Wednesday, October 27, 2010

DRY by Augusten Burroughs: Case Study

DRY is Augusten Burroughs’ second memoir and the sequel to RUNNING WITH SCISSORS. Augusten’s parents divorced early in his life. His father was a professor, who abused Augusten physically when he was drunk. Augusten described an incident at nine years old in which he had to jump out of the car his father was driving because his father threatened to crash the car and kill his son. On another occasion, his father burned Augusten on the bridge of his nose with a cigarette.

When he was 12, his mother sent Augusten to live with her psychiatrist. The adopted 33-year old son and former patient of the psychiatrist raped Augusten at 13, and he was sexually abused for the next three years by this man. By the time Augusten left the psychiatrist’s house at age 17, he had little formal education, having dropped out of school after sixth grade. He instead obtained his GED. Despite this lack in education, Augusten was able to work his way up, by his mid-twenties, to a high-paying job in the advertising industry earning $200,000 as a Manhatten copywriter.

Augusten had his first drink at age 12 when he drank a bottle of red wine. Between the ages of 13 to 17, he smoked marijuana and drank alcohol once a week. At age 18, he drank nightly, always to intoxication (five drinks or more). Between ages 19 to 20, he was drinking 10 drinks per night. He also used cocaine once every six months. At age 21 to 30, he was drinking a liter of Dewar’s a night and using cocaine once a month.

When the book opens, Augusten describes being unable to limit his drinking. “I would plan to drink only until 11 or 12, but it would never actually happen. The few times that I didn't drink for a night, or alcohol wouldn't have the desired effect of numbing, I'd be overwhelmed with emotions, usually grief, and it was just really upsetting. It freaked me out because I felt like a wreck inside, like my structure was rotting and alcohol was sort of the glue holding me together. In a lot of ways, I felt like it was the only thing allowing me to function. In fact, it was the opposite. I was able to function despite it.” Augusten drinks even though he actually has an allergy to alcohol, necessitating his taking several Benadryl tablets before imbibing.

Augusten’s apartment is filled with hundreds of empty Dewar’s bottles because he is embarrassed to be seen (or heard – the clanking bottles) disposing of them. Because of the bottles, he never invites anybody to his apartment. Augusten’s support network comprises his best friend Pighead, an investment banker dying of AIDS; his drinking buddy Jim, a coffin salesman; and Greer, his tightly-wound colleague. His mother had a stroke 10 years prior, which left her paralyzed on one side and wheelchair-bound. Augusten doesn’t visit, although e-mails daily. Although he feels pressure from her to take care of her, he believes, after her giving him away to be abused, she does not deserve more than this.

His alcoholism begins to interfere with his performance at work. He starts missing meetings, shows up late, and smells like alcohol. Eventually, his co-workers stage an intervention. His boss and his partner at work, Greer, propose that he go to rehab or risk getting fired. He agrees to go to a gay rehab clinic in Minnesota, the Proud Institute, for 30 days. There, he is given Librium while he is detoxing to prevent him from physical shock from the alcohol withdrawal.

After 30 days at Proud, Burroughs returns to New York and takes his recovery seriously, throwing himself into his work with renewed vigor, and attending Alcoholics Anonymous meetings and outpatient therapy. He is clean for awhile, but Pighead's illness and a relationship with a man Augusten meets at A.A. who is addicted to crack cocaine cause him to relapse. He not only drinks but now starts using crack cocaine and puts himself at risk by going to a “crack house” one night. Despite hallucinating spiders, he retains his employment, although it takes him two years to return to A.A., where he recovers once more.

Thursday, October 21, 2010

Critique of the DSM and Biomedical Perspective

Although Prozac lifted Lauren’s depressive and obsessive-compulsive symptoms, antidepressants generally are not as effective for everyone. Indeed, they may work better for anxiety than depression. About 68% of the improvement in depressive symptoms is from the placebo effect; additionally, only a third of people remit from depression with their first course of antidepressants, and half experience a 50% reduction in symptoms. In sum, although people respond to antidepressants, the effect of medication for depression is not spectacular. A recent meta-analysis showed that only for severe depression were antidepressants worth the risk-benefit ratio.

Finally, side effects are underreported to doctors. The main side effect with which Lauren struggled was lack of sexual desire/difficulty having orgasm, a common reaction to antidepressants. This seemed to become more of a problem when Lauren entered into a monogamous relationship; she and her then boyfriend tried all sorts of alternative remedies to try to correct the side effect, but nothing appeared to help with this issue.

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Acknowledgement: Warm thanks to Diane Hazzard, my student of summer 2008, for the majority of this analysis of PROZAC DIARY.

Wednesday, October 13, 2010

Treatment Plan

Treatment Plan

Lauren’s treatment plan is mainly biological and the book is about her experience of taking Prozac. From her account, it seems that she has regular contact with her prescribing psychiatrist.

Based on Lauren’s past suicide attempt(s) and suicidal ideation, the practitioner must assess her current risk for suicide and continue to monitor this throughout treatment. The practitioner can make sure to assess risk using a strengths-based approach by inquiring how Lauren has dealt with and got over her thoughts of self-harm in the past.

Although we know that Lauren has been hospitalized, it isn’t clear the treatments she received. Her “anxiety about eating” remains a concern (she claims that she had anorexia nervosa when she was younger). Further assessment of her eating patterns and extent of body disturbance is warranted.

Clearly, the writing of her memoir was a way that Lauren worked through her depression and her recovery. The fact that it was published and reached such a wide audience likely helped her experience meaning from the depression.

As part of her recovery from depression, which Lauren attributes to Prozac, she says that she was able to have friends when she returned to graduate school and she eventually met a romantic partner. However, at the outset of the book, it seems that a referral to a cognitive-behavioral group might have helped her cope better, teach her needed social skills, and address some possible cognitive distortions that may get in the way of her recovery (“I’ll lose my creativity if I’m depressed). One of her major risk factors for a compromised adjustment is her isolation and lack of social support and group treatment may provide her with some beginning support and skills that she can take into other relationships.