Mr. Dully, is that you?

I've posted about Mr. Howard Dully, who had a lobotomy at the age of twelve. He was recently interviewed on NPR.

What's this, in the comments to my post?

lonegunmen100 said...

Freeman, wait until my book comes out.... we are currently writing the outline

Howard Dully
howarddully@comcast.net

(Mr. Dully's lobotomy was performed by a Dr. Freeman.)

Is it really him? Did Mr. Dully visit my blog? He left a link to this blog. There, one finds photos of the NPR studio...

Mr. Dully, if that's really you, and you visited me here...I'm amazed, and humbled. Please, keep telling your story.

Psychiatrist as "Ice Queen."

Maria tries not to reinforce unhealthy behavior.

...the goal is to discharge patients who repeatedly engage in self-harm behaviors (stabbing or slashing themselves, etc.) as soon as possible because, unfortunately, some people reap great rewards from hospitalization (three meals; a bed; warm attention from other human beings; etc.) and thus may continue to physically hurt themselves so they will emotionally feel better. Ultimately, these people benefit greatly from consistent outpatient care where, in the non-crisis situation, they can learn how to obtain these emotional rewards without resorting to these dangerous (and potentially lethal) methods.

These outpatient providers thus ask us to not be warm to them so that, in comparison, the outpatient providers are more appealing and amiable than those cold-hearted, aloof, and seemingly unkind hospital psychiatrist bastards. (It is honestly difficult to act like a jerk, though, because we’ve been trained to exude warmth and that is what we usually do.)

So I put forth my best efforts in not being warm today and it worked. Which totally sucked for the patient and it wasn’t fun for me, either. Ultimately, perhaps, it was the best thing I could have done for the patient, but I just don’t enjoy being an Ice Queen...

Delusions.

CNN.com:

"SANTA FE, New Mexico (AP) -- A state judge has lifted a restraining order granted to a Santa Fe woman who accused talk-show host David Letterman of using coded words to show that he wanted to marry her and train her as his co-host...

Nestler's application for a restraining order was accompanied by a six-page typed letter in which she said Letterman used code words, gestures and 'eye expressions' to convey his desires for her.

She wrote that she began sending Letterman 'thoughts of love' after his show began in 1993, and that he responded in code words and gestures, asking her to come east.

Nestler said Letterman asked her to be his wife during a televised 'teaser' for his show by saying, 'Marry me, Oprah.' Her letter said Oprah was the first of many code names for her and that the coded vocabulary increased and changed with time."

Dr. Neubauer explains:

The quick definition of a delusion is a fixed false belief. It’s fixed because the person can’t be convinced otherwise, even though it’s obviously false to others...Delusions, while untrue, may be entirely plausible or they may be quite bizarre.

Some people have particular types of delusions, such as paranoid, persecutory, religious, or grandiose. People may believe that others control their thoughts and actions or that everyone around them can hear their thoughts.

Delusions, along with hallucinations and disorganized speech, are a psychotic symptom characteristic of schizophrenia and related psychiatric disorders. Usually, these symptoms are transient or are controlled with medications."

And from Schizophrenia.com:

Arguing with a delusion only leads to further mistrust or anger. The beliefs are tenaciously held, against all reason, & they are characteristically not shared beliefs. They are held only by the person himself & by no one else.

Families & friends must first realize that delusions are a result of illness & not stubbornness or stupidity. Although fixed delusions can be irritating, emotional reactions should be avoided, as should taunts or threats...

"So You Want to be a Doctor"

A rant from the 1970's:

We of the AMA are concerned over the current wild proliferation of doctors in America today. There are simply more than enough physicians to serve our society efficiently already, yet increasing numbers of students think they want to plan for a career in medicine...

A doctor cares for, maintains, and treats the human body. They cure diseases that have names they can barely pronounce. They tell people that they are going to die of cancer. They spend all of their time either in their too-small, suffocating office–where the brats scream at the sight of a tongue depressor–or, worse, in a hospital—where the halls are full of the dying and the dead, and everybody and his brother is throwing up. On you, yes, doctor, on you and your nice white slacks...

Someone has a bit of an anger problem, don't you agree? Mind you, this was years before anyone had heard of "managed care." The part about training is giving me some flashbacks:

Begin with four years in college: you must take biology courses (where you will most certainly dissect frogs, pigs, and Christ knows what else) and chemistry courses (where you will inhale things unknown in hell itself). Then if you are accepted, you will go to medical school. For four years. I say “if you are accepted’’ because you will not be accepted. Nobody is accepted, and those who experience rejection undergo permanent damage to their self-esteem...

Today, Dr. Sepsis would have a blog, I think. An angry blog.

"Did I Bury My Mother Alive?"

"No," says Dr. Zeus. But the bereaved is not reassured.

“This is Mr. X. I need to know something very important. Did you make sure my mother was dead?”
“Excuse me?”
“Her doctor told me she had a pacemaker, and that it would work for over ten years.”
“Yes, those batteries run a long time.”
“Well, if the pacemaker was working, that means she was still alive, so I buried her when she was still alive. Did you check that she was dead?”
I look at the phone. Take a deep breath. Always tell the truth.
“We don’t make a diagnosis of death here at the Coroner’s Office, sir. They’re pronounced somewhere else.”
“Do they ever wake up?”
Another look at the phone. I explained that people are examined before they arrive, and they are put on a cold metal tray in a freezer. If they were asleep, they’d wake up.
He wasn’t convinced...

They speak for an hour. But two days later, he calls back:

He’s still upset and can’t sleep. He still thinks his mother is buried alive. As it’s been three months since his mother’s funeral, she’s not alive anymore—even if she was buried alive, which she wasn’t...

This conversation takes another hour. Logic is not helpful; his fear is neither logical nor rational. Finally, I refer him to my boss. I take his number, and tell him the boss will call.

I go to the boss’s office to brief her. She looks at me like I’ve grown a third head.

“Does he think a pacemaker makes his mother immortal?”
“I made that point boss.”
“A pacemaker won’t work on a dead heart, William.”
“I told him that, too.”

Ultimately, the man is referred to a grief counselor.

Merry Christmas

(My, how that looks like Young Shrinkette, in the sled.) Merry Christmas, everyone. I hope you're all healthy and happy.

I'm on call today! Hope it's not too bad.

If you have time to browse, the Flickr Christmas tags should be fun...

Update: By "Young Shrinkette," I mean "Before I Turned 40." And to those who think I still look like that: please, stop snickering.

"Bittersweet season"

On the last office day before Christmas, Medpundit's patient is suicidal. Where are the psychiatrists? I'll tell you where I was yesterday: in my office, working. But I saw no one who was suicidal. I spent hours trying to contact patients with abnormal lab test results. It might have been better if Sydney and I had switched places...

Suicides don't actually peak in December, as Maria notes in the comments. MSM seems to be catching on to this fact, according to the Annenberg Public Policy Center. But suicidal patients are challenging for physicians in any season. More on this problem here.

"The Twelve Neuroses of Christmas"

Times Online, on the fears that grip us at Christmas. For Sarah Vine, it's illness:

There is an upside to neurosis in that the true neurotic also enjoys the gift of prophecy. Worry enough about any problem and you can make it happen, no matter how highly the odds seem stacked against it. The healthy individual thinks herself thin or rich, the hand-wringing worrymonger thinks herself into a 102-degree fever, accompanied by a vile chafing cough, on Christmas Day.

It’s amazing the power of negative thinking. You can do it too, merely by spending hours picturing yourself laid out in bed, martyr-like, while the rest of the family tucks merrily into the Christmas goose downstairs. You can achieve this goal despite logic or major obstacles such as spending the month leading up to the big day mainlining carrot juice...

(-cross-posted at Kevin, MD.)

Guest-blogging!

(...with five other medbloggers.)

"Infant discovered in barn, Child Protective Services launch probe"

Thoughts and Musings:

Bethlehem, Judea - Authorities were today alerted by a concerned citizen who noticed a family living in a barn. Upon arrival, Family Protective Service personnel, accompanied by police, took into protective care an infant child named Jesus, who had been wrapped in strips of cloth and placed in a feeding trough by his 14-year old mother, Mary of Nazareth.

During the confrontation, a man identified as Joseph, also of Nazareth, attempted to stop the social workers...

Also being held for questioning are three foreigners who allege to be wise men from an eastern country. The INS and Homeland Security officials are seeking information about these who may be in the country illegally. A source with the INS states that they had no passports, but were in possession of gold and other possibly illegal substances...The chemical substances in their possession will be tested.

Mighty Medpundit hosts Grand Rounds!

"Welcome to Grand Rounds, where medical bloggers from around the world meet once a week to share their rants, ramblings, and observations.

"This being the blogosphere, however, our ramblings and observations are not limited to doctors and nurses, but include patients and administrators, lawyers and health policy analysts, and, of course, information technology specialists. So welcome to our cocktail party, where people from all walks of life mingle and share their take on the medical world and life in general..."

The patient who Does. Not. Want. To See Me.

And yet...here she sits. She can hardly meet my gaze, or say "hello." How anguished she looks! She would rather be almost anywhere else. If only the floor would open up and swallow her, right now...

Perhaps her family led her to my office. Something happened at home, or at work, or at school...something that scared them. How did they get her here?

Did she come from home, or from a doctor's office? Did she come from a courtroom, or a jail? A nursing home, a homeless shelter, an alley?

Is this her first time in a psychiatrist's office...or her thirtieth? What can she possibly expect from me?

My first task is to slow down, and search for ways to help her tell her story. Sometimes it helps when I say,

"It must have taken a lot of courage, for you to see me here today."

"The Book of Jobless"

Ian Frazier, in the New Yorker:

Jobless sits, wretched, upon a curbstone. Everything he possessed has been taken from him. His accounts have been closed, house sold for taxes, warranties voided, policies cancelled, back wages garnisheed. His wife has left him for a vintner. His children have run away. He has become afflicted with piles, boils, and scours. Creditors give him no peace...

Then the Lord answered Jobless out of the whirlwind of hot-dog wrappers and plastic drink tops with straws still stuck through them, saying, “Who is this that darkens counsel with poorly researched statements? Suck up your insides into yourself like a man, and hear me, and answer what I will ask...

A Eugene tradition: the Santa Claus Pub Crawl

You are all invited to take part!

Q: WHAT IS THE EUGENE SANTA PUB CRAWL?

"Well it is a tradition whose origins are steeped in mystery, but suffice it to say that for the last (eight) years a bunch of fun-minded Eugene folks have dressed up in Santa gear (as well as elves & reindeer) and gone pub crawling en masse (In past years we've had over 60 Santas and we hope to reach 75-100 this year!!!) to some local watering holes and have a BLAST!. Along the way we give out candy and little gifts to unwitting passersby, sing slightly naughty Christmas Carols and help spread (and drink) some Holiday Cheer. Along with all the fun, we'll have Designated Drivers, Musicians, Santa Marching Songs..."

Invite your friends. Any and all Santas, Elves & Reindeer are welcome...

Why we live in Eugene, #2

from Robot Vegetable, at Far Cartouche (who commented on the last post).
And yes, let's not forget our abundant annual rainfall. A definite plus.

Why we live in Eugene

Three Sisters, originally uploaded by L. A. Price.

One reason, from L.A. Price.

In the Pipeline: Grand Rounds!

"On behalf of the greedy rapacious pharmaceutical industry, I'm glad to be hosting this week. Unfortunately for everyone, the research end of the G.R.P.I. is not immersed in the ceaseless flow of promotional swag that the medical community has come to know us for. So for you practitioners dropping by today, enjoy a rare chance to interact with the drug industry with no free samples, pens, calendars, or trips to Martinique. Never been there, myself. . . (gazing at ice-covered yard). . . OK! Where were we?"

Derek Lowe has done an outstanding job. Be sure to check it out!

Disclosure

Via Kevin, MD:

Dr. Lei believes that medical bloggers should be held to high standards. She has questions. Here are my answers:

1. Who runs this site?

I do! I'm a psychiatrist in Eugene, Oregon. I don't post my name, because I have concerns about confidentiality. I wish I had chosen a different name for this blog! (One commenter says it sounds like "an inept laundromat.") We must think of a better one...

2. Who pays for the site?

Blogspot blogs are free. I have no ads.

3. What is the purpose of the site?

There's no simple answer. It's commentary. It's an online diary. It's ego, it's an escape, it's a a game. It's a wish to connect with others. Why shouldn't doctors join the fun of blogging?

Truthfully, it's not that different from what I've always done. I've been writing since I was very young. I also took writing and journalism courses (before and during pre-med). I chased news stories. I wrote features, interviews, and puzzles for school papers. I wrote fake horoscopes that told readers where to park, what to wear, and to "circle B on all multiple-choice tests today." (One year, I gave the editor so many ramblings that he got fed up. He said, "Look, why don't you get your own magazine?")

4. Where does the information come from?

I look for specific stories: patients and doctors talking about their experiences, trying to communicate. Readers send "blog fodder." I link to mainstream media, to other blogs (see blogroll), and to anything that looks interesting.

5. What is the basis of the information?

It should be clear from the links. Or, it should be clear that it's my own voice. But no medical advice is given on this blog! (Except "talk to your doctor" and "take a CPR class.")

6. How is the information selected?

Ah, the creative process! If it's not in the headlines (or in another blog), then it's something that might have occurred to me at home or on the job.

7. How current is the information?

This should be clear from the links. Note: when I say, "I saw this at work today," you can be sure that it was, actually, a totally different day. (Confidentiality!)

8. How does the site choose links to other sites?

See above. I also have a mental representation of what is "appropriate." This involves some combination of: (a) Can colleagues and superiors read this? (b) Will a patient read this and say, "hey, that's me?" and (c) Can mom read this?

9. What information about you does the site collect, and why?

Sitemeter tells us a little about who's visiting and what they're reading. But we can't really identify anyone. (I am fairly sure, however, that the hits from the Chinese coast are from my husband.)

10. How does the site manage interactions with visitors?

Comments are welcome! I haven't had to delete a comment in a long, long time. If a comment doesn't meet criteria a, b, and c (above), out it goes.

There you have it. Any more questions?

(Sigh.) Why didn't I think of this?

"Beer For Dogs."

-via Eugene Rant.

"I don't think racism is a mental illness, and that's because 100 percent of people are racist,"

...said Dr. Paul Fink, in WAPO ("Psychiatry Ponders Whether Extreme Bias Can Be an Illness").

"If you have a diagnostic category that fits 100 percent of people, it's not a diagnostic category."

We already have diagnostic categories for delusions, obsessions, anxiety, phobias, and depression. Do we need a separate category for "pathological bias?" Would it change our approach to these patients? Would their treatment be any different? Should we be doing research to find out? Personally, I don't buy this, but is that just my prejudice?

What do you think?

Medical errors: why apologies are important

"Once in the hospital, I was given another patient's medications by accident. I was angry when I found out. I didn't suffer any serious problems because of it, but I wanted to know if the person even cared that this had happened. I will tell you that when the nurse came into my room soley to apologize to me, my anger was gone. I just needed to know that the person was sorry and that they recognized the magnitude of it. I told the nurse how much I appreciated that he told me the truth and that I thought it took a lot of guts to do that. If I had never received an apology I still would not have sued, but I might have reported it. I needed to know someone took that seriously. Mistakes happen, doctors make mistakes, nurses make mistakes, and patients make mistakes. But showing sincere regret when a mistake occurs is so important."

-from the comments to this post.

"So I went in one day and said, 'Can I have therapy?' and he said, 'Sure, sit down.'"

Jack Black talks about his treatment.

"...by about 15 I was in full meltdown. I was really searching for a father figure and I hooked up with a really bad crowd. My parents realised I was in trouble, so they pulled me out of high school and put me in this school where there were, like, 20 pupils and a therapist."

Your parents? Didn't you just say that you were searching for a father figure? Wasn't your dad around back then?

For the first and only time in the course of our conversation, Black - who could ramble on about most subjects until you stopped him - is lost for words. This is exactly how he replies: "There is dad. I don't know why he wasn't, er ... Yeah. I don't know why he wasn't, er ... but he was there. Er, my dad was a good dad but he, um, I'm just sort of ... For some reason I wished that I had a Harley-Davidson-riding heavy-metal dad, and that's what I went to find."

Did you try the therapy on offer to you at this point? "Some of the more intense kids were going in every day and I was, like, what happens in there? So I went in one day and said, 'Can I have therapy?' and he said, 'Sure, sit down.' "

Black recounts the experience as if looking back on a day at the spa: "I don't remember exactly how it went down, but I started confessing - 'cos as a Jew you don't have confessional, so I had years of guilt - and I told him about how I stole money from my mom to get coke, and I just cried and cried and cried my eyes out. Came out a different guy one hour later. Soooooo good."

And is he still the guy who came out, cleansed and purged, from that room? "I don't know," he admits. "I like to think that I'm not at odds with myself but I know that I still hide things..."

-in the Independent.

"We are quick to provide solutions but not keen to listen to their voices."

Today is International Human Rights Day. This year, WHO focuses on the rights of the mentally ill. From WHO's website: A psychiatrist's view.

"'Across countries and cultures, I am amazed by the resilience of people who have mental disorders. [They are] Living with illnesses that are difficult to understand and which affect the very core of our sense of self; battling on a daily basis to live ordinary lives like you and me; trying to live a normal life in a society that will not try to understand their reality and views them with fear and suspicion.'

'I am saddened when I hear and see how mental health services fail to understand the simple desire to work and live a normal life in the community with friends and family. It is highly disappointing to see many mental health services do not perceive their primary role as facilitating the fulfillment of this desire.'

'We (the professionals) frequently fail to understand their need to be in control of their lives and their bodies, just like any of us would want to. We are quick to prescribe solutions but not keen to listen to their voices. We frequently refuse to acknowledge their identity – I hate it when people say so and so is a schizophrenic – as if the illness is their identity.'

'You might wonder why I continue to remain in this profession. Because I also have some memories that I cherish a lot. Seeing the smile and the excitement on the face of a person standing in the checkout queue at the supermarket. For the first time. Someone who had spent the greater part of their adult life in a mental asylum but was now living in their own home. I am proud to have been part of a mental health service that made this smile possible.'

'Mental illness affects people like you and me. Its time we realized this is about us, not about them.'

-- Soumitra Pathare, Psychiatrist, Pune, India. Via WHO, via Liz Ditz, via Pax Nortona.

"I heard her say, 'he's bipolar, he doesn't have his medicine.'"

CNN:

Witnesses aboard an American Airlines jetliner say that Rigoberto Alpizar's wife pursued him, saying he was mentally ill, just before federal marshals shot and killed him. Air marshals said Alpizar had announced he was carrying a bomb.

Later, no explosives were found. The incident remains under investigation.

"She was chasing after him," said fellow passenger Alan Tirpak. "She was just saying her husband was sick, her husband was sick." When the woman returned, "she just kept saying the same thing over and over, and that's when we heard the shots."

"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering..."

-Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6.

The new Medscape student blog is really good.

Thanks to Kevin, MD, for pointing us to "The Differential." It's about life in med school. Five students are posting. Here's Kristen Heinen, blogging about her Peds rotation:

You Know You're on Peds Rotation When ...
-- Your stethoscope covers 3/4 of your patient’s chest.

The resident on call with you has a flashing stethoscope.

You decide that your name badge is boring, so at the solemn advice of one of your patients, you decorate it with a little glittery nail polish....

And Ali Tabatabaey blogs from his Psychiatry rotation (in Iran!). When he meets his first patient, he focuses on her medical complaints, and finds few psych symptoms. Later, he presents the case to the staff doctor. It's a genuine "teaching moment":

Remember the man she saw on the street? It turns out he did not have any legs and was floating in the air. Yet, she insisted he was real.

I was lost for words. I had spent the last hour talking to her and had missed the main points altogether. I was so obsessed with her leg pain that I left everything else unnoticed. I was beginning to feel depressed myself. I have to admit, examining the mind is a very complicated challenge...

The new blog has a personal, non-corporate tone (which tells me that Medscape "gets it"). Thanks, Medscape! I'll be following this one...

Grand Rounds at Dr. Charles!

Dr. Charles survives the Great Blogspot Outage of 2005 (last night) to bring us this week's Grand Rounds. Go there at once!

"Mitzvahpalooza"

"For his daughter's coming-of-age celebration last weekend, multimillionaire Long Island defense contractor David H. Brooks booked two floors of the Rainbow Room, hauled in concert-ready equipment, built a stage, installed special carpeting, outfitted the space with Jumbotrons and arranged command performances by everyone from 50 Cent to Tom Petty to Aerosmith.

"...The party cost an estimated $10 million, including the price of corporate jets to ferry the performers to and from. Also on the bill were The Eagles' Don Henley and Joe Walsh performing with Fleetwood Mac's Stevie Nicks; DJ AM (Nicole Richie's fiance); rap diva Ciara and, sadly perhaps (except that he received an estimated $250,000 for the job), Kenny G blowing on his soprano sax as more than 300 guests strolled and chatted into their pre-dinner cocktails.

"Hey, that guy looks like Kenny G," a disbelieving grownup was overheard remarking - though the 150 kids in attendance seemed more impressed by their $1,000 gift bags, complete with digital cameras and the latest video iPod...

"I'm told that Petty's performance - on acoustic guitar - was fabulous, as was the 45-minute set by Perry and Tyler, who was virtuosic on drums when they took the stage at 2:45 a.m. Sunday.

"Henley, I hear, was grumpy at the realization that he'd agreed to play a kids' party..."

-New York Daily News.

TV news anchors joke about face transplants.

A neurologist blogs:

Yesterday, I watched pieces of what one would have to characterize as a 'humorous, human-interest story' which, of all things, was related to the partial facial transplant that happened in France.

It started out with allusions to the movie Face Off and then the movie in which Hannibal Lector wears the face of a man after cutting it off his head (cut to video clip of this). All this delivered by the perpetually beautiful anchorpersons, female and male, with wisecracks. Then we go to interviewing people on the street, with the question being, 'Would you donate your face to someone?' At the end, Mr. Cute anchor jokes about maybe having a different face for every day of the week(?).

I'm sorry, I just find this sickening. Maybe they should in their off-work hours visit some people who have had their faces torn to shreds by a dog or in an accident, or had very extensive surgery for cancer of the face. What's it like to go through life without a face? That is what facial reconstruction is about...

"Interpreting a patient's wishes is as much art as science."

At 70, Susan Sontag was diagnosed with myelodysplastic syndrome. She had fought cancer twice before, aggressively, with "positive denial." Would she go after MDS with guns blazing? How would she - and her doctors - decide? Her son writes in NYT:

Dr. Stephen Nimer, my mother's principal doctor, heads the division of hematologic oncology at Memorial Sloan-Kettering and is also one of America's foremost researchers in the fundamental biology of leukemia. As he explained it to me: "The fact is that people are never as educated as the doctor. You have to figure out something about the patient" - by which he meant something that takes both patient and physician beyond the profound, frustrating and often infantilizing asymmetry between the patient's ability to comprehend the choices to be made and the doctor's.

...the ethical challenge, vital for a doctor to recognize and impossible (and ethically undesirable) to deal with formulaically, comes not with the 30 percent of patients Nimer estimates know for certain whether they want aggressive treatment or not, but with the "undecided" 70 percent in the middle. As Nimer told me somewhat ruefully, the doctor's power to influence these patients, one way or the other, is virtually complete. "There are ways to say things," he said. "'This is your only hope.' Or you could say, 'Some doctors will say it's your only hope, but it has a 20 times better chance of harming you than helping you.' So I'm pretty confident I can persuade people." Groopman, in his clinical practice with patients like my mother, patients for whom, statistically, the prognosis is terrible, at times begins by saying, "There is a very small chance, but it comes with tremendous cost..."

Head Nurse's Very Bad Day

One of the worst:

"Something must've blown in on the wind night before last, because when I woke up yesterday, every cell in my body was poisonous to every other cell. It felt like a hangover without the alcohol.

Add one patient who seemed determined to seize, code, and die. Before 8 am...

It's all downhill from there, and ends with a crushing indignity...for Head Nurse. But a few days later, she's in fine form. I admire her resilience!

A Blog-Fu Master

Scott Adams has set forth rules for debate on the Internet. Lotharbot adds his own, in a comment at Chicagoboyz:

1) Find someone else who has the same label as the person you're arguing with. Find a ridiculous opinion of theirs. Argue about that...

2) Answer each half-sentence separately, especially sentences using the word "but". Don't bother trying to fit the context; just find a way to interpret the half-sentence that's false and argue against it. Bonus points if you can get away with grouping half-sentences talking about totally different things together.

3) Bring up the opinion of a Known Idiot. When your opponent says that person is an idiot, ask why they've "suddenly" decided to distance themselves from the person...

My favorite:

6) Tell your opponent (who is clearly quite happy) that you're sorry they got upset, and that you'll stop arguing because you don't want to anger them any more. If they respond by saying they're not angry, tell them you're glad they calmed down, but you still don't want them to get angry. Keep doing this until they flame you, and leave their angry response as the last word.

Who dares to tangle with Lotharbot?