazine (Thorazine) and Haloperidol (Haldol). The “atypicals” include:Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel),Ziprasidone (Geodon), Aripiprazole (Abilify), Paliperidone (Invega), and Lurasidone (Latuda).

In recent years (say the past 10 or so), I’ve seen antipsychotics also being used as sleep aids and to help when patients are highly agitated. I’m not sure I really agree with this, particularly because of all the side effects. But I have seen it. BTW, the use of antipsychotics for agitation has been something I’ve seen in hospitals and is usually administered by injection (at least in my experience).

The side effects are numerous and can be very serious. Here’s what the NIMH (National Institute of Mental Health) has to say:

Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

  • Drowsiness
  • Dizziness when changing positions
  • Blurred vision
  • Rapid heartbeat
  • Sensitivity to the sun
  • Skin rashes
  • Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person’s metabolism. This may increase a person’s risk of getting diabetes and high cholesterol.

In addition they note:

Typical antipsychotic medications can cause side effects related to physical movement, such as:

  • Rigidity
  • Persistent muscle spasms
  • Tremors
  • Restlessness.

Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can’t control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.

These other side effects are not as common with the atypicals.

The next question is whether or not a person on any of these medications should be flying. Unequivocally I can say: NO! No matter what the reason for the use of the meds. My opinion. I don’t think a person on antipsychotics should be using heavy machinery either. Should they drive a car? Not at first, not until they know how it’s going to affect them. I can tell you, though, that most of those clients of mine in the past who were on antipsychotics *did* drive. To the best of my knowledge, psychiatrists are not required to contact the Department of Motor Vehicles (DMV) when they prescribe antipsychotics. They probably don’t contact the FAA either if the patient happens to be a pilot. Is this a loophole that should be plugged? I don’t know.

For you writers: consider having a character who is taking Seroquel for sleep (i.e. she’s not psychotic) and struggling with the side effects of that medication. A number of the soldiers I’ve worked with had been prescribed this med for sleep and they had a horrible time showing up on time for formation at zero-dark-thirty. So, now they were getting in trouble for that!

Mar 30 2015

Suicidal Thoughts and Pilots…and the rest of us

flying

CNN tells me this morning that Andreas Lubitz was depressed and suicidal back in 2009, before he got his pilot’s license. It is unclear at the moment if he was experiencing only thoughts or had actually made an attempt. We also don’t know what prompted him to think about suicide. We do know that becoming a pilot was a dream of his, something he was apparently passionate about.

We do not know how he was doing psychologically between 2009/2010 and now, about 5 years later. Depression doesn’t necessarily linger. It is treatable or can even go away on its own in come cases. Suicidal thoughts also come and go. And it’s important to point out that many, many people — I’d actually say most people — have suicidal thoughts at some point in their lives.

In the US, pilots can apply for a waiver if they are suffering from mild to moderate depression and are on certain medications. It is not an automatic grounding in the US any more for a pilot to be depressed. I don’t know what Germany’s standards are. If any of you know, please let me know!

When I’ve dealt with suicidal patients (and a lot of them were at some point or another), I asked about plans and intent. Most had no plan or intent. They’d insist that they’d “never do that” for a variety of reasons and in most cases, I believed them. I’d be more concerned if they had a specific plan. “I’d blow my brains out.” However, if they didn’t have a gun or access to one I’d be less concerned. However, I would be concerned. As a psychologist, my duty is primarily focused on taking care of my patient, so I’d be working hard to convince the patient that hospitalization would be a good move. On a couple occasions, I’ve called the police out for clients who’ve called me and led me to believe they were suicidal. Some got mad at me for doing this, but I was glad they were still around to be mad. Yes, under the law, I can break confidentiality if I think a person is a harm to self (or others). Calling an employer … that’s something I’ve never done and I wonder if, given the confidentiality laws, I’d be allowed to do that. I think if I had a pilot who told me he was suicidal and planned to crash an airliner, I’d call the employer or at least a doc working for the airline and take the hit on my license later.

I suppose that if Lubitz was still in therapy (that’s still unclear to me) and he told the therapist that he was suicidal and planning on crashing an airliner, the therapist would have taken some action to prevent this. More likely, if Lubitz mentioned anything at all about being suicidal at present, he was vague about it. Consider also that this guy loved flying. It was important to him. Very important. Perhaps the most important thing in the world to him. As a therapist, I’d have to consider this. If I take steps to ground him, am I actually increasing the odds that he’ll take his own life? Have I then removed the last thing that mattered to him? It’s a horrible dilemma, one I’m glad I’ve never had to face. (BTW: for you writers. This could make a really interesting short story.)

Mar 29 2015

Generalized Anxiety Disorder

Just heard that the copilot, Andreas Lubitz, on the Germanwings plane that crashed in the Alps suffered from Generalized Anxiety Disorder. But I’m also hearing about some sort of “psychotic episode” in 2010 and had anti-psychotic medications. Let’s talk about each of these issues separately.

First off, just what is “Generalized Anxiety Disorder”. In a nutshell, it means that a person is having anxiety that is triggered by any number of things. If he felt anxiety related to just one thing, say heights, he would have been diagnosed as having a Simple Phobia. The sufferer from GAD feels anxiety and worries about all sorts of things “such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties.[2][3] Individuals often exhibit a variety of physical symptoms, including fatigue, fidgeting, headaches, nausea, numbness in hands and feet, muscle tension, muscle aches, difficulty swallowing, bouts of difficulty breathing, difficulty concentrating, trembling, twitching, irritability, agitation, sweating, restlessness, insomnia, hot flashes, and rashes and inability to fully control the anxiety (Wikipedia). As you can see, there are a lot of physical type symptoms related to GAD. How this may or may not relate to the previously mentioned “psychosomatic illness” is unclear at this point. Should Lubitz have been flying with this problem? It depends on the severity of the symptoms and which ones he was having. Could he have concealed these problems? Possibly, though that probably would have only added to the stress and anxiety.

Next, let’s look at “psychotic episode.” This is not really a diagnosis, but is often part of a diagnosis of some sort of psychotic disorder. In essence, it involves either hallucinations or delusions or both. There are other symptoms often associated with the psychotic episode, but these vary. Is this schizophrenia? It could be, but it could be related to a wide variety of other disorders or causes. This statement about Lubitz having had a psychotic episode tells us only that he had a period of time when he was not really in touch with the reality most of us share. It could have been brief. It could have been a one-off situation, never to recur. It could have been related to medication or physical illness (some illnesses like measles or other infection with high fever can result in hallucinations). Again, as with so much in this case, we just don’t know yet.

Now to talk about the “antipsychotic medication”. These include medications like Haldol, Thorazine, Seroquel, Zyprexa and a slew of others. Drugs like Haldol and Thorazine are often called “typical” antipsychotics, while the others are called “atypical” and are the drugs of choice nowadays. I’d like to know when this medication was prescribed. Back in 2010 or more currently? I guess it could be possible that he had left-over meds from that psychotic episode in 2010. If he was currently on an antipsychotic medication (which I’ve seen used as a sleep aid in patients who were NOT psychotic), that’s a whole different story…...UPDATE: just heard that he was given antipsychotic injections back in 2010 and that antidepressants were found in his apartment.

Once again, we’re left with a lot of questions still about this tragic case. BTW: It’s been my experience that docs often prescribe antidepressant medications for GAD. Also, the FAA (don’t know about the regulations in Germany, any help here would be appreciated) announced it would consider waivers that would allow a pilot taking certain antidepressants to continue flying.

UPDATE 3/30/15:  I heard a report on CNN that back in the 2009/2010 time frame, Lubitz was given Zyprexa. This medication is an “atypical” antipsychotic medication in wide use. It has some serious side effects, including sedation, weight gain, visual problelms, muscle problems, and a whole lot more. On the other hand, it’s very effective for individuals suffering from hallucinations and delusions. No, he wouldn’t have been able to fly while taking this medication.

Mar 29 2015

Psychosomatic Illness

It appears as of this morning, that Lubitz, the Germanwings copilot responsible for the crash in the Alps, was reported as suffering from a “psychosomatic illness.” Just what does that mean? Well, to put it in the simplest terms, it means that his emotions were affecting his physical functioning. For example, stress is well-known to have many physical effects. It is a strong contributor to Irritable Bowel Syndrome. What it does not mean is that it was a “made up” or imaginary illness. As a sufferer of IBS, I can tell you that my multiple trips to the bathroom are not imaginary! 😀

Wikipedia provides this definition (seemly derived from DSM 5): A somatic symptom disorder, formerly known as a somatoform disorder, is a mental disorder characterized by physical symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder. There are several somatic symptom disorders recognized in DSM 5 (Diagnostic and Statistical Manual, edition 5). In essence this definition means that Lubitz likely was presenting with at least one physical symptom that was not explained by a physical cause. We don’t know what symptoms he was reporting.

Just what the nature of Lubitz’ problems were is still unknown. And that’s important here. We just don’t know. I’m sure that the various investigators are looking into what was going on with this young man. But if they want to be thorough and come up with as accurate picture of what was going on with him, then it will take time. This, of course, is a problem for the media which needs to have a near-constant stream of new material, but this is the reality here. Diagnosis of a mental condition is difficult enough in a clinical setting with a cooperative (and alive) patient. And in this case, the investigators aren’t just looking for a diagnosis, but for the reasons for a specific act.

UPDATE 3/30/15:  Heard some psychologist on CNN saying that the reported psychosomatic illness suffered by Lubitz indicated that he was not in touch with reality and that he was psychotic. That’s just plain wrong.

It seems that Lubitz was having visual problems, but docs couldn’t find an organic reason for those problems so suggested that it was psychosomatic. Okay, that can happen. Think back to old WWII movies and soldiers suddenly unable to see but there are no physical wounds. That used to be called “hysterical blindness.” It doesn’t happen as much any more, but it does occur. But, it does not mean the patient is psychotic or out of touch with reality. It means that the psychological stress and upset the patient is suffering from is manifesting through the visual system.

I am also concerned about just who called this a psychosomatic illness. Was it the eye doc after finding nothing physically wrong with Lubitz’s eyes? Hmm. Reminds me of many, many years ago when I was complaining of pain in my knee. This was before CAT scans or MRIs, so when nothing showed up on X-Rays, the orthopedist called it psychosomatic, a way to get out of phys ed at school. Jump forward a couple years and another orthopedist decided to do surgery since at that point I’d been having pain for quite a number of years. Lo and behold, he found a torn cartilage. Bottom line: just because a doc doesn’t find something physically wrong doesn’t mean necessarily that it’s “all in your head.” Thank goodness my docs never suggested that I was psychotic. I wasn’t.

I’d need a lot more information to say whether or not Lubitz was psychotic in the past or at the time of the crash. Just because someone labeled him as suffering from a psychosomatic disorder DOES NOT make him psychotic!

Mar 27 2015

Duty to Warn

I’m seeing on CNN some discussion about what the physician should or should not have done regarding notifying Lufthansa and/or Germanwings about the copilot’s (Lubitz) medical condition and his reported unfitness for “work”.

Here in the US, as a psychologist, I have a “duty to warn” based on various court cases in the past. This duty to warn involves situations during which a client makes a specific, imminent threat against an identifiable individual. This derived from the Tarasoff case. The rulings in this case have been extended over the years. I don’t know what the requirements are for German doctors. If someone knows, please let me know!

So, would a “duty to warn” pertain here? Maybe. Let’s take the case to the US and say the pilot is seeing me. The pilot comes in and reports feeling very depressed. He hasn’t been sleeping. He’s refused medications (because of flying) but has engaged in therapy on a regular basis. Now he reports having some thoughts about wanting to die. I ask if he has a plan. No, he replies. It’s clear to me that he’s depressed and at some risk for suicide, but there’s nothing that would set off alarm bells here. In this case, I’d ask more about his ability to concentrate. I’d try to engage the pilot in a conversation about whether or not he feels able to fly. He says, “I don’t know.” Perhaps in that situation, I’d give him a note that would cover him if he chose not to go in to work.

Now let’s up the ante. Same initial situation, but now he reports some strong feelings of wanting to die. When asked if he has a plan, he looks up with a half smile and says, “I could always crash a plane into some mountains. That’d be the way to go.” His risk for suicide just goes up. He actually has a plan but it’s still vague. He could mean taking a private plane up and crashing it. I think in this scenario, I’d work really hard on getting him admitted to a hospital. But, he’s likely to refuse to do that since it would come to his employer’s attention and likely result in being grounded. This puts me in a real dilemma. If I take away something he loves (flying), am I increasing his level of depression and actually giving him even more reason to suicide? I think I’d put him on a daily call in to me and strongly recommend he take a few days off, perhaps even see me more frequently while he’s on sick leave.

Now, let’s say he says “Doc, I just want to die. I keep thinking about getting into the jet, waiting till the pilot goes to the bathroom, and then crashing the plane into a mountain.” I argue about the other people involved. “Their families will get over it.” or “People die all the time.” I ask when he’s going to do this. “Soon.”  Okay, the threat is imminent and specific enough that I’d feel compelled to do something. True, the victims as individuals aren’t specified, but it’s clear he’s talking about crashing an airliner. Needless to say, I’ve never been in this situation. However, I think, given the laws here in the US and my own morality, I’d act to get him involuntarily committed to a hospital. He clearly (at least to me at that point) is a danger to both self and others. I think I’d also contact his employer, just in case anything fell through and he was released and tried to go back to work. I could be faced with a lawsuit due to break of privacy, but I think I could fight that with the help of a good lawyer.

Mar 27 2015

To Fly or Not: Thoughts about the Germanwings crash

I’d like to talk about the crash in the French Alps, apparently caused deliberately by the co-pilot, but with things developing so rapidly, I hesitate. Still, I’m going to go ahead with the caveat that much of what I have to say at this point may later prove moot.

What do we know? The plane crashed. The co-pilot was in the cockpit; the pilot was not. There were apparently deliberate actions taken by the copilot that set the plane on its trajectory into the mountains. He apparently was under doctor’s care for some illness and had received at least one note providing a medical excuse from flying, including on the day of the crash.

What we don’t know: we don’t know what illness he saw the doctor for. We don’t know why he had the break in training a couple years ago. From what I’m getting on CNN, I can’t tell exactly what the note from the doc said.

I am a licensed pilot, although I haven’t flown in many years. When I was actively flying (private), I was required to see a flight doc every couple years. The rules for airline pilots are different, requiring more frequent checks. The flight doc was not my regular doc. There may have been some questions about my mood, stress, but it was cursory and easy to fake had I so chosen.

I have also worked with populations, including AF pilots, where reporting of any condition that would render them unfit for work would be required. Since I have never been a flight doc, nor worked with civilian pilots, I don’t know the requirements on the doc to report. It seems like …. and I could be very wrong here….. the onus is on the pilot to self-report. But there are a lot of reasons a pilot would not do so. One of the worst things you can do to many pilots is to remove their wings, ground them.

So, where does that leave us? I’m not sure. The story isn’t finished yet. Was Lubitz depressed? I have heard nothing credible to say that he was or wasn’t.

—–

There is another issue here. Let’s face it. Most people who commit suicide don’t involve other people. On the other hand, most perpetrators of mass murder do not expect to live beyond the act. Many kill themselves; others set things up so police will kill them. So, where does Lubitz fall? Suicide or mass murderer? There are some different dynamics that go with each way of looking at this. Unfortunately, mass murder has not been studied as well or written about as much as with serial killers. Perhaps one of the reasons is that so many mass murderers do end up dying before we can question them. So, we are left wondering what was going on with Lubitz. Will a diagnosis of depression really answer the questions? For some of us, probably not.

UPDATE:   A clinic Lubitz had visited in Dusseldorf just reported that Lubitz was NOT seen for depression.

Mar 5 2015

What Do You Want To See?

This morning I’d like to try something different, my fellow writers. I’ve set up a poll so you can let me know what you’d like me to blog about. Do you have a Work-In-Progress (WIP) with a character who’s depressed and you’d like more information about what that’s like for the character? Do you have a character taking medications and wonder about the side-effects? (Remember, I’m not a psychiatrist.) Do you want to see more of my own writing (Gasp!)?

 

Mar 4 2015

Your character sees a psychiatrist

Let’s suppose you don’t want to have you character hospitalized but he needs to see a shrink of some sort. How do you handle this?

First off you need to decide what sort of shrink. Does your character need meds? Let’s say you’ve got a tough guy who can’t see the point of talking about stuff, but his stress level is causing problems on the job. So, he goes to his primary care doc who says: “I don’t prescribe psych meds, but I can send you to a psychiatrist.” Now, if the primary care doc is part of a group, he can make some entries into his computer and the referral is sent. If the doc is on his own, he can make some suggestions. Or Mr. Tough can call his insurance company and see what their procedures are.

So, now Mr. Tough arrives at the psychiatrist’s office. This could easily be quite a while later since demand is high in a lot of places while supply of psychiatrists is low. Nice set-up for some conflict there. “Yes, boss. I’ve got an appointment but the soonest they had was six weeks from now.” What’s a good boss to do?? J.

Mr. Tough finally gets in to see the psychiatrist and checks in with the receptionist who takes insurance cards and has him fill out paperwork, including stuff about privacy. (You don’t really want a discussion about HIPAA, do you? Didn’t think so.) The waiting room is likely to have one or two other people there, or maybe not. Anyway, it’s probably pretty plane with the obligatory magazines scattered on the tables.

Eventually, the psychiatrist comes out and conducts Mr. Tough to the office. Please, do not expect a couch! There will likely be a desk with a couple chairs arranged in front. On the wall, Mr. Tough will likely see the psychiatrist’s diploma. The furnishings are likely to be bland. You never know what someone might find offensive or upsetting. Do not expect Mr. Tough to be sitting in some gorgeous, high-end office. They exist, I’m sure, but in today’s managed care environment, most of us see a doc with rather utilitarian offices. You can add setting details like books and photos. The doc may or may not have a computer on his or her desk. Maybe on a credenza behind the desk.

The initial appointment may last 45 minutes. This allows the doc to get some background and an idea of what’s going on with Mr. Tough. The focus will mostly be on signs and symptoms and any history of mental health problems. This history will include any family history of mental illness since a number of illnesses have strong genetic components. The psychiatrist will then write out a prescription (or several) and suggest that they get together again in a few weeks. Hopefully this will be only a couple weeks so the psychiatrist can check on side effects and well as the impact of the meds on the problem.

Please be aware that many psychotropic meds take a while to “kick in”. This is true particularly of antidepressants.

So, Mr. Tough is given a prescription for antidepressants even though he insists the problem is anger. That happens a lot. The reasoning is that what’s underlying the anger is unhappiness and stress and these meds have been shown to be effective. He may also be given a prescription for something to help him sleep. I’ll discuss some medication issue at a later date since side effects can really give your client some problems to deal with.

When Mr. Tough comes back, the appointment will only be for about 15 minutes and focused on how the meds are doing and any side effects noted. The psychiatrist will, hopefully, be supportive and allow some discussion about the problems in Mr. Tough’s life, but this will be limited. I can’t tell you how many times I’ve had clients come to me, complaining about their psychiatrist’s failure to talk to them about anything other than the meds. It’s just the way things are nowadays in the US. The doctor may or may not change medications around. He’s not likely to refer to a psychologist or social worker.

So, that’s essentially outpatient treatment with a psychiatrist in the US. In a later post I’ll talk about seeing a psychologist on an outpatient basis. As usual, please leave any questions or comments below.