Controlling healthcare costs

Despite trying to engage in distractions and diversions during every waking moment and engaging in supposedly cognitive and memory stimulating reading (I can’t concentrate, can’t comprehend and can’t retain much info, so consider everything I write with a healthy dose of skepticism), I am increasingly experiencing noticeable memory lapses and episodes of confusion.  The memory lapses are annoying and disheartening.  The confusion is frightening.  Because no one was interested in learning about those problems and instantly dismissed them as “due to the depression”, I am left to my own devices to manage them. Enter Google.  There are self-assessment tools which purport to distinguish between dementia and depression in memory loss.  I tried them out and came away with a 100% alignment with depression.  However, these tools, and the physician feedback I received, conflated correlation with causation.  The real answer is that no one knows. After a winter of experiencing much more back and joint pain, the inability to self-plan and perform even a basic yoga practice, and a months long stretch of not leaving the bed except for bodily functions needs, I find myself so fatigued, dull, and slow that forcing myself to stay alert, attentive and mobile is a monumental task.  And really, since I do not have any obligations to work, socialize or contribute in any way, no one cares or is affected, which brings me a perverse sense of relief of not failing anyone.  When all of society yanks those away and sends you off to a life of dying and social death, this apparently is the benefit. (For all of you psychiatrists who found your “EBM” on that most medically scientific principle of false hope and optimism serving as a default component of “insight”, this is it for optimism and flexible thinking.  Insight I’ve got in spades.) I have struggled to attend scheduled volunteer activities.  But I think I am bringing a poor benefit/risk ratio to the organization.  I can’t perform much of the physical work, and sometimes I can’t remember the very simple instructions to carry it out. The people I’ve met are seriously smart, wise, witty, knowledgeable and committed to the goals and work.  The leaders lead well (coming from me, that’s the equivalent of the Nobel Peace Prize).  Two of these people are dealing with immediate end of life issues, and I try to be a reliable and comforting presence.  That, at least, I can offer and carry out. So back to self management.  I started looking around again for resources and strategies to try.  Because I root around in PubMed, am located in a city where a vast amount of clinical research is occurring, and have a sense of what I need in the way of outcomes, I called the HMO and asked to speak with the mental health case manager.  The marketing and sales people weren’t happy with that.  The person I spoke with was sullen and only after repeated requests and my refusal to give her clinical info was I transferred.  And I got the same woman who when I first called to find a psychologist with expertise in both PTSD/trauma and depression gave me four names where either the person was no longer in the plan or was outside my ability to travel. When I called to report this and ask for appropriate options, she became belligerant and defensive, and so I ended the call since I had already been through the provider list and discovered that there weren’t any at all who met the above criteria. This time, I asked her if she knew of any research or clinicians who dealt with ketamine for severe depression, or with rapid responses to severe depression.  She started in on the spiel that it wouldn’t be paid – it was experimental.  After a few minutes of this abuse – no referrals, no answer,  I told her I’d had enough and hung up. Ten minutes later the police were at my door.  Luckily, my computer screen was on and open to the complaint and disenrollment line, the coffee pot was full, and no weapons were    in sight (that last one is a joke).  The sergeant grilled me about what I had said that “would make her call”.  I explained about inquiring about the ketamine research.  I offered him the phone number to call the woman.  He couldn’t get past the telephony.  I had to sign a form declining emergency transport to the ED. The officers declined coffee, inquired as to the rent I pay for this attic dump, rolled their eyes at the response, and then changed the conversation to “we have to do our jobs.” I replied that experiencing public humiliation (lovely lights, multiple police cars and ambulance in the drive and street) and terror (nothing like having 5 uniformed and armed men on your doorstep banging on the door and demanding to be let in.  NOW.) was obviously what the HMO’s objective was, and they agreed. Which is just the latest experience which illustrates why I still have no health support, no trusting relationship with anyone, and no hope of finding same. What I ended up doing was perusing the research studies for chronic pain and finding several that are non-pharmacologic and low risk to enroll in. I was assigned to the treatment arm of two, and two more are simply looking at different biomarkers and immune responses.  I’m an easy stick, so I’m happy to donate a little serum to that cause.  However, one study requires a combo PET/MRI along with an arterial lineinsertion.  Having been on the managing end of those before as a critical care nurse, I think receiving one (they are uncomfortable at best) is a dose of my own former medicine. I wasn’t permitted to disenroll from the HMO.  The abusive case manager is still a “valued employee”, and I effectively have no health insurance, because there I will not provide any information to, use any provider affiliated with, or voluntarily use any aspect of that HMO’s products and services.  They really have the keeping costs controlled portion covered.  Abuse, terrify and threaten enrollees, collect their premiums and watch the profit margin soar. And the research compensation (for “subject “expenses”) will pay for dental and vision exams.  At least those don’t come with threats of imprisonment and assault and battery. (Optimism and hope, psychiatrists.)

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Hurts So Bad

Illustration of the pain pathway in René Desca...

Image via Wikipedia

Social rejection, that is.

Current theorizing suggests that the brain systems that underlie social rejection developed by coopting brain circuits that support the affective component of physical pain (1, 2, 9). The current findings substantively extend these views by demonstrating that social rejection and physical pain are similar not only in that they are both distressing, they share a common representation in somatosensory brain systems as well.

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Although the experience of social rejection is commonly accompanied by reports of various emotions (e.g., fear, sadness, anger, anxiety, and shame), it is generally assumed that these feelings cumulatively give rise to a unique experience of “social pain” (3537). The results of the meta-analyses we performed in this study, which indicated that fMRI studies of specific emotions rarely activate OP1 and dpINS, are consistent with this view.

Decision making ability goes down the tubes:

Researchers have known for a long time that there is a link between social exclusion and the failure of self-control. For instance, people who are rejected in social situations often respond by abusing alcohol, expressing aggression or performing poorly at school or work.

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The new study, however, is the first to use MEG to show that there are actual changes inside the brain when test subjects are manipulated to feel socially excluded. MEG is an imaging technique that measures the magnetic fields produced by electrical activity in the brain.

Analogous to a trapped, wounded animal, no?  Except in this case, being trapped means being trapped in ongoing living with intentionally inflicted and unrelieved distress.

Here’s the linkage:

“Although it has long been suggested that mu-opioids play a role in social pain — and there are convincing animal models that show this — this is the first human study to link this mu-opioid receptor gene with social sensitivity in response to rejection,” Eisenberger said.

“These findings suggest that the feeling of being given the cold shoulder by a romantic interest or not being picked for a schoolyard game of basketball may arise from the same circuits that are quieted by morphine,” said Baldwin Way, a UCLA postdoctoral scholar and the lead author on the paper.

Eisenberger argues that this overlap in the neurobiology of physical and social pain makes good sense.

“Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them,” she said. “Over the course of evolution, the social attachment system, which ensures social connection, may have actually borrowed some of the mechanisms of the pain system to maintain social connections.”

Back to the usual: the interpersonal theory of suicidality.  The two conditions of thwarted belongingness and perceived burdensomness are met with social rejection that isn’t fully remediated. Baumeister explains that human attachment is a fundamental – essential for survival – need:

A hypothesized need to form and maintain strong, stable interpersonal relationships is evaluated in light of the empirical literature.  The need is for frequent, nonaversive interactions within an ongoing relational bond.  Consistent with the belongingness hypothesis, people form social attachments readily under most conditions and resist the dissolution of existing bonds.  Belongingness appears to have multiple and strong effects on emotional patterns and on cognitive processes.  Lack of attachments is linked to a variety of ill effects on health, adjustment, and well-being.  Other evidence, such as that concerning satiation, substitution, and behavioral consequences, is likewise consistent with the hypothesized motivation.  Several seeming counterexamples turned out not to disconfirm the hypothesis.  Existing evidence supports the hypothesis that the need to belong is a powerful, fundamental, and extremely pervasive motivation.

 

Suicide becomes the means to put a permanent end on an inflicted permanent unbearable degree of suffering – real physiologic and psychologic suffering.