Abnormal Psychology

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    • 00:00

      [MUSIC PLAYING][Abnormal Psychology]DR. AMANDA KLEINMAN So how have you been feeling?

    • 00:12

      SPEAKER 1: I'm really struggling at work.I feel like I just can't get any traction done with any onething.So I get home, you know, I just can't be there for my wife.I can't be there for our kid.And it's just-- it's really hard.

    • 00:24

      DR. AMANDA KLEINMAN: My name is Doctor Amanda Kleinman.[Amanda Kleinman, PhD, Psychiatrist]

    • 00:27

      DR. AMANDA KLEINMAN: I am a psychiatrist.I work in private practice.I have the distinct pleasure of being able to be my own bossand to take care of some wonderful individuals.Hey, good morning.

    • 00:38

      SPEAKER 2: How's it going?Good morning, how you doing?

    • 00:39

      DR. AMANDA KLEINMAN: Good.FYI, I just added one patient for 1 o'clock.I'll send you an email about that.

    • 00:44

      SPEAKER 2: All right, no problem.Thanks.

    • 00:46

      DR. AMANDA KLEINMAN: The conditionsI treat include depression and anxiety, ADHD or attentiondeficit hyperactivity disorder, and I alsotreat some folks with OCD, bipolar disorder, and evenschizophrenia.The key to being in outpatient psychiatryis to have some relative stability.Patients who may have their symptoms

    • 01:08

      DR. AMANDA KLEINMAN [continued]: but can manage them in a regular wayare perfect for outpatient psychiatry.If the severity of symptoms becomes more intense,then they may need a higher level of carelike a partial hospitalization programor an intensive outpatient program.In my experience, I had the great fortuneof working with folks who may have very severe pathology,

    • 01:29

      DR. AMANDA KLEINMAN [continued]: but are at a place where they're able to be functional.They're able to work with their symptomsand truly create lives worth living.

    • 01:36

      SPEAKER 1: I don't know what I'm doing wrong.I feel like I'm trying as hard as I can,but it's just the same treadmill over, and over, and over,and over again.

    • 01:45

      DR. AMANDA KLEINMAN: Depression may manifestwith folks feeling low.They're feeling blue, and they just can't get out of it.Anyone can have a blue day, anyone can feel bummed out.But when you have those feelings that continue day after day,and those feelings take start to take a toll on the whole body,such as folks finding that their energy justisn't what it used to be.

    • 02:05

      DR. AMANDA KLEINMAN [continued]: They have a difficulty concentrating,because their mind is otherwise preoccupied by their moodstate.And they just can't actually sit and focuson what they need to get done-- peoplewho may find that they're just not as interested in eating,or they're eating too much, people whomay find their sleep changes.All of that can start to translate to a feeling

    • 02:28

      DR. AMANDA KLEINMAN [continued]: that this life isn't what it used to be.And people start to question, what are they doing?What is this all about?You can get a sense of worthlessness,a sense of guilt. And then, with time,even symptoms of suicidality may start to arise.Anxiety manifests usually from an early age.

    • 02:51

      DR. AMANDA KLEINMAN [continued]: And it tends to be a sense of worry thatis more often than not, all the time, difficult to control,and may concern things from the minor things they haveto do the next day to the major things like where is therelife going.When there's worry that's all the time,and it's starting to take a life of its own,that's when folks can kind of find themselves

    • 03:13

      DR. AMANDA KLEINMAN [continued]: in difficult times where they may find ittheir energy is not what it was.Because they're spending so much energy worrying,they don't have energy to do other things.Any symptoms of depression and anxietycan happen to anyone, at anytime,in any level of severity.When they're happening a lot and with increasing intensity

    • 03:34

      DR. AMANDA KLEINMAN [continued]: for a long enough period of time,that's when folks may find themselvesin a position of wanting to seek care.So bipolar disorder is a distinct entitywhere you truly have mood episodes that fluctuate.And in some ways, it is truly the opposite of depression.It is having so much energy and so muchmotivation and enjoyment in life that people go,

    • 03:55

      DR. AMANDA KLEINMAN [continued]: and they stay up, and they're not evensleeping for more than four or five hours or maybe twoto three hours a night for days.So you have folks who get into a manic phase.And it feeds off itself and gets worse and worse.And what happens for them as they stay upfor many, many days on end, what they'll get

    • 04:16

      DR. AMANDA KLEINMAN [continued]: is more irritability and potentially even psychosis.So when they come to treatment, or get hospitalized,or whatnot, they often get put immediately on medication.And then there's a crash into depression.And with depression, it's all the symptomsI mentioned before-- very low energy,can't concentrate, feeling that they can't enjoy anything.And it's in that initial stage of depression

    • 04:38

      DR. AMANDA KLEINMAN [continued]: that they might start to become suicidal as well.I know we've talked about that there couldbe some element of ADHD happeningwith some of the difficulties that you're experiencing.Sometimes it's really hard to stay focused at work,as you're saying.Sometimes things really kind of get out of hand.

    • 04:55

      SPEAKER 1: The classic example is I'll send an emailand then realize that there were three or four thingsthat I should have put in that email.And so now I have to go back and saythis other part of the email.And people are getting three or four emailsfrom me, when they should be getting one.And that makes me look bad.

    • 05:12

      DR. AMANDA KLEINMAN: Mental illness is very muchbiologically determined.We have increasingly good data to support the notionthat mental illness and mental healthsymptoms do pass from family members to family members.We can often see generations of questionable functioning,

    • 05:33

      DR. AMANDA KLEINMAN [continued]: questionable symptoms even when those people in the familiesnever actually sought treatment or gotto the level of needing care.So genetics plays a huge part of this.The environment is not completelyinnocent in all of this.Truly, it is the combination of genetics and environment

    • 05:54

      DR. AMANDA KLEINMAN [continued]: that bring out all of these illnesses.So for something like depression, you often have,again, a biologic predisposition.And then, you know, it may be the every day stressorsor challenges that bring some of those symptomsand predispositions to the fore.

    • 06:16

      DR. AMANDA KLEINMAN [continued]: You can then see a spectrum of that.A person who has a predisposition to depressionwho's with a family that's especiallyinvalidating, or abusive, or very especially difficultgrowing up experience may bring those depression symptoms outsooner and maybe even more severely.A family that's more supportive and understanding

    • 06:37

      DR. AMANDA KLEINMAN [continued]: or is a better match for that individualmight be able to stave off either depression at allor degrees of depression by that goodness of fit.Same thing with schizophrenia, ADHD, anxiety--there is some combination of the genetics,and the biologic disposition that's there,

    • 06:59

      DR. AMANDA KLEINMAN [continued]: and the environment.I get a lot of patients who are confused because they say,OK, I have a fine environment.I have a great family.I went to school.I'm very successful.I did what I need to do, and I'm still anxious.And I'm still depressed.And now you're telling me I have bipolar disorder.What is this all about?It comes back to genetics-- that it'sas if people have a certain DNA that is just a ticking time

    • 07:22

      DR. AMANDA KLEINMAN [continued]: bomb.And at some point, we cross a threshold, oftenin our early 20s, that then causes these symptoms to showthemselves.And it can be a very challenging time in the 20s.Because when those symptoms present themselves,individuals are often faced with the notion ofdo I want to take medication?Do I want to do therapy?Do I want to do both?

    • 07:43

      DR. AMANDA KLEINMAN [continued]: And even before we even get to that,there's still a process of even appreciating and acceptingthat maybe this is part of who they are.So in these situations, we can sometimesfind that stimulant medications can helpful.I can tell you about a couple of them.And you can see which one you might like to try.Some of this is based on personal preference

    • 08:04

      DR. AMANDA KLEINMAN [continued]: on those, maybe based on what you've heard of.

    • 08:06

      SPEAKER 1: If I have to take meds, is that every day?Is it twice a day?Is it for the rest of my life?I mean, what's the--

    • 08:12

      DR. AMANDA KLEINMAN: Good question, good--I can give medication, and I can do therapy.A lot of psychiatrists primarily do medication and maybea little bit of supportive therapyas they meet with patients.I'm a psychiatrist that actually enjoys doing psychotherapy.So when patients are interested in psychotherapy,I'm happy to be able to provide that.

    • 08:32

      DR. AMANDA KLEINMAN [continued]: Therapy is very much a very individual choice,an individual choice as to whether they want to do therapyor whether they decide that I as an individualwould be a good match for them.Sometimes I'm a good match for my patientsas far as therapy goes.Sometimes I'm not.And my hope with all of my patientsis that they get the care they need,

    • 08:54

      DR. AMANDA KLEINMAN [continued]: so they can really start to improve and get better.There's times where I may strongly recommend,and rarely, there's times where actually insistthat folks do take medication.But generally speaking, it's a very collaborative process.It's a question of how are they thinking about medicine?

    • 09:15

      DR. AMANDA KLEINMAN [continued]: Are they ready to start that journey of medicine?Because it is its own journey.And in my experience, it seems like folksare best ready to start medicine when they are, as it were,sick and tired of being sick and tiredand when they've tried everything.They've done all their coping skills.They're in great therapy, and they still feel like junk.And they just need to get better.Then working with me or any psychiatrist

    • 09:38

      DR. AMANDA KLEINMAN [continued]: can be a useful step to at least getting that biology piece upand running.

    • 09:43

      SPEAKER 1: I don't even like taking aspirinif I can avoid it.So are these gonna--

    • 09:47

      DR. AMANDA KLEINMAN: Sure, you're not alone.

    • 09:49

      SPEAKER 1: No, I want to know, do they taste weird?Are they going to make me feel funny?What's the side effects that I should be worried about?

    • 09:55

      DR. AMANDA KLEINMAN: Ethical concerns in whatI do can be pretty subtle.I sometimes find myself strugglingwith patients who have significant severityof symptoms and either are not on boardwith the kinds of treatments that Imay be suggesting or offering.

    • 10:19

      DR. AMANDA KLEINMAN [continued]: And what we have to do is work together over time.And my hope is that ultimately, I can convince or persuadethem to consider the treatment modalitiesbefore the symptoms get worse or more detrimental.Other times, I'll have patients whoneed a different level of care or different kind of care

    • 10:41

      DR. AMANDA KLEINMAN [continued]: than when I can provide.And I'm someone who has no problem kind of bringing thatup and discussing that.Some patients have no problem with thatand can make that switch.Other patients can feel rejected.Because it's like, well, they found me.There working with me.Things are going well.And now they have to move.

    • 11:03

      DR. AMANDA KLEINMAN [continued]: And that can be daunting for them.Especially when it comes to issues of addiction--I don't consider myself an addictionologist.I consider myself as someone who can help folks with addictionproblems at a basic level.But there are people who do so much better jobthan I do with it.I really often encourage folks whohave serious problems with addiction that

    • 11:23

      DR. AMANDA KLEINMAN [continued]: keep coming up over and over againto really seek more specialized care.And some folks, as they are strugglingto accept that maybe they have an addiction,may also struggle to then accept the care.And that can be ethically challenging.As an outpatient psychiatrist, I'mdealing with folks who have symptomsthat are of lesser acuity, symptoms that

    • 11:43

      DR. AMANDA KLEINMAN [continued]: can tolerate being managed by the patient themselvesin between visits.On inpatient, they're dealing with caseswhere the symptoms are so bad, and so severe,so prevalent that they really can't justtake care of themselves in between seeing a provider.What I'm doing is establishing a relationship that's

    • 12:03

      DR. AMANDA KLEINMAN [continued]: really meant for the long term.That what I'm trying to do is set up a healing relationshipwhere folks can really start to trust me, trust the process,and truly start to grow in ways that are helpful and can putthem in a better place long term,as opposed to an inpatient, certainlyfolks can work with relationships.

    • 12:24

      DR. AMANDA KLEINMAN [continued]: But it's a little bit more paternalistic.It's-- your here.We're trying to keep you from dying.We're trying to keep you from killing yourself or hurtingother people.And in that sort of paternalistic way,you can get more-- here, take this medicine.Or you have two options of medicine,and you have to take something, or we won't release you.So you get kind of a more parent/child kind

    • 12:46

      DR. AMANDA KLEINMAN [continued]: of experience.In addition, depending on the kind of psychiatric ward,folks are, in inpatient, surroundedby other folks suffering with mental illness, whichon the one hand can be liberating,and validating, and incredibly helpful to see-- almosthelp them maybe get some perspectiveon what they've actually been going through.On the other hand, it can be daunting and scary,

    • 13:07

      DR. AMANDA KLEINMAN [continued]: and actually cause folks to worry, oh my gosh,I don't want to become like that person down the hall.So in outpatient, we're able to keep some modicum of privacy--that folks can be seen by an individual like myself-- youknow, I work in an office that doesn'tlook like a medical office or like an inpatient ward.

    • 13:28

      DR. AMANDA KLEINMAN [continued]: So folks can open up and explore things hopefullywith a little bit more courage or feelinga little bit more safe.And ultimately, it's a collaboration.So when I'm offering medication, it's-- her's two, three, four,five options.Here's what they could do-- and thengiving the patient ultimately the control and power to say,

    • 13:48

      DR. AMANDA KLEINMAN [continued]: yes, I do want to try that.I don't want to try that one.And I really depend on patients using their autonomyto pick medicines.I think it helps them feel more empowered in their care.It also helps them take more ownership.So if they start a medication because I told them to,then again, we're back into that parent/child dyad of,

    • 14:09

      DR. AMANDA KLEINMAN [continued]: well, you told me to take it, but I want to take it,as opposed to-- here are some options.You're feeling lousy.What do you think?And if they say, yeah, I think I wantto try that, then they will be automatically more investedin actually seeing how this goes.I'm really sorry this is so, so hard for you right now.

    • 14:29

      SPEAKER 1: The real problem that I'mstruggling with is just trying to get stuff done at workand have something left over so that when I get home,I'm not just a waste of space.

    • 14:39

      DR. AMANDA KLEINMAN: My job is done when my patients don'tneed me anymore, which is to say,if they don't need to come as frequentlyor can sustain a sense of healthy emotional resilience,contentment with their lives, enjoyment,and overall sense of peace that they are truly

    • 14:60

      DR. AMANDA KLEINMAN [continued]: living a life worth living, that'swhen I know I've done my job.My goal is not to have patients seeing me forever, and ever,and ever.I hope to become almost more like a primary care doctorafter a while, where I'm there for maintenance if peopledo end up on medication long term,again, that I'm there for maintenanceand help them as they go.

    • 15:21

      DR. AMANDA KLEINMAN [continued]: And if they're not on medication or able to come offof medication-- that they do well.They develop their friendships.They develop their partnerships.They explore their career.They start to feel pleasure and a sense of accomplishmentin all of their important domains in their life,so that I become a fallback.

    • 15:42

      DR. AMANDA KLEINMAN [continued]: So if in case things get uncomfortable or questionableagain, they can always come back to me, but that ultimately,they are able to live on their ownwith tremendous emotional resilience, and wisdom,and peace of mind.That's when I know we've done a good job.

    • 15:57

      SPEAKER 1: I'm trying-- I'm reallytrying to get stuff done.But everybody's coming and bugging mefrom one project and then another project.And I'm trying to do eight things at once.[INAUDIBLE]

    • 16:07

      DR. AMANDA KLEINMAN: Environment and illnesscan work independently and also work togetherto create what we ultimately see at a first evaluation.So at that first evaluation, what I'm doingis trying to take stock of what it's allhappening in their life as well as what their symptoms are,how their bodies are reacting, how their world

    • 16:29

      DR. AMANDA KLEINMAN [continued]: seems to be relating to them.There are times where it's pretty clearthat the environment is the key operative in the situation.For example, I have a wonderful lady whose husband of 40 yearsis now facing a legal issue.And she had never had depression before.

    • 16:51

      DR. AMANDA KLEINMAN [continued]: And in the years that this legal battle has gone on,her symptoms have attained a level of major depression.So it's very clear that she has these symptoms becauseof that situation.Now, is it possible that she could have ever had depression,and she just wasn't ever cued to that point?It's possible.Is it also possible that sometimes there

    • 17:12

      DR. AMANDA KLEINMAN [continued]: are life experiences that are so intense and so overwhelmingthat a person who'd never had depressioncould get pushed to the point of depression?Yes, that's possible too.So generally speaking, when thereis a mix of stressful situation and symptoms, whichis for most people, what we try to dois just give a modicum of time to see how things kind of sort

    • 17:35

      DR. AMANDA KLEINMAN [continued]: themselves out.It can make it interesting to decide, well,do we want to take medication for symptoms even though theymay be situationally bound?Or do we want to just do psychotherapy,given that if it is situationally bound,things should get better with time?That's a very individual decision.And I try to just help patients navigate what's goingto be the best choice for them.

    • 17:56

      DR. AMANDA KLEINMAN [continued]: Hi.

    • 17:57

      SPEAKER 1: How you doing?

    • 17:57

      DR. AMANDA KLEINMAN: Good to see you.

    • 17:58

      SPEAKER 1: How are you?

    • 17:59

      DR. AMANDA KLEINMAN: Come on back.

    • 17:60

      SPEAKER 1: Thanks.

    • 18:01

      DR. AMANDA KLEINMAN: When patients come outinto the waiting room from the elevator,I come out to get them, bring them back to my office,and then we spend 30 minutes to 60 minutes touching baseon stuff.So often that means reviewing howthey have been since the last time we met,reviewing what their thoughts are on any medication they mayhave taken, considering any further thoughts

    • 18:23

      DR. AMANDA KLEINMAN [continued]: they may have had about other issues that were discussedthe last time, and then discussing any other stressorsthat have arisen.Sometimes things can be a pretty boring.And we can have a nice boring visit.Like, you know what?I'm feeling great.And my medicine's great.And we're all great.And hey, if that's the case, we end soon and call it good.But oftentimes, folks are like, well,

    • 18:44

      DR. AMANDA KLEINMAN [continued]: this funny thing happened.And then it's my job to kind of explore that and bring that outto really get them to start to appreciate what'scausing the difficulty in a situation that seemed like sucha minor thing, but may actually have repercussionsto other issues that the patient's dealing with.I try to get notes written, i.e.

    • 19:06

      DR. AMANDA KLEINMAN [continued]: that will show what happened and some descriptors of whathappened with the visit, again, all the things that wediscussed in the visit, as well as talking about in the notewhere to go from here, and to be a legal record.That happens sometimes in between visits, sometimesat the end of the day.I find myself talking on the phone with colleagues

    • 19:26

      DR. AMANDA KLEINMAN [continued]: to get some conversation going as to how we can best worktogether to help the patient.If I have a patient who was recently hospitalized,I will try to reach out to the inpatient team, social worker,provider, et cetera, to see how they think the patient hasdone, what choices they made to change medications, et cetera.I might also talk to colleagues who are maybe

    • 19:47

      DR. AMANDA KLEINMAN [continued]: in the medical practice who have patientsthat they're very worried about.And they want them specifically to see me for some reason.And they want to give me a heads up on what to look forand how to help them.Becoming a psychiatrist is a good venuefor people who have a very balanced sense of themselves

    • 20:09

      DR. AMANDA KLEINMAN [continued]: and the world.To go to medical school, you haveto have a good grounding in science.And science and math don't come easy to everyone.But they are important tools to help a person understandthe body, understand the physiology of what'shappening in the brain.We get more and more information all the time telling us

    • 20:31

      DR. AMANDA KLEINMAN [continued]: how the brain is working, how these medicationsare operating with the brain, how different treatments maybe improving the brain.So it's important to have all that science,even though it feels very remote from any kind of psychiatry.It's important have all that scienceas a foundation from which to really understandall the new developments that are coming unbelievablyquickly.I think for psychiatry, as for psychology, it also

    • 20:54

      DR. AMANDA KLEINMAN [continued]: takes someone who can appreciate the human condition-- so peoplewho find themselves interested in English literature,interested in philosophy, interested in how people work,what motivates people, why they do what they do,some of your sociology, anthropologykind of components.I think having a grasp on what humanity does

    • 21:16

      DR. AMANDA KLEINMAN [continued]: and how humanity operates is also really critical.Because as you are working with a single individual,you're also bringing in elements to helpthem ground themselves in the larger world,to help reduce that sense of isolationand help them begin to heal.So I think as an individual, being someonewho can follow current events, can watch trends

    • 21:37

      DR. AMANDA KLEINMAN [continued]: in society, trends in the economy--I feel like I bring a lot of that with meas I'm trying to work with patientsand helping them see themselves in larger contextand begin to feel some connection to the world,whereas previously they may not.You have to really want it.You have to really-- have to want it and pushyourself to get it.

    • 21:57

      DR. AMANDA KLEINMAN [continued]: I'll say, when I went to medical school,I did not expect to become a psychiatrist.I thought that I might end up in pediatrics or to do somethingwhere I would be able to take care of peopleand really be there for them.And when I got to medical school,I found that a lot of the technical aspects of medicinejust weren't-- they were interesting,but they weren't quite stirring my passion.

    • 22:19

      DR. AMANDA KLEINMAN [continued]: But the patient experience-- how patientswere feeling about their experiences, how patients couldbe motivated to improve themselves-- that I definitelyfound stirring my sense of larger purpose.And so I think, like anything else,just sort of being open to any fluctuations in your own path,

    • 22:41

      DR. AMANDA KLEINMAN [continued]: but also be ready to work for it.One thing I would love to see wouldbe to have younger generations appreciate mental healthin increasingly more nuanced and realistic ways,such that the stigma of mental illnesscould further decline with time.

    • 23:01

      DR. AMANDA KLEINMAN [continued]: I don't know that anyone can ever completely understandmental illness without having either gonethrough it themselves or being part of a family where that'sthe case.But I think with terrific films beingmade that do a much better job now than 50 years agodescribing mental illness, I think with a younger generationthat is maybe more prone to things like ADHD and more aware

    • 23:22

      DR. AMANDA KLEINMAN [continued]: of things like substance abuse, and with allof that becoming more fluid in society,my hope is that folks will have the humilityto appreciate that and further lessenthe stigma of mental illness.So I'd love to see the mental health stigma get better.And they think, as anything else, knowledge is the answer.

    • 23:45

      DR. AMANDA KLEINMAN [continued]: [MUSIC PLAYING]

Abnormal Psychology

View Segments Segment :

Abstract

Dr. Amanda Kleinman discusses abnormal psychology and her job as a psychiatrist. She has an outpatient clinic that treats relatively stable patients. Kleinman talks about the differences between inpatient and outpatient treatment, about different treatment styles, and about having a career in psychiatry.

SAGE Video In Practice
Abnormal Psychology

Dr. Amanda Kleinman discusses abnormal psychology and her job as a psychiatrist. She has an outpatient clinic that treats relatively stable patients. Kleinman talks about the differences between inpatient and outpatient treatment, about different treatment styles, and about having a career in psychiatry.

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