Monthly Archives: November 2011

Hypnagogia, misdiagnosis and Kermit the Frog

It’s a too-common newbie mistake: a therapist fresh out of grad school assesses a client who reports mild anxiety and maybe a little depression. Do they hear voices? Sure… every now and again. The poor client winds up misdiagnosed with Psychotic Disorder NOS, because the rookie assessor didn’t ask a crucial follow-up question: “When do you hear these voices?”

Hypnagogic  hallucinations are visual, auditory, or tactile hallucinations that occur while drifting off to sleep.  The term ‘hypnagogia’ is taken from the Greek for “inducing sleep”,  and was coined by Napoleon III’s librarian, Louis Ferdinand Alfred Maury. Bódizs, Sverteczki, et al [i] suggested that elements of REM sleep continue in the hypnagogic space between full wakefulness and true sleep. If they’re right (and follow-up EEG studies [ii] support the hypothesis), it would seem our dreams can briefly blend with our waking awareness, like a computer-generated movie monster matted in with the actors. Psychic researcher Frederic Myers noted something similar can happen when we wake, and termed this a hypnopompic state. The DSM says this part of the normal human experience, like the illusion of hearing someone call your name.  I won’t count any reports of hallucinations in bed as a sign of mental illness, even if the client insists they were wide awake at the time.

Necessary follow-up questions can fall victim to time pressures. In community mental health, the pressure can come from management less concerned about about  precise diagnosis than they are about meeting Medicaid timelines . In private practice, the pressure can come from clients impatient to move past formalities and start fixing their problems. A client’s eligibility to adopt a child or buy life insurance can hang on the question of, “Have you ever been diagnosed with…?” Misdiagnoses based on something as ordinary as hypnagogia can affect them long after their actual mental health problems are resolved.

How ordinary are hypnagogic hallucinations? Muppets have them:

Key lines come at the start of the third verse:

“Have you been half asleep, and have you heard voices?
I’ve heard them calling my name.”

@ 2011 Jonathan Miller All Rights Reserved

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Filed under Diagnosis

Can police peers prevent PTSD?

The DSM-IV-TR defines traumatic events (TE’s) as  “events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.” That’s a  fair description of  situations police officers might find themselves in every day. In Quebec, the Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST) has found that police officers are less vulnerable to Post-Traumatic Stress Disorder than previously thought. Per the IRSST, they’re actually no more likely to develop PTSD than any one else.

The American Medical Network reports:

“Providing police officers with interventional support shortly after and in the weeks following a TE improves the chances of preventing PTSD,” explained André Marchand, lead author of the study, researcher at the Fernand-Seguin Research Centre of Louis-H. Lafontaine Hospital and Associate Professor at Université de Montréal’s.”

What is intriguing here is how much “interventional support” sounds  like Critical Incident Stress Management. With CISM,  emergency service personnel and accident victims meet mental-health professionals for information and support immediately after a traumatic event. It’s an intervention that seems logical, but can actually increase the risk of developing PTSD. So what’s the difference?

…  the police officers stated that talking to their colleagues, obtaining peer support and taking part in leisure activities are particularly helpful after a TE. “The police offers involved in this study even advise their colleagues who experience this kind of event to consult a psychologist and are themselves open to the idea of receiving psychological support if need be,” said Mélissa Martin, co-author and psychologist at the Trauma Study Centre at Louis-H. Lafontaine Hospital.

This is a tantalizing hint of two key differences:

  • support from friends and family, rather than a stranger with a psychology degree
  • choosing to meet with clinical staff, rather than being presented with them

The original study has not been translated into English. Man, I wish I spoke French.

@ 2011 Jonathan Miller All Rights Reserved

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Filed under Post-Traumatic Stress Disorder

Why vodka is like depression

Photo by Rob Nova - robnova.wordpress.comEvery week, in some major city,  a bar, distillery or festival holds a vodka tasting.  This sparks skepticism among non-aficionados, because vodka is tasteless – literally. The USA’s code of federal regulations title 27, volume 1 defines “vodka” as “neutral spirits so distilled, or so treated after distillation with charcoal or other materials, as to be without distinctive character, aroma, taste, or color.”

Which makes it a lot like depression. Sip a screwdriver and it tastes just like orange juice, except for the ethanol kick. Depression can feel just like everyday life, only with a deadening lack of pleasure or motivation.

When a client says, “I didn’t really feel anything this week,” it helps to ask, “What has your appetite been like? How about your temper? How many hours have you slept? What all did you do this week?” Too often, the answers are, “Terrible,” “Terrible,” “Who knows,” and, “I got the kids off to school, then I went back to bed.”  Emotional numbness isn’t one of the DSM-IV-TR’s criteria, but it notes, “(with) individuals who complain of feeling ‘blah’, having no feelings or feeling anxious, the depressed mood can be inferred from the person’s facial expression and demeanor.”

Clients often assume depression always means sadness. They can know the dishes have piled up in the sink, or that formerly-reasonable family members are suddenly impossible, without recognizing these are signs that their mood has declined. They’re more alert to such shifts when they know depression can creep up in the form of a slow, steady, subtraction – the loss of energy, appetite,  interest, or hope.

Vodka is like ‘nothing’, with a kick. Depression can be a ‘nothing’ that hurts.

@ 2011 Jonathan Miller All Rights Reserved

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Filed under Useful Metaphors

Welcome to the ’Sphere!

“My analyst told me that I was right out of my head.
But I said, ‘Dear doctor, I think that it’s you instead’.”



Filed under Uncategorized