Secret Doctor Language

Dr. Gary Small

Not long ago, I was listening to an NPR segment about patients getting easier access to their medical records (  Being a doctor and a patient, my first thought was, what a great idea.  But then I wondered how helpful it really would be for my patients to read my notes.  Could it somehow harm them to share my detailed psychiatric conclusions and thoughts?

During my training, I learned to take notes on patients so I could keep track of their progress and communicate with other doctors.  These notes were never intended for the patient to see.  But times have changed, and now insurance companies review notes to justify billing, and notes are sometimes used to ensure quality of care.  Unfortunately, some mental health professionals still don’t consider the potential impact their notes could have if patients were to read them.  What if someone learned from his doctor’s note that he was a help-rejecting demander who suffered from primitive oral rage? Ouch . . .  that could hurt . . . if he figured out what that means.

Many doctors were trained in a tradition of benign paternalism.  This means they take care of their patients, do their best for them, but they’re not expected to explain everything they do.  And some have an unfortunate attitude that patients couldn’t possibly understand their secret doctor language anyway.  Wouldn’t the patients have to go to medical school and complete residency training first? By embracing this attitude, doctors thought they were protecting their patients from the truth.

When the first major genetic risk for Alzheimer’s disease, apolipoprotein E-4 or APOE-4, was discovered in the 1990s, the leading experts of the day advised patients not to obtain their test results.  The experts feared that the information could somehow harm the patient psychologically.  Years later, a large-scale longitudinal study found that when people were informed of their genetic risk for Alzheimer’s disease, they didn’t get any more depressed or anxious than a control group.

That secret doctor language stuff doesn’t fly anymore.  Many patients know as much as or even more than the doctor about the latest diagnoses and treatments, thanks to WebMD,, medical television shows, and a host of other health care information sources.  And many patients want to know what’s wrong with them and how to take care of it.  It gives them a feeling of involvement and control.  Of course, doctors do give their patients this information by talking with them and explaining the details, but rarely by handing over a copy of the complete medical record.

In my practice, our group has revised the templates we use for reports so that now patients can better understand their results should they request to see their records.  Also, when we write notes of any kind, we try to ask ourselves, “How would I feel if this were a medical note about me?” Of course, we have to be accurate in what we write, but we can also be mindful of how we phrase the information.  Did the patient really have “severe behavioral aberrations?” It might be better to write that he presented with rapid speech and appeared fidgety as he whispered that aliens were following him.

Many years ago, I was treating a patient with borderline personality disorder.  Borderlines are people whose psychological state straddles the line between normal anxiety and psychosis.  Under stress, they tend to distort reality and have delusions and hallucinations.  This patient was coming to therapy once a week, and her behavior was unpredictable.  At the beginning of one session, she stomped into my office, threw a magazine on the coffee table, and shouted, “Have you seen this article?”

The magazine’s cover teased a feature story about borderline personality disorder.  I assumed that she was enraged that the secret doctor language had been revealed to her and that perhaps by not sharing enough information with her myself, I had behaved like one of these paternalistic psychiatrists who throw around pejorative labels in their notes about their patients, more interested in keeping their secrets than in healing their patients.

With trepidation, I said, “No, I haven’t read that article.  What did you think about it?”

She calmed down and said, “It was such a relief to read it.  Now I see that other people experience what I do.  I don’t feel so alone anymore.”

Gary Small, MD, is a professor of psychiatry at UCLA, and author of the forthcoming book (Morrow, September, 2010), “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases.”

Copyright Gary Small, M.D.

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Paul McCartney’s Memory Lapses

Dr. Gary Small

I was about to board my flight back to Los Angeles and turn off my cell phone – I was being thrifty with the battery since I had forgotten where I left my travel charger – when a journalist called urgently asking for a comment on Paul McCartney’s recent admission that he was having trouble remembering the lyrics to some of his old songs.  I envisioned him singing “She loves you – hey, hey, hey…”

“So you’re trying to get me to go on record that Paul McCartney is getting Alzheimer’s?  I won’t do that,” I said in anticipation of where the interview was going.

I flashed back to 1993 when Ronald Reagan announced that he was suffering from this devastating illness, which robs the mental life from millions of Americans.  Back then, reporters kept asking me to speculate about whether Reagan might have been slipping mentally while serving as our commander in chief.  For our former president, his senior moments may have been early warning signs of further cognitive decline.  In fact, an analysis of his progressive extemporaneous speech errors during debates over the years pointed to such subtle progressive deficits.

But for the average aging Baby Boomer like Sir Paul, middle-aged pauses and senior moments do not necessarily mean that rapid mental decline is inevitable.  The risk for Alzheimer’s disease is only about 10 percent for people age 65 or older.  Misplacing keys or struggling to find a word is what we all joke about as we age.  Sure, our memory abilities are not quite what they were when we were in our twenties, but age-associated memory impairment is an expected and quite common experience of aging.  Approximately 85 percent of people 65 years or older complain that they often recognize a face but can’t recall the name that goes with it.

How can we tell if this normal memory loss will progress? It’s not easy, even for doctors.  We often look for risk factors:  age, family history, or other illnesses like diabetes or Parkinson’s that predispose someone to neurodegeneration.  If your memory challenges symptoms begin to interfere with your everyday life, if others start commenting on them, or if you find yourself worrying about them, it may be time to discuss it with your doctor.  Because of the general fear and denial about Alzheimer’s disease, many people ignore early symptoms.  That’s not always a great idea, since the earlier you get help, the better your chances of staving off future symptoms.  Clearly, it’s easier to protect a healthy brain than to try to repair one once damage has set in.  We don’t yet have a miracle cure for Alzheimer’s disease, but there are treatments that improve symptoms and keep people functioning better, longer.  In general, earlier intervention translates to better outcomes.

The emotional impact of the illness is huge. We may joke about our memory lapses, but behind the humor is anxiety and fear.  I have spent a good part of my career studying and caring for patients and families who have had to cope with this tragic mental struggle.  And although I’m an expert, I initially refused to accept the fact that the illness was causing subtle personality changes in a close friend and mentor.  I looked for almost anything else that could explain his symptoms – a possible medical condition, a depression, or maybe a drug side effect – but I eventually had to face the fact that his mind was drifting away and I couldn’t stop it.

When Sir Paul McCartney was 16, he wrote “When I’m Sixty-Four.”  Now that he’s 67, I’m not too worried that he may not remember a few of his old lyrics – chances are that his senior moments won’t progress too quickly over the years.  I, on the other hand, wish I could remember where I left my cell phone charger.

Originally posted on Huffington Post.  Copyright Gary Small, M.D.

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Spotting a Sociopath: The Top Three Tells – by Dr. Gary Small

Dr. Gary Small

Sociopaths are people who think only of themselves.  They have no conscience or empathy.  Whether it’s an Ernie Madoff, Adolf Hitler or Charles Manson, they wreak havoc on other people’s lives.

But what about the everyday sociopath who sneaks into your life and befriends you.  When you discover his true colors, you’re shocked, you feel violated, and you often blame yourself for being duped.  How can you spot these predators before they gain your trust?

First impressions count.  If someone seems ingenuine, they just might be.  Also, watch out for people who seem too good to be true.  Sociopaths often anticipate your needs in order to get what they really want.  Finally, look for typical character traits:  no sense of remorse, short-tempered and quick to blame others, and few or no long-term relationships.

Remember, sociopaths can be smart and even when you’re on alert, they can slip into your life.  Don’t blame yourself, just cut them out and move on.

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De-Clutter Your Life – by Gigi Vorgan

Gigi Vorgan

My girlfriend was in from New York and stood in my bathroom convulsing in laughter, “You don’t have shampoo? Not any?” She sputtered.

“Well, no. You can use the kids’.” I said. For some reason this made her laugh even harder and she had to sit down on my mini-glass-tiled tub surround. “I get my hair blow-dried twice a week, and I don’t see why I should clutter my cabinets with hundreds of hair products I never use. I just threw everything out.” It seemed perfectly reasonable to me when I did it. Maybe not so much right now.

I was at the end of a month-long de-cluttering bender, and my house looked like one of those model homes – no piles of anything, anywhere. Even my closet was color-coded and everything was hung on new, dark-brown wooden hangers. I may have gone a little crazy there – they cost a fortune – but they looked really cool. And organized! I had always wanted to be organized but never seemed to quite get there. Life constantly put something in my way that was more important than organizing. And so the clutter grew. Kitchen drawers so full of junk we could never find a pen; candles, vases, bowls and frames we had been given were crowded on every surface; magazines I’d already read but had to save were piled by every sofa and my bed, and the pantry didn’t have room for a box of jello because it was filled with important things like cans of tuna from 1979.

I had a break between projects – also known as being unemployed – and I decided this was my chance to finally get rid of the clutter around me, which tended to make me nervous and down. I was running out of steam by the time I got to my office, and I have to admit, right now, that I never got to my t-shirt and jeans drawers, but no one’s perfect.

I was so proud of my new Zen-empty house that I insisted my book club meet at my place. My club is made up of my old friend Carol from school and mostly newer friends. I got my children and husband out of the house for the evening and actually considered baking a cake – but that passed. I mean, there’s a perfectly good bakery right down the street.

Some of the women were late, and my friend Carol, who showed up first, didn’t even notice how I’d de-cluttered the place. When I told her, she hardly reacted; except to open a kitchen drawer and tell me it’s too bad I didn’t get to the drawers, too. Carol was starting to bug me a little lately. She only called when she needed something, which was often, and she relished in any bad news I had to share. Good news not so much. I offered her a piece of coffee-cake, but she declined – too fattening. She did say I should have some.

Two women didn’t show at all, so we decided to get started. The book was Eat, Pray, Love, which I hated (okay, I’m ready for the hate mail), and everybody else loved it – such a wonderful experience to share with the author; an amazing soul-searching and self-discovering trip through the world; blah, blah, blah. Carol loved it more than anyone. After about ten minutes of discussing the book, the meeting turned into a gripe session about husbands and kids. I tried to get us back on track, at least to pick the next book, but it was impossible.

I was relieved when they left. I realized that my friendship with Carol had changed in the last couple of years, and now it seemed like she took much more energy from me than she gave back. Being around her was bringing me down and making me uneasy, a lot like the clutter in my house did. I suddenly recognized that I had to de-clutter my life, too. Just as we spend extra time and energy working in the cluttered environments we create in our homes and our work spaces, many of us waste our precious free time and energy on people that no longer make our lives better; in fact, they may diminish the quality of our lives.

De-cluttering our lives means cutting out the people that we keep around us out of habit, but who actually bring us down. And putting those piles of old magazines we’ll never look at again in the recycling bin helps, too.

Gigi Vorgan is co-author with Dr. Gary Small of “iBrain: Surviving the Technological Alteration of the Modern Mind” (HarperCollins, October, 2008) as well as several other books. Visit for more information.

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Why Do You Need a Therapist if You Can Talk to a Good Friend? – by Dr. Gary Small

Dr. Gary Small

A psychiatrist or therapist, unlike a friend, has no agenda of their own when listening.  When a friend gives you advice, he may be thinking about how your actions will affect him, as well as you.  When you’re in therapy, it’s all about you, not the therapist.  Also, anything you tell a therapist is strictly confidential, and unless your friend has the training, you may not be getting the greatest advice.

Having good friends is important to our mental health, but if you need it, don’t hesitate to call a professional.

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You’re Only Young As You Feel – by Gigi Vorgan

Gigi Vorgan

I was savoring my ritual cappuccino across the street from my dentist’s office as I did every time I went there, when this incredibly handsome young guy sat down two tables over. Our eyes met and he smiled seductively. I practically choked on my biscotti. I could have sworn I knew him from somewhere… But it wasn’t the gym… He sipped his sparkling water and gave me a little wave. I felt myself blushing like a teenager. Where the heck could I know him from? He was so young. And I have been married a long time.

Oh my God, I thought, as he started to walk over. Could this amazing hunk possibly be hitting on me? Ridiculous. No way! I could be his mother. Thank God in heaven I just had my teeth cleaned.

He grinned broadly and said, “Hi! Remember me?!” I was at a complete loss. I was definitely going to have my memory checked. He went on, “I’m Andy!” Andy Carter!” Carter… Carter… from the tennis club? He continued, “I was on your son’s basketball team in middle school.” I sat there frozen with an absurd smile on my face and a sudden urge to evaporate into thin air.

Age reminders happen to everyone at some point. It could be as simple as the appearance of a single grey hair, the first time someone calls you “ma’am,” or perhaps walking into a room and forgetting the reason why. None of us can stop time, but we can slow down the aging effects – and sometimes even reverse them. Can anyone here spell BOTOX?

A mere 100 years ago, people were lucky to live beyond the age of 40. Now, modern medical science is striving to keep us alive well into our nineties and beyond, and most people say they want to live as long as possible. But who wants to live to be 100 without their health, vitality, and faculties intact? And frankly, who wants to look 90, when you can be taken for a strapping 84? That’s where lifestyle choices come in. The key to healthy longevity, according to UCLA aging specialist Dr. Gary Small, is to keep it all together – our brains, our bodies, and our attitudes.

For our brains, he suggests keeping them young and agile with puzzles and other challenges such as learning a foreign language or taking up a new hobby like painting. For our bodies, it’s the old ‘use it or lose it’ theory – a 10 to 20 minute walk each day is enough to keep the cardiovascular system in shape. Of course, more is better. And attitude, well, it’s like the old Jefferson Airplane lyric, “You’re only pretty as you feel.”

Gigi Vorgan is co-author of with Dr. Gary Small of “iBrain: Surviving the Technical Alteration of the Modern Mind” (Harper-Collins, October, 2008) as well as several other books. Visit for more information.

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Serial Addiction – by Dr. Gary Small

Dr. Gary Small

When we think of addition, alcohol or drugs usually comes to mind, but a person can get addicted to almost anything they enjoy:  food, tobacco, sex, gambling, the Internet, or even videogames.

Some people have addictive personalities.  When they “kick the habit” of one thing, they simply move on to something new and get addicted to that.

In The Naked Lady Who Stood on Her Head, a woman who has an eating disorder overcomes it.  Then, her shopping gets out of control, and she just can’t stop until she moves on to something else.  This kind of serial addict usually exhibits the same behavior patterns regardless of the object of their current addiction:  They crave the experience all the time, have withdrawal when they can’t get it, are secretive and defensive about the behavior, and the addiction interferes with everyday life.

Anyone who’s struggled with addiction or dependency, should be aware of the possibility of becoming hooked on something new.

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