Health and Psychology

There are two types of doctoral degrees in psychology.  A Doctor of Philosophy (PhD) and a Doctor of Psychology (PsyD). The first degree is heavily involved in training in the scientist practitioner model and focuses on research, statistics, and evaluation.  The second is applied psychology with a focus on training, experience, and applications of psychological theory.

I have a PhD.  I am a researcher.  I value research. And I like good research.  Good research enlightens and moves the field into newer areas. It can be replicated.  It actually seeks to know new information.  The best research is published in peer reviewed journals.  It looks at research scientifically.  Poor research sets the field back.  It pushes future research into attempts to replicate the research multiple times and not being able to do so.  Poor research has an agenda.  It's not designed for scientific inquiry but to prove a point.  Poor research can also be research that can't get published in scientific journals but gets published as articles in pop magazines. 

Individuals with a PsyD also do research but they tend to look at the experiences people are having.  Not just data but what people think about their experience.

The Mental Status Examination

The mental status examination is a screening test for a wide variety of mental disorders and conditions. In it’s most common form it is abbreviated to a mini state exam with fewer categories and often used to evaluate cognitive difficulties.

The full exam consists of evaluation in multiple categories:

• Appearance and behavior
• Orientation, concentration and attention
• Language and memory
• General information and intellect
• Thought process
• Thought content
• Mood and affect
• Delusions, illusions and hallucinations
• Insight and judgment
• Abstract reasoning and synthesis of thought
• Reading, writing and math
• Drawing and copying
• Repetition, Registration
• Risk assessment
• Validity of assessment results and effort of person being evaluated

The mini exam has fewer categories and is generally used to assess significant cognitive impairment:

• Orientation
• Immediate Recall
• Counting backwards
• Spelling backwards
• Delayed Recall
• Language Naming
• Repetition of a complex phrase
• Following a three step-command
• Reading
• Writing
• Copying

A standard verbally based IQ test combined with behavioral observations will provide as much or more information than a full mental status examination if performed by a skilled examiner. If the examiner is familiar with a wide variety of psychological and neuropsychological test instruments the screening test can be scaled up to reflect a higher general education or premorbid level of intellect or scaled down to reflect someone from a more culturally improverished environment. Items can be substituted to document more subtle degrees of impairment and to clarify areas of strengths as well as areas of weakness or concern.

A skilled examiner performing the examination in it’s complete form can be as much art as science. Some parts of the test are developmental in nature, so some items are easier to complete than others for average people with no impairment. Most people with no difficulties will pass a mental status examination with very few minor errors. Significant cognitive impairment is readily apparent to a trained observer on presentation and a mental status examination is simply for the purpose of documenting global difficulties. Likewise, individuals attempting to fabricate results often perform so poorly as to be obvious.

If you know of someone needing an assessment, feel free to contact our office. We offer a wide variety of assessment and treatment services.

I don't believe I know any woman over the age of 15 that hasn't been sexually assaulted, inappropriately gropped, fondled or touched without her consent by someone.  So I'm not surprised that when @kellyoxford asks women on twitter to share their first sexual assault stories that there are more than 1 million responses with most of the events starting in childhood.

While the tipping point in the conversation about the prevalence of assault against women may be the latest video clip about Trump, it started earlier with the story of the rapes on campuses across the country, the victim letter from the Stanford rape case, the film The Hunting Ground, and the dozens of women talking about Bill Cosby assaulting them.   It started with Anita Hill talking about sexual harassment at work before congress and that conversation about how a reasonable person and a reasonable woman might have different perspectives.  

On Friday President Obama signed into law the Sexual Assault Survivor's Rights Act that allows rape kits to be preserved for up to 20 years or the State's maximum statue of limitations.  It also lets survivors be advised in writing 60 days before their rape kit is destroyed and lets them request preservation beyond the scheduled destruction date.

Sexual assault is one of the most unreported crimes.  Reading through the responses to Kelly Oxford's post on twitter, men apologize, point out that Bill Clinton did bad things too, or talk about how people are innocent until proven guilty.  They blame the media and point out that men are sexually assaulted as well.  

To men out there, you don't need to apologize or deflect.  What you need to do is to speak out.  The conversation Trump had in 2005 is common.  It's not okay and it normalizes inappropriate behavior.  It's your turn to speak out against the men that talk like this.  Get offended.  The men that talk this way prey upon your mothers, sisters wives and daughters.  Talk to the women that have been assaulted.  Find out for yourself that it's almost every woman you know and often most girls you know.  You have to get horrified before you support tremendous change.

I am as appalled by the media coverage of the Pulse Nightclub massacre and the Stanford Rape case as I am of the events themselves.  I'm chairing a dissertation on rape and I have a clinical practice that is LGBTQIA friendly.  The media turns these events into single incidents rather than common place occurrences.  The rape case stands out only because of the articulate first person account of the victim.  Rarely do we hear the words of the victims.  And 7000+ words not only captured the nation but put focus on the judge for handing down the light sentence to Brock Turner.  And there is a discussion about rape culture and the misrepresentation of men like Brock as boys and just drinking too much, and not as the face of the rapists they are.  So that discussion is well needed.  But the sentence itself is common.  The rapist I saw a week or so ago was given 3 years for breaking a woman's jaw twice during her rape.  He was out in less than two years.   He's already violating his parole.  I'll see 2 or 3 more just like him over the next few months.  It's common.  So women don't get to feel safe because we know.  We know that reporting gets nothing more than a slap on the wrist.  That going to court gets a laughably light sentence.  That we will be blamed for the rape instead of the rapist.  We know that.  I was told my rapist couldn't be convicted so no charges were brought.  He raped acquaintances.  I know three other women he raped.  There were no charges brought by the State.

The massacre at the Pulse Nightclub is marked by the lack of media coverage of it being a place of safety for people within the transgender drag Latinx community.  It was a continuation of the violence that has been historical from the time of colonization on.  It was the continuation of violence against the community that occurs within a daily basis.  This is a community that wakes up knowing people want to kill them every day. It's not about guns or Muslims.  It's about a massacre that normally happens piecemeal.  The media usurps the community by not naming them. By not calling this what it was, part of the ongoing massacre of people of color, of the homosexual and transgender communities, of the marginalized.

My cisgender white male friends of privilege do not understand.   They think nothing of walking outside, alone, at night.  They think nothing of going to a nightclub and maybe having a drink.  They do not understand why I own a gun, why I'm afraid, or what it means to be a survivor of crime.  A survivor of rape.  They think the police the police will help if something bad happens.  They think the police will come.  But what the media gets so wrong is that as members of these communities, we know the police will not come, if they do come they will come late and ineffectively, they will blame the community, and if we defend ourselves we will be vilified.  The script the media endorses is that these are gun crimes or terrorist activites or the problems of mental illness.  No.  They are the problems of marginalization and dehumanization.  There are countless murders and countless rapes.  It's not about guns, or terrorists or the mentally ill.  It's about a lack of safety and a lack of awareness of how often these crimes are occuring.

Depending on the study, somewhere between 58 and 79 percent of all psychological diagnoses have a substantial medical component.  That's a very alarming statistic.  In the 1970's the field of medical psychology was created to address this need.  By the late 1980's it had all but dissappeared, replaced by the less medically intense health psychology field or the broader behavioral medicine field.  

When I first went into practice I worked with a family practice physician.  My office was located in his office.  The referral question was simple: "This person has been seeing me (the MD) for 4 or more visits and the diagnosis is unclear" or "This person is not responding to treatment."  Of the hundred or so people I saw over the first year, I diagnosed about 30 cases of cancer, 20 cases of heart disease, and 35 cases of endocrine disorders.  The rest were a mixture of psychological conditions and non-compliance with complicated medical treatment.  My private practice geared to work with heart disease and cancer was starting to be filled by men with what would eventually be diagnosed as HIV/AIDS.  I drove to San Francisco on the weekends to be with a client who was being treated at San Francisco General.  I stopped counting the deaths at 175 and closed my practice to start working for one of the insurance companies.  

At a risk management seminar I was sitting at a table of physicians.  They presented a case of a woman with persistent neck pain.  The cardiologist at the table and I were arguing over the diagnosis. The case was presented in pieces, just like it is in a medical office.  She had been cleaning the shower and her neck started hurting.  It felt better after some rest but still didn't go away.  She thought maybe she had the flu.   I was telling the cardiologist the woman had a heart attack.  He was telling me I wasn't a doctor.  After the third visit for neck adjustment the woman collapsed at home.  She'd had three heart attacks.  I explained to the cardiologist that women experience heart attacks differently than men and they have different symptoms mainly neck and jaw pain, fatigue and muscle aches.  Almost all my heart patients were women.  Almost all were misdiagnosed in medical offices or even at emergency rooms.

The endocrine diagnoses were worse.  Almost all my endocrine patients were misdiagnosed with depression, anxiety, or personality disorders.  Some had endocrine tumors.  Some of those tumors were malignant.  Just trying to get the correct tests done or imaging studies done was challenging.  Eventually I had physicians I worked with because we knew each other, and they understood what I did.  For physicians not trained in clinical medicine, they decided I was psychic.  For physicians trained in clinical medicine, they honed their skills and trusted them more than the lab studies they treated like oracles.  

Now I tend to work with more neurological symptoms, recent head injury or abnormal test results that don't seem to correlate with any illness.  When the Dr. House series was on television it was easier to explain what I did.  That was a show about clinical medicine.  I like the puzzle.  I like figuring out what's going on.

If you don't have a diagnosis and have seen your physician for more than 4 visists, or if you aren't responding to treatment, contact me.  I'm likely to be able to help with diagnosis and treatment.

Disability is a complex system of insurance companies, state regulations, federal regulations and governmental bodies with competing and differing codes for determination. It’s confusing to a lot of people. Our office can help with all forms of evaluation.

DEFINITIONS

A disabling condition is a physical or emotional illness or collection of symptoms that impairs the ability to function in one or more areas of life. Accommodations are methods to assist someone in performing tasks so they can function better.

Accommodations may include a device such as a computer that recognizes speech, or converts speech to text, or reads text aloud. It may be a wheelchair or a cane. It may be a device that helps to put on socks, or grab items, or button. It may be a device that helps someone hold a spoon, or fork, or pencil. It may be a cell phone or tape recorder. It may be a system of applications that says what color something is, what denomination of money someone has, or a prompting system to help with memory. It may be a medical device to test blood sugar, blood pressure, temperature, pulse. It may be extended time on exams, a private room, natural lighting, a test given on computer or a paper based test. It may be a service animal or emotional support animal. It may be voice activated door bells, light switches, smoke detectors. It’s not an advantage, but it may be an equalizer.

An off work notice. This is a letter to an employer indicating a disabled person is not able to function in their usual and customary job as a result of a temporary disabling condition. This usually needs to come from a physician (psychologists count as physicians in this regard). The person is expected to undergo some form of treatment to return them back to their usual and customary job.

Evaluation of disability by a treating provider. This is a letter or report of the symptoms and a description of functional impairments. This may be requested by an employer or by an insurance company handling a disability claim. This letter does not have to be written by a physician.

Evaluation of disability for the Social Security Administration. This is an evaluation of how an individual is able to function in their ability to perform simple work in the general labor market. The is not an evaluation of their ability to perform their usual and customary job. This is simple work. Examples would be the person who bags groceries at a grocery store and retrieves shopping carts, or the helper that waters plants at the local nursery. It involves some degree of judgment such as not putting the gallon of milk on top of the carton of eggs.

Evaluation of disability for accommodations. This is a complex evaluation involving multiple layers of documenting what is required and what is available. For conditions such as ADHD, or for tests such as licensing board tests these evaluations are lengthy and extensive.

We perform all tyes of evaluaitons on all age groups and write letters as part of those evaluations.  Feel free to contact our office.

Many people think their insurance covers psychological or neuropsychological testing.  Insurance will stipulate that psychological or neuropsychological testing if it meets criteria for medical necessity.  That doesn't mean that a physician or a school or a teacher thought the testing would be necessary.  It means that psychological or neuropsychological testing meets the strict criteria set forth by the insurance company.  

Medical necessity means that there is no other agency or organization that can provide testing at state or federal expense.  So that eliminates testing for:

• educational placement 
• disability 
• Regional Center services
• Gifted placement
• ADD/ADHD

 It means that psychological or neuropsychological testing will produce a change in diagnosis or treatment plan and is the most cost efficient method of obtaining that information.  So an MRI or CT scan may be able to rule out memory problems related to brain disease or defect.

• Schools provide psychological testing for placement in special education including gifted classes.  
• Schools can evaluate for ADD/ADHD and learning disorders to determine accommodations
• Regional Center provides their own testing to confirm the need for services
• Social Security Disability provides testing to document disability for benefits

If you are interested in obtaining insurance benefits to cover psychological or neuropsychological testing GET AN AUTHORIZATION NUMBER from the insurance company.  

If you are interested in having psychological or neuropsychological testing feel free to contact our office.  We have access to a large number of psychological and neuropsychological tests at reasonable fees.  If you are eligible to use a free service we will advise you of that.  Feel free to contact us.  Our main office number is 818-223-4116.  My cell phone is 818-389-8384 Margaret Donohue, PhD.

Some of you know I used to work with and train cats.  This infomation is put out by the International Veterinary Academy of Pain Management http:https://ivapm.org/for-the-public/animals-and-pain-articles/how-we-assess-your-felines-pain-level/" target="_blank">//ivapm.org/for-the-public/animals-and-pain-articles/how-we-assess-your-felines-pain-level/

We're setting up a new phone system.  Someone suggested the voice mail include the phrase "In case of emergency call 911."  When I asked why they would want that, they mentioned that everywhere else where they worked had that.  It's a convention.  But none of the staff in my office would actually call 911 unless they had a medical emergency.  What we all had was a list of people, therapists, colleagues, agencies, or groups we would call in case of psychological emergency. 

I remember the story I heard about someone cutting their holiday ham in half because "that's how it was always done."  They came to find out, it was done that way because there wasn't a big enough pan to fit a large ham.  The call 911 message is done for risk management at large agencies, not because it's helpful, but because it mitigates risk.  

911 gets you the police, maybe an ambulance, maybe the fire department.  If you're sad or suicidal it may get you a trip to the hospital.  If you are angry or homicidal it may get you arrested or killed.  So a friend of mine has his voice mail message that says:  "In case of emergency call 911, and good luck."  Mine just says I'll call you back as soon as I can.  It's my cell phone.  I answer it most of the time.  Sometimes it goes to voice mail.  I get back to them when I can.  If it's urgent people call me then text me.  Psychological emergency calls about other people the kind where we've been fighting and now I'm afraid for them, or my child is out of control and I don't know what to do, just mean the person is out of resources.

I don't have "In case of emergency call 911" in my voice mail message.  If I had to have a voice mail system that tells someone who to call in case of an emergency it wouldn't likely be 911 unless there was a dangerous situation.  It would likely be "if this is a psychological emergency call everyone you know and call a crisis line. I'll call you back as soon as I can, but in the meantime go do something that makes you feel worthwhile, or helpful to someone, or go out in nature and find something beautiful.  If you are feeling really angry or hurt, go watch a cartoon, find something to laugh at, go for a walk, be in the moment with your surroundings, go play with an animal.  Write down everything you are angry about.  Write down all the different ways you can choose to feel instead of being angry.  Write down all the things you want to live another day to experience.  If you have a blank page, you don't have enough things to do.  

And maybe "If your psychological emergency is about someone else, please do the following assessment:  First make sure you and the other person are physically safe.  If there is a weapon, leave and call 911 if you can't get them to put the weapon down.  If you are safe and there is no weapon, then just say "Let's take a break and calm down. I don't want to fight."  Or "This is scaring me."  Or "I know you're upset, but I'm overwhelmed."  Second, call a crisis line if someone is suicidal.  If someone is psychotic or under the influence, get them to a hospital if you can do that safely.  If they are psychotic or under the influence and dangerous, call 911.  

The research studies go back to the 1930's and were quite prolific through the 1970's.  Most involved individuals admitted to psychiatric hospitals as the result of severe symptoms of depression, anxiety, mania, psychosis, or neurotic symptoms.  The rates of undiagnosed medical illness CAUSING the symptoms ranged from 10% to 50% and of that population, 77% had a complete remission of symptoms when the underlying medical condition was treated.

Back in the late 1970's when I was in graduate school, the field of Medical Psychology was being created.  It was conceptualized that Medical psychologists would work in physicians' offices to assist with diagnosis and differentiation of medical and psychiatric symptoms.  We would refer back those patients with medical conditions for further evaluation and treatment and continue to treat psychiatric symptoms with psychotherapy and also address issues of compliance with medical treatment.  To that end, we were taught to take thorough medical histories, do medical symptom evaluations, perform basic vital examinations such as heart rate, respiration rate, blood pressure, height and weight, and temperature. We were also taught to recognize medical symptoms through an understanding of clinical medicine.

Clinical medicine existed at the beginning of the field of medicine.  It is the evaluation of a patient by looking at them and listening to them.  It predates laboratory medicine by thousands of years.  The field of clinical medicine is generally no longer taught in medical schools.  It's been replaced by laboratory medicine described as "more accurate and evidence based."  But it's not.

Ideally, clinical medicine should allow for an andequate index of suspicion to present for laboratory based medicine to confirm symptoms and establish a diagnosis.  But if a physician relies only on laboratory based medicine they will miss anywhere from 12-25% of cases where the laboratory findings are just under abnormal, but still indicative of disease.  In psychiatric illness, where diagnosis by general physician is based on symptom report or rating scales, the error rates skyrocket.    

I have some rare genetic condition, one of which is low blood volume.  That means my labs are normal even when I have obvious manifestations of disease clinically.  Physicians trained in medicine after 1985, have little to no training in clinical medicine and will inevitably pronounce me "normal" and "healthy" even if I'm fainting in their office, pale as a ghost, bruising easily, complaining of long muscle pain, tongue scalloping, and tongue burning--all symptoms of significant anemia.  If they finally look up from their lab sheets, they will confusedly remark "but your labs are normal!"  As a result I became invested in learning as much clinical medicine as I could.  

I started off working for a general physician right out of graduate school.  The majority of missed diagnoses were of endocrine disorders, anemia of chronic illness and malignancy, cardiac conditions, lung conditions, kidney disease, substance abuse and poor nutrition.  He was a good physician.  The difference between what he was doing and what I was doing was in taking an adequate history.  He had 10 to 15 minutes to see a patient, establish a diagnosis, order labs and tests and write a prescription.  I had an hour and, if needed, I could take 90 minutes.   It makes all the difference.

So here are the people I treat:   

• Anyone who has seen a physician for 6 medical visits and still doesn't have a diagnosis
• Anyone who has had an evidence based treatment for anxiety, depression, or other psychiatric illness, and is not significantly improved.
• Anyone who has relapsed from an evidence based treatment.