Tuesday, January 31, 2006

Why we sing in the shower

Today's "Ask Yahoo!": What is it about the shower that makes people want to sing?
...As we learned from the San Francisco Exploratorium, the sound of a person's voice actually improves in the small, confined space of the shower. When you sing in an open area, you "basically only hear your voice as it is produced." However, in the shower, the sound waves reflect off the walls, producing a much richer sound, improved bass, and more volume. Goodbye, William Hung. Hello, Bette Midler.

Some theories are less scientific...
(In case you were wondering. And here's "how magicians 'saw' people in half.")

"Holding Hands"

NYT: Holding Loved One's Hand Can Calm Jittery Neurons.

Michael McFee:
After weeks of yearning
half-taps and near-grasps,
my sweaty palm found hers
and we made a leaky basket
of our interlaced fingers
and that was it, hallelujah,
finally we were holding hands
in public, we were shaking
sideways on a visual contract
everybody could understand,
I was hers and she was mine,
the two of us had begun
becoming one clasped flesh,
now we were happily coupled
from the supple wrists down,
we were carrying the pet
with two backs between us
as if we'd never before
squeezed another human
in such a meaningful way,
as if she had never seized
her tall anxious mother
when first learning to walk
or cross the lethal street,
that firm grip saving her,
as if I would never clutch
a dying father's calluses
in cardiac intensive care
and feel our shared pulse,
the mutual prayer of blood,
as if she and I would never
tire of each other's touch
and try to figure out how
to escape this embarrassing
collision of crinkled skin,
this padded cage of bones,
these too-long-opened fists
before somebody passing by
mistook for love our resigned
inability to quite let go.

Monday, January 30, 2006

Grand Rounds: the "Down Under" edition

...at Barbados Butterfly. Lots of great posts this week...and new medbloggers, as always. (How can we possibly keep up with all of them?)

Sunday, January 29, 2006

"A taxonomy of people."

NYT: A new diagnostic manual, written by psychoanalysts.
Unlike most psychiatrists, psychoanalysts focus their efforts on understanding the meaning and the psychological roots of mental suffering, rather than on diagnosing mental disorders and treating them with drugs or less intensive methods of talk therapy.

The new guidebook, unveiled Saturday at the annual meeting of the American Psychoanalytic Association, is modeled on the standard diagnostic manual in its format and its title, the Psychodynamic Diagnostic Manual. But it emphasizes the importance of individual personality patterns, like masochistic, dependent or depressive types, which are found in many people but which qualify as full-blown disorders only at the extremes...

"We wanted to say to therapists: find out and discover the nature of the internal experience before you pigeonhole a person based on symptoms only," Dr. Greenspan said.

...The new guidebook, some experts said, is partly intended to reassert the value of psychoanalytic thinking before it is lost for good. "Psychoanalysts have recognized that they are getting more and more outside the mainstream," said Dr. Drew Westen, a professor of psychiatry and psychology at Emory University in Atlanta. "And this project is an attempt to say, Wait, there is something that this tradition really has to offer."
"Whether the world's psychotherapists, or the public, will find the new manual helpful remains to be seen. But few experts doubt that there is an appetite for a guidebook that adds to the D.S.M..

"'Honestly,' Dr. McWilliams said, 'most of the people who come in for therapy do so for a kind of sickness of the soul, or for some interpersonal disaster. It's very artificial to chop them up into these
(DSM) symptom syndromes.'"

At the Medscape discussion board, psychiatrists are debating: is there a place for analysis in the treatment of mental disorders? One says,"We are all like the Sufi story of the 7 blind professors and the elephant. We do know there is an elephant, but the whole is so much more than the sum of the parts. Many years ago a psychologist friend of mine said: We shall stumble in the dark into progress..."

Friday, January 27, 2006

Can bedside manners be taught?

Dr. Abigail Zuger, in JS Online, via the OB-Gyne doc at Red State Moron: "A course helps cancer doctors discuss devastating news." (Registration required, sorry.)
Aspen, Colo. - In one room, a woman sobs into her hands after learning that her breast cancer has spread to her liver. Next door, a young man cured of lymphoma two years ago listens impassively to the news that his disease is back. Down the hall, a grizzled, middle-aged hardware store owner hears that despite radiation treatment his prostate cancer is now in his bones.

"You sure of that?" he asks incredulously to the young doctor breaking the news. "You sure those were my films?"

It could be any hospital's outpatient clinic. Instead, it is a small experiment in teaching cancer doctors to do the hardest part of their job: not doling out radiation and chemotherapy but caring for the patients who do not improve with these treatments. The patients in this case are actors, but the doctors are all real: young oncologists who converged at this off-season ski resort for a five-day course in how to talk to patients about the worst possible news...

"The general feeling has been that these are not teachable skills - that either you have it or you don't," said Anthony Back, an oncologist at the Fred Hutchinson Cancer Research Center in Seattle.

Not only do most doctors not have it, Back said, but those who do generally hone their skills by trial and error, saying all the wrong things until they find the right ones, leaving a trail of tangled miscommunications and alienated patients.

Five years ago, Back and four colleagues obtained a $1.4 million grant from the National Cancer Institute to devise a better way.

What they have created is a short immersion course in the language of bad news, one which, like all good language courses, leaves the lecture hall far behind. Instead, students spend their time with native speakers - in this case, four preceptors, or teachers, who are experts in medical communication and five actors who stay in the roles of patients with terminal illness for the duration of the course, each growing sicker as the days go on...

Does this kind of training work?

The actors, all members of the local Aspen acting community, have now watched eight batches of doctors progress through the course and are enthusiastic. "Sometimes the doctors who show up are so bad you say, 'Oh God, this is hopeless,' " Walla said. "Then you watch them actually improve..."
(Someone copied the article here.)

Don't try this with me.

"25 Fun things to do at the Psychiatrists:"
Ask to borrow his comb then comb your tongue.
Take random objects in his office and glue them to the floor.
Refuse to co-operate unless he trades his trousers.
Bring pots and pans. Bang them together when he asks a question you don't like.
After everything he says, say, 'And how does that make you feel?'
Point at random things and say, 'Where did you get that?'
Complain that his chair looks more comfortable...

Never stop smiling.
Scream every word.
Repeatedly tell him to look at the ceiling. When he finally does, repeatedly tell him to look at the chair. When he finally does, repeatedly tell him to look at the desk.
From "Caught At Work." (Someone was searching for this list...and somehow, Google sent them to my blog!)

"Frey's other addiction"

Maureen Ryan blogs at the Chicago Tribune:
By now, we all know that James Frey has been treated for drug and alcohol addictions.

That’s seems to be the one aspect of his “memoir,” “A Million Little Pieces,” that has not been disputed.

But what’s Frey going to do about his addiction to lying?

..."I still think it’s a memoir,” he whined at one point (and let’s face it, this big guy with the tough guy/hard case reputation came off on Thursday’s “Oprah” like Eddie Haskell put on the spot by the Beaver’s mom).

Really? It’s still a memoir? Well, that would require defining “memoir” as “thing I made up to make boatloads of cash.” If that’s the definition of the genre, I’m going to have to take a break from blogging to pen my memoirs about the career I had as a cross-dressing pirate before becoming the queen of Romania...

Frankly, Frey didn't give the impression of a man hooked on Step 4 of the Twelve Steps of Alcoholics Anonymous, which directs those who wish to conquer their addictions to make "a searching and fearless moral inventory" of themselves.

Thursday, January 26, 2006

"Experience changes the brain..."

From the Psych Pundit blog: The Mind-Body Problem.
...if I had to nominate the one myth that's the most widespread and damaging in its influence, I think I might pick the "myth of mind-body dualism".

This is the idea that the mind and the body (brain) are completely different entities, made of completely different 'stuff'. It's an idea with an impressive pedigree (luminaries like Plato and Descartes), but that's not why most people believe it...

Anthropologists tell us that remote people groups all over the world are mind-body dualists. They've yet to encounter a clan, band, or tribe that's not. Likewise, researchers have found that children are natural born dualists - making claims about non-physical minds as early as age 4-5.

But science, of course, is about discovering things that aren't obvious...

We know from neuroscience that the mind is what the brain does. In fact, the mind and the brain are flip sides of the same underlying reality.

This means anything that changes your brain also changes your mind. But perhaps more importantly - it means anything that changes your mind also changes your brain.

If, as a psychologist, I can help change a patient's thoughts, I've also (by definition) helped change his brain. Changing behavior changes the brain. Changing feelings changes the brain.

In a nutshell: experience changes the brain...
Much more at the link. Must add Psych Pundit to my blogroll!

Monday, January 23, 2006

Blogging creates communities

...but what kind of communities? It's no secret that medical bloggers are still figuring this out. Have I thought about this enough?

Scroll down and observe: while I am posting about suicidal cartoon characters and women who eat crayons, some commenters are sharing intensely personal stories of suffering.

These stories are so valuable! They need to be heard. But I have to remind myself that I'm not Dr. Freud Online, and that there can be no therapy on this blog. I do hope that anyone who needs to talk to their doctor, is doing so.

Amazing Grand Rounds at Kevin, MD

...with more than sixty entries! He's done a spectacular job. Don't miss it!

Shooting diagnostic fish in the psychiatric barrel: part two

More thoughts on this article. (Part one is here.) Dr. Savodnik writes:
"All medicine rests on the premise that disease is a manifestation of diseased tissue. Hepatitis comes down to an inflamed liver, while lung tissue infiltrated with pneumococcus causes pneumonia. Every medical student learns this principle. Where, though, is the diseased tissue in psychopathological conditions?

Unlike the rest of medicine, psychiatry diagnoses behavior that society doesn't like. Yesterday it was homosexuality. Tomorrow it will be homophobia. Someone who declares himself the messiah, who insists that fluorescent lights talk to him or declares that she's the Virgin Mary, is an example of such behavior. Such people are deemed — labeled, really — sick by psychiatrists, and often they are taken off to hospitals against their will. The "diagnosis" of such "pathological behavior" is based on social, political or aesthetic values.

This is confusing. Behavior cannot be pathological (or healthy, for that matter). It can simply comport with, or not comport with, our nonmedical expectations of how people should behave. Analogously, brains that produce weird or obnoxious behaviors are not diseased.
He's not just shooting the fish. He's attacking the barrel.

I’m no philosopher. I can’t offer a discourse on the meaning of illness or disease. But I wonder: why dismiss the mounting evidence (hormonal, neurochemical, and genetic) that's converging on a physiologic mechanism for so many mental disorders? (See here and here...and my current favorite bit of thought along these lines: here.) The work is far from done. (Will it ever be done?) But why dismiss what we've already discovered?

Here’s Dr. Peter Kramer (of Listening to Prozac fame):
Some of the brain research that we have seen in the past seven or eight years has really made it clear that depression is a disease--there are neuroanatomical changes that are associated with depression, either causing it or being caused by it. But we don't have the kind of consistent marker that allows us to say in the way we can say with polio, ‘You have the symptoms of the disease, but you don't have the disease,' because we don't have the biological marker...
For some, the argument ends there. No biological marker? Then no disease called "depression." Yet so many lines of research have offered up clues. We seem so close...

So, Dr. Maurice, since you asked: here (finally) is my response. Yes, I think that we psychiatrists tend to over-pathologize. Yes, psychiatry must take responsibility for this behavior, and be vigilant about exposing and preventing it. No, I don't think that mental illness is a myth. I don't think personal responsibility is a myth, either. One of our most important jobs is to help patients take responsibility for their behavior. (And one of our thorniest issues is: when does illness impair a person's capacity to take responsibility?)

Yes, I think that research actually tells us something about the pathological basis of certain behaviors (unless the research was done by this guy.) As I've said before: the debate most certainly does not end here.

(APA President Dr. Steven Sharfstein answers Dr. Savodnik here. I wonder how he would answer Dr. Andreasen...)

Shooting diagnostic fish in the psychiatric barrel: part one

Does psychiatry pathologize normal behavior, inventing diseases with the reckless abandon of Dr. Unheimlich? Is the DSM an atlas of cultural bias, without a shred of tissue-based evidence to support it? Yes, says Dr. Irwin Savodnik, in this provocative, satirical LA Times editorial. He blasts the APA and its diagnostic manual:
...in 1994, the manual exploded to 886 pages and 365 conditions, representing a 340% increase in the number of diseases over 42 years.

Nowhere in the rest of medicine has such a proliferation of categories occurred. The reason for this difference between psychiatry and other medical specialties has more to do with ideology than with science...Where, though, is the diseased tissue in psychopathological conditions?

Unlike the rest of medicine, psychiatry diagnoses behavior that society doesn't like...
One of my supervisors was fond of such arguments. He would whip out his pocket DSM during rounds, recite criteria for cyclothymia or dysthymia, and ask, "How is this a disease?" It's easy to shoot diagnostic fish in the psychiatric barrel - in fact, one can make a career of it. It's not hard to see why.

Many psychiatrists agree that things have gotten out of hand. Here's Dr. Andreasen, an early author of DSM, in the New Scientist. She explains how DSM was conceived, and how it expanded. She's very critical of DSM now:
DSM is based on careful observation but it is just not complete - it was never meant to be the absolute truth. That's what people miss. We put in enormous caveats: use this book as part of a total clinical evaluation, use with great care, for use only by qualified doctors, and so on. But it represented a huge shift. It introduced diagnostic criteria. We wanted to make a statement about the importance of making psychiatry more objective.

One example is the description of schizophrenia: in DSM II, it is about five sentences. In DSM III, there are four or five pages of description followed by diagnostic criteria. We also managed to take out neurosis, which was important because we thought it was especially vague - and we put in a new approach to classification so we could incorporate medical and psychosocial elements of a clinical evaluation when it came to reaching a diagnosis.
Before the ink was dry on the first DSM, problems were apparent. Because the DSM-described behaviors have a social component and occur in a social context, they reflect biases in our culture. DSM has always been a work in progress (and it always will be). We must use extreme care when we use the term "pathological." Here's more from New Scientist:
In psychiatry, the cost of erroneous scientific theories can be incalculable. Get things wrong (or even only half right) and once adopted by the profession it can take years to weed them out. The result can be millions of shattered lives...

Some of the world's leading psychiatrists believe that this is just what has happened in their craft today...

Now into its fourth edition, DSM was meant to help doctors diagnose mental illnesses by categorising diseases according to a small number of telltale signs. What has happened, say Nancy Andreasen and many other psychiatrists who have helped to write DSM, is that it has become the main reference for diagnosis, something it was never intended to be. Now psychiatrists everywhere are reluctant to diagnose an illness unless its symptoms can be found in DSM...As the revisions to DSM multiplied, so did the criticisms: the manual's diagnostic categories were called prescriptive, arbitrary and driven by literal-mindedness. They did not reflect all opinions in psychiatry, said the critics, nor even a complete set of all psychiatric disorders worldwide.
This is serious criticism, and points toward some possible solutions. Clearly, we have tremendous work ahead of us.

But Dr. Savodnik seems to say: let's toss out the whole enterprise. Why does he send up Seasonal Affective Disorder? He doesn't cite any research or diagnostic criteria that trouble him. Satirized and oversimplified, his take on the disorder makes nice holiday copy, and illustrates his chief complaint: that APA is "selling mental illness," when there isn't any such thing.

...which brings me to part two. Next!

Sunday, January 22, 2006

Angry octopi, laughing rats: animal personality studies

"Does one duck behave consistently differently from another duck, over time and across situations? If so, why doesn't that meet the definition of personality as we apply it to ourselves, regardless of the presence or absence of self-awareness?" In NYT Magazine this morning: "The Animal Self." Favorite quote:
"Of course, we still have to be suspicious. People will also rate the personality of a loaf of bread or a car. A colleague has poked fun at me about that: 'A temperamental car is difficult to start across time and situations. So why isn't that personality?' Well, the fundamental difference, of course, is that with an animal there is an underlying physiology and biology. Saying my car is temperamental is an analogy. And some people will rate dogs not only as friendly or fearful but as philosophical. Now, I do not believe dogs are philosophical, whereas I do believe in their fearfulness. So we have to be careful where to draw the line between what's reality and what's analogy."

Saturday, January 21, 2006

No more "sick-note culture?"

Telegraph: NHS doctors told to clamp down on sick notes.
Doctors are to be told to help to end Britain's "sick note culture" in a crackdown on incapacity benefit to be unveiled this week.

A long-awaited green paper will pave the way for employment advisers to be stationed inside general practitioners' surgeries and for doctors to take part in "educational programmes" designed to help claimants to get back to work.

Under the slogan "work is good for you", John Hutton, the Work and Pensions Secretary, will say that the Government will offer more support to people looking to re-enter the job market, but that this must be matched by "increased obligations" for claimants.

People on incapacity benefit will be summoned to interviews to see if they are genuine cases and risk losing part of their benefit if they refuse to take part in back-to-work programmes...Mr Hutton is determined that GPs play their part, and wants a "culture change" from the current system which sees some doctors all too willing to sign patients off for long periods.

A source close to him said: "We want GPs to be part of the gateway back to work."
Update: The excellent NHS Blog Doctor has more.

Lady McCartney wants to buy 100,000 dogs

...to save them from the fur trade. An interview in the Observer. She talks about her cause, and her troubled past. And what's this? She told Sir Paul:
'I would not get married to him if he was taking drugs. I hate it. I counselled people on drugs. Fifty per cent of people can smoke joints their entire life and be fine. But the other 50 per cent, if there is a history of depression in their family or in their genes, then they can not smoke marijuana. If I had it I'm sure I would go wacky because we obviously have this history of mental instability in the family. And I could not have him lying to our child about not taking drugs and then going out for a sneaky puff.'

Did he find it hard to give up?

'He says he had a good incentive.'
I'm not sure about her statistics. But she seems very sure of them.

(Oregon has legalized "medical marijuana." Some users have complained to me about memory problems. It's one cause of memory loss that we can actually do something about. More on MJ here.)


The Cheerful Oncologist, on the woman who received a face transplant after being mauled by a dog. She's smoking!
...it seems to me that a patient receiving a face transplant who willingly endangers her skin graft is like a lottery winner who, flush with cash, can finally begin to make arrangements to receive all that money Dr. Olu Oboba, the Nigerian Minister of Natural Resources has been begging to send him.

Okay all the time

Dr. Maria observes:
"I don’t know when or how it happens—or, more bluntly, right now I don’t want to think about when or how it happens—but somewhere along the timeline, we learned that we’re supposed to be okay all the time. I don’t even know what that means, but I know I play along with that game. And this is how we’ve all gotten so good at looking so much better than we feel. This goes across all the disciplines. I don’t think we deny our emotions, but we cannot always experience them the moment they arise due to other pressing concerns that involve the patient."
In the comments, Sera says:
It’s not just physicians that are required to be “ok” all the time...Our society requires that everyone be “ok." This is one reason for the stigma mental illness carries...

"Leaving the 'safe' world of disability"

Andy Ward, on his recovery from lymphoma. Why was it so hard to leave the wheelchair behind? Times Online:
For the first two years after diagnosis and radiotherapy treatment, my survival instincts kicked in. I spent the first 12 months in a wheelchair, the next with walking-sticks. This may sound like the most difficult part, but in fact, the last three years learning how to re-enter the world have, at times, been the hardest.

After recovering, understandably, I began to grieve for the life I might have had without illness and injury. But I also grieved for some parts of my wheelchair experience: being looked after; special times with friends and family...I lived in a restricted world, but it was slowly becoming familiar and safe. When my world opened out again (I) faced scary choices...

"Grieving the loss of a normal life"

Indie Cooper-Guzman, RN, blogs at WebMD:
Several years ago while working in long term care, I suffered a lifting accident that changed my life forever...I remember what it was like when I realized my life would never be "normal" again. I would never do bedside nursing again. The doctor told me it would be too much of a risk to do any lifting, pushing or pulling over 10 lbs or remain on my legs for extensive periods of time. I was devastated. I had spent so much time and commitment learning and becoming a good nurse and now it was all over...
She learned to cope and adapt. How? She tells us, here.

What Dr. Helen hears

...when her doctor speaks.
I have to admit--I am afraid to go to the doctor. I have always hated hospitals--they seemed so depressing and scary--which is why I have a PhD and not an MD...I can usually interpret with fair accuracy what my own clients are trying to tell me but my translation of what a doctor is saying about my medical condition is so far off the mark, I sometimes wonder if a diagnosis of 'medical psychosis' should be added to my chart. My translation goes something like this:

Doctor: Hi, I'm Dr. so and so, nice to meet you.

My Translation: I'm here to give you your last rites.

Doctor: Your potassium is a little low.

My Translation: You're lucky your heart is beating at all.

Doctor: Your heart is beating a little fast, are you nervous?

My Translation: Your heart is pounding out of your skin, you'll be lucky to make it out of this office without a major heart attack..."
It sounds like the doctor did notice her anxiety. How to calm an anxious patient? Often we'd like to be reassuring, but we have to be careful. My (brand new) risk management newsletter says:
It is a common and appropriate practice of medical providers to address the worries of patients regarding their symptoms with words of reassurance....But beware, sometimes "reassurance" can backfire on us when an unexpected diagnosis turns out to actually be involved. There are going to be times when we miss a fracture or inflamed appendix or MI or brain tumor because it did not have a typical presentation. What is the best way to include reassurance in your conversation with the patient and in your documentation without setting yourself up for later criticism of missing a diagnosis?
· Be sure to include in your conversation and documentation of the reassurance that
o you have considered the more serious possible diagnoses but,
o at this time,
o with this presentation of signs and symptoms,
o you think the more serious diagnoses are unlikely, and,
o advise the patient that if the symptoms worsen or change he/she should come back in.
· Include important warning signs in the follow-up instructions to the patient.
· Do not diminish the patient's concerns. Do not say, "I am not impressed" with the patient's symptoms. This tends to be misunderstood by laypersons and can erode the relationship.
· For example, "I can see that you are concerned about this severe headache and what might be causing it. We have done the standard imaging test and there is no abnormality found. It is very rare that a headache is caused by something so serious as a brain tumor and in your case this is very unlikely. I would like to work with you to find ways you can cope better with these headaches. And, it is important that you let me know if anything changes such as worsening pain, etc..."

Tuesday, January 17, 2006

Supreme Court upholds Oregon's assisted suicide law


Flashback: Spring, 1990. "The Hemlock Society called," says Mike. Their local chapter wants someone to tell them about "depression and suicide." I'm finishing my fellowship at Large Urban Medical Center. My program director told them to call me. Might I give them a brief talk?

"Of course," I tell them. I'm young and terribly naive. I bring my slides and handouts to their meeting.

They greet me warmly. It's a genteel group. They're all over sixty. I start my spiel: symptoms, statistics, treatments. There are conditions that cause such suffering, such hopelessness, that patients want to kill themselves. But often they improve when they're treated. Then patients say that they're glad they're still alive.

The group listens closely. (But "Please speak up, dear, we don't hear well.") Half of them have walkers. Some have oxygen. One in the back...looks awfully thin. Another is pale. Question time; any questions?

"Doctor, don't you think, if someone is terminal...and suffering intolerably...shouldn't they have the right to end it all, if they choose?"

Well, I say. Let me explain, I say. (Is it getting awfully warm in here?) Often that hopelessness is due to depression and pain. We can treat depression, we can treat pain...

They are patient, they are polite. They press me gently...then, firmly. They won't let go. "Suppose there is no hope. The suffering is not endurable. Even if you are trying to help us, it's just not endurable. Then shouldn't we have the right...and the means?"

Now they start to talk about themselves. One says she has advanced cancer. So do I, says another. Strokes, MS, pain...terrible pain...They peer at me across a chasm of illness and suffering.

An elderly man struggles to his feet. "I'm sick, do you hear me? Sick! And I'm dying! If I want to kill myself, I will, dammit! That's my choice!" The group applauds him. I'm sweating profusely now. My notes...my slides...did I volunteer for this?

Things continue in this vein, until they pry a tortured statement from my lips: If conditions are truly as they've described them...then they each have an important message that deserves to be heard, and respected. Ah! The relief in the room! They're beaming. The sandwiches are here; let's eat!

Their leader clasps my hand. "They love you!" he says. (Mike whispers, "Shrinkette, they want you to kill them.")

"Take me home, please," I moan. "My headache is killing me..."

Two months later, they call me again. They're worried about a new member. He's not terminally ill. He's not even physically sick, but he has some strange ideas, and he's suicidal. He sounds like some of those people I was telling them about. Could I please see him?

"Of course!" said I.

GruntDoc's Third Grand Rounds


CNN.com meets a patient in intensive therapy for severe obsessive-compulsive disorder.
"Just before her admission to McLean, Shannon had gotten to the point where she would just give up. Folding one shirt would take hours. She could go grocery shopping just fine, but in the end the food would sit out on the counter, because she couldn't line the cans up exactly right in the cupboard, and she'd give up.

She would rise at 7 a.m. to get ready for work, which started at 5 p.m. It took her that long to shower and get her clothes ready...
More on obsessive-compulsive disorder here.

Monday, January 16, 2006

"Miracle Workers"

Coming soon: A Reality Show about "seriously ill people who lack the contacts or the money for treatment." Felicia Lee, NYT:
The very name embodies both show-business hyperbole and a country in thrall to feel-good entertainment and the possibilities of transformation...ABC will pick up the bill, allowing a regularly featured team of doctors and nurses to steer people to the latest medical breakthroughs as cameras capture the travails of patient-hood, from consultations to surgery to recovery...

Robert Kubey, director of the Center for Media Studies at Rutgers University in New Brunswick, N.J., said the popularity of the softer side of reality programs was proof that in a country rubbed raw by terrorism, war, natural disasters and other bad news, "there's this yearning for community, for positive endings."

But house building is one thing; brain surgery is another, ratcheting up the reality-television stakes. Although Mr. Kubey applauded "Miracle Workers" for providing medical information, he said one critique of such shows is that they allow viewers to evade pointed questions about the fates of those without angels to provide housing or medical care. He called it a "false consciousness" that things are being taken care of...

Sunday, January 15, 2006

Suicidal Mickey

How did Maria find this? A series of strips from 1930, in which Mickey Mouse believes he's lost Minnie, and tries to end it all.

He tries shooting, drowning, gas, and hanging. His ambivalence is clear, as he rejects or is thwarted in one attempt after another. He does not attempt to be rescued, though (unless you consider that leap onto a boat a "cry for help"). Squirrels finally persuade him to live.

Such torment, Mickey! I had no idea!

Saturday, January 14, 2006

How badly do you want your newsprint?

Michael Kinsley, in Slate:
"The trouble even an established customer will take to obtain a newspaper continues to shrink...Once, I would drive across town if necessary. Today, I open the front door and if the paper isn't within about 10 feet I retreat to my computer and read it online. Only six months ago, that figure was 20 feet. Extrapolating, they will have to bring it to me in bed by the end of the year and read it to me out loud by the second quarter of 2007."
I fear for the future of print journalism.

"Indigo" children?

NYT: Are They Here to Save the World?

I have met some blue-hued children. They were desperately ill, on ventilators, in a Peds ICU. But “Indigo Children” breathe normally. They are called “Indigo” because a psychic discovered their “blue aura,” as reported (with earnestly straight face) in the NYT. (Does “balanced reporting” mean that you give equal time to facts and to magic?)

These children are said to have traits that some might call “hyperactive,” and others call “undisciplined.” But the article quotes some true believers. They state that “Indigo Children” represent an advance in human evolution, and will bring peace to earth. Are there any studies of these children? No, say the psychiatrists. It is a fantasy, a fairy tale. It tells us something about the parents – their needs, their wishes. How does it affect the kids?

The psychiatrist at Follow Me Here observes:
I have treated ADHD for a long time in my psychiatric practice but have been appalled by its burgeoning and unsystematic, laughably faddish overdiagnosis. It is now a wastebasket diagnosis...

While I have no affinity for diagnosis by aura, I think Carroll and Tober may be overcompensating for the overpathologizing with an equally silly lionization of the 'ADHD child'. On the other hand, I do think that some children come to be seen as having attention deficit disorder in the classroom because the stultifying curriculum does not hold their interest and they are all over the map seeking stimulation. In my children's school system, the townwide parent interest group for gifted and talented children is full of the parents of children with different, and often difficult, learning styles, and it is no accident.
If you choose to delve further, be sure to bring your Field Guide. You may also wish to consult the Museum of Hoaxes and the Skeptic’s Dictionary.

At 11D, a commenter reports:
…now, after all these years, I finally have a diagnosis for my son: he's not a smart but annoying child who won't stop yakking. He's an indigo! There's only one problem: he spends the majority of his mental energies scheming for more television and snacks, not thinking about environmental issues. Maybe his aura is Snickers colored?

Update: see Liz's excellent post, and her comment below. So, the kids risk a narcissistic blow, from their inability to manage school or discipline; their developing egos then might take another hit, in the opposite direction, from the idealizing, magical fantasies of the parents...

Thursday, January 12, 2006

Blog Love

A New York physician posts:
Oh, all right, I’ll just say it. I am in love with my own blog.

As in the I can’t wait to see you, you’re the last thing I want to see before I go to bed and the first thing I want to see when I wake up kind of love. The I can’t get enough of you love. The what did I ever do before I met you kind of love.

And the worst thing is, I can’t stop looking at my blog. Any excuse I can make –“I wonder if there are any comments?' 'Did I spell that right?' 'Oops – didn’t realize it was still loaded in my browser...'
Blog love, recipes, and advice on how to get pregnant, at The Blog That Ate Manhattan.

Professor Batty's Lecture To Young Men

...who are looking for a wife.
...the professor has prepared a list to help you along on your way to matrimonial bliss:

#1. Talk. Unless she really desires a Neandertal, speak up. Find some topic of conversation that is not: A. You. B. Sex. C. Money. You'll find that these subjects will be covered at length later, don't wear them out now.
#2. Listen. To what she says. Think about what she is saying. There is a pretty good chance you might actually learn something you didn't know. If you don't like what you're hearing, you've already learned enough about that person. Try again.
#3. Learn to cook, and feed her. Take a class if you have to. You will never regret it.
#4. Be sociable. Ties in with #1,#2,#3. The idealistic rebel quickly turns into a cranky loner.
#5. Wash your own clothes. You aren't Momma's boy anymore.
#6. Don't wash her clothes. Ever. You will ruin them.
#7. Clean the toilet. It's your turn...
More advice, at Flippism is Key.

From man to woman...and back

A change of heart. (And more.) Alas, some surgeries are difficult to undo. Times Online:
A PRISONER who had a sex change operation to become a woman is to undergo further surgery to become a man again.

John Pilley, currently known as Jane Anne, is in Holloway women's jail in North London. The prisoner made legal history in 1999 when he became the first inmate in England and Wales to be granted permission for a sex change operation. He is understood to have undergone the gender reassignment operation on the NHS in 2001 at an estimated cost of �15,000 pounds.

Pilley, 54, was moved from Gartree Prison, in Leicestershire, where he was serving life for attempted murder and kidnapping a female taxi driver, to Holloway, but after living in the female jail has decided to become a man again. He is waiting to have his second operation on the NHS, then will be transferred to a male prison.

Christine Burns, of Press for Change, a pressure group for transsexual rights, said: "Although it is not unheard of, it is very rare indeed for people to have regrets and want to change back." The surgery would be similar to that used for female-to-male transsexuals, she said.

"Fat Doctor"

New favorite medblog. Would she do it all again?
Every now and then someone interested in becoming a physician asks me if I'd do it all again. Yes, I think. No, I think. Maybe. It's hard to remember when I made the conscious decision to be a doctor. It seems I just kept taking classes and here is where I landed. Truth is, I was unhappy before and I thought this career would solve that. It didn't. I had to get happy on my own. And if I'd made the effort to get happy while still a secretary, perhaps I could have been a happy secretary.

Most of this job is immensely satisfying, such as seeing a happy birth, being able to support a family during a death, easing pain and watching people transform their lives. Other times, my job is heartbreaking. People are lonely. People hurt. People are poor. Children and elderly are ignored. Sometimes I feel my patients want me to fix everything and I can't. Sometimes I think they expect nothing, perpetually, because life has never given them anything...
She has marathon clinic days. Some of her patients are scary (What, hers, too? I can relate.) Spend some time with her excellent blog!

"What More Can I Do?"

From the nurse at Digital Doorway:
You are a middle-aged man with poorly-controlled diabetes. You inject heroin and cocaine periodically. Since your veins are shot, you often inject using a technique called "skin popping" wherein you inject under the skin rather than intravenously, sometimes developing infected abscesses in your arms that have to be surgically debrided...

I'm worried that you may lose your leg or die from an infection. I have the visiting nurses see you every day to dress your wounds and administer your medications and insulin. As far as the open wounds, I now have you connected at the Wound Clinic. Since transportation is an issue, I actually pick you up and take you personally to your appointments so that your treatment is expedited. I also serve as translator. When you're sick I come to the house to visit you, and I keep your primary physician updated regarding your status. When you miss an appointment, I reschedule it since you don't have a phone. The visiting nurse and I consult about you almost every day. Only a handful of patients in the United States have this type of intensive and personalized healthcare delivered to them at no cost. I wish you could grasp the reality of that.

Despite all that I do, you still miss appointments, avoid the visiting nurse, skip medications, make excuses, and increase your chances of harm to yourself. I don't know your complete history, but I imagine there is a long story rife with psychic trauma, perhaps violence, abandonment, addiction, family stress, poverty, mental illness, and learned helplessless. I have no idea what experiences brought you to this point. From my standpoint of relative normalcy and stability, I cannot really understand your life, but only empathize with what it must have been like.

I want nothing more than to spare you frightening and painful outcomes which are lurking around every corner, but I can only do so much. Compassion fatigue is real, no matter how traumatic the patient's past. There's a point where I have to decide that I'm working too hard for you, doing too much, enabling you to not help yourself. Where do I draw that line?

Tuesday, January 10, 2006

"I will make you walk again."

Dr. Hwang promised a young paralyzed boy that his stem-cell research would cure him.
Nine-year-old Kim Hyeoni had been hit by a car while crossing the street the previous year. Once a chubby-cheeked child who loved baseball and practical jokes, he now was paralysed from the neck down.

'Sir, will I be able to stand up and walk again?' he asked the leader of the team, a South Korean veterinarian named Hwang Woo-suk, according to his father.

'I will make you walk. I promise,' replied Dr Hwang, who would shortly announce a breakthrough in the cloning of human stem cells...

The boy gave three skin samples taken under local anesthesia. His case appeared in a now-discredited paper published last May in the U.S.-based Science magazine in which Hwang claimed to have produced genetically matching stem cell lines from 11 patients...
"Now the family is faced with the sinking realisation that 'it was all a big lie', said the boy's father, Kim Je Eon.

Dr Hwang fabricated evidence for all of his cloning research, according to a report released yesterday by a Seoul National University panel investigating his work. In his string of splashy papers, his one legitimate claim was to have cloned the dog he named Snuppy, the panel said..."

The family has told the boy that he will walk again, but that he "might have to wait a little longer."

Monday, January 09, 2006

Lonely blog

Post-call...coming home. Busy call. Steady, Shrinkette...at least it's over...

Notes and files are strewn about. Coffee cups, fast food leftovers...Nine messages on the machine. I'll get to them. Untouched newspapers, still in their wrappers.

Nothing new on the blog.
Lonely blog, waiting for me to come home. Should post something...Can I do it?

Quick look around. Cars that talk to each other...why can't we get people to talk to each other? Keep looking...

Here's an all-male brothel in Nevada.
Anyone else posting on this? Can I think of a few hundred concerns about this?

This seems more suited to Wonkette, not Shrinkette. Maybe I don't want the sort of comments you'd expect from a post like this. On the other hand...I'm tired. Maybe I can just say, "Here's the link. Have at it." See what the commenters say...

Wait, what's this? Two men rowing across the Atlantic. They were a bit impulsive. One really didn't know how to row. And they really didn't know each other before they started. They're rowing in shifts, two hours on, two hours off, around the clock. Should someone save them from themselves?

Their trip sounds like a metaphor...for...for what? Oh...wait... It sounds like last night's call. The patients and I have just thrown down our oars, and touched shore...Okay, scratch that one.

And must my cat choose this moment to sit on my keyboard?
He's staring at me. I know that look. It's "Where have you been? Why aren't you paying attention to me?"

Cat-blogging! I've sunk to the depths. (I am so "post-call.") All right...I think I'm done now. No more Lonely Blog. Push the "Publish Post" button.

Good night, all.

Saturday, January 07, 2006

"It deeply engages all of us."

Dr. Richard Shannon, MD, at a press conference on Mr. Randal McCloy Jr.'s recovery. A reporter asks him for his personal view: how important to a patient's recovery is emotional support?
"Let me just say personally it's very important to the care team, it's extremely important to have all of that positive love and affection that one sees, it deeply engages all of us in our work. And so that's for sure an effect that I can tell you is personally measurable on myself, certainly on the nurses..."

He says the nurses have been like "guardian angels" and "surrogate mothers at every moment." "...And so you feel all that and I have to believe that, as I'm sure you do, that when you feel love and affection you feel better, even when you're asleep.

"I think that's the effect of this outpouring..."
(live-blogged from TV!)

Afterthought - No reporter asked about the opposite situation, when a patient is unloved and unfamous...

Thursday, January 05, 2006

Doctors battle to save Sharon after massive stroke.

Only about 17% of strokes are hemorrhagic. But they account for 30% of stroke deaths.

Left-sided bleeds cause severe language difficulties. Right-sided bleeds cause problems with understanding abstract concepts, and recognizing what you see. Right-sided strokes can also cause extreme personality changes. Often, I am consulted to try to address agitation or aggression after a stroke. And whichever side of his brain is affected, he will be paralyzed on the opposite side.

The vigil continues. He may not survive. But if he does, he will not be able to return to politics...

"It wasn't bad. I just went to sleep."

Miners' Notes Reveal Their Final Moments.

Precious notes, delirious scrawls, recovered from Sago. The miners chose not to tell of their headaches, nausea, and dizziness. Here are the symptoms of carbon monoxide poisoning.

But it is possible for someone with early CO poisoning to drift off to sleep, and die when the concentration becomes lethal. Perhaps they didn't suffer too much...

We watch the lone survivor anxiously. He's at risk for delayed effects: motor abnormalities, cognitive impairments, mood changes. It will be a long struggle.

Wednesday, January 04, 2006

"Harnessing the power of placebos"

...without sugar pills. Emily Singer, LA Times:
Sham treatments, medical science is learning, can have a powerful effect on health. Researchers have found that administering sugar pills and saline injections can ameliorate pain, depression and anxiety. Such treatments can reduce tremors and other symptoms in Parkinson's patients, lower blood pressure in those with hypertension and open up airways in people who suffer from asthma.

Researchers have even shown that sham knee surgery can alleviate arthritis pain and sham chest surgery, angina pain.

Now doctors want to harness that power as a tool for treatment — without resorting to trickery.

This is not as far-fetched as it sounds. Scientists are learning more about the response of the brain to placebos and about the various elements of treatment that help a patient feel better.

Say you go to the doctor with a headache, and your doctor secretly gives you a candy mint rather than an aspirin. That fake pill gives you an expectation that you will feel better — and the so-called placebo effect kicks in, and you do. If that were all the placebo effect was about, doctors would be stuck. Deceptively prescribing a candy instead of medicine to a patient in pain is not considered ethical behavior.

Luckily, other aspects of the doctor's visit — such as the whole doctor-patient interaction — play a role in placebo healing as well.

"The response to placebo is not just a response to an inactive pill, it's a response to the entire treatment situation," says Dr. Walter Brown, a psychiatrist at Brown University in Rhode Island. "It's everything: going to an expert, talking about the problem, getting a diagnosis and a plausible treatment."

Researchers are studying the best ways to capitalize on these cues...
(-emphasis added)

Update: Joel asks if he's hearing doubletalk in this article (see comments). What do you think?

"The White Swan dances on point atop the prince's head."

Sporting Life in America II: Napping at the gym

Times Online:
"It’s 9.30 on a Thursday night at Crunch, on Sunset Boulevard, one of Los Angeles’ hippest gyms and I’m in “corpse pose”. That’s got nothing to do with how I’m feeling after a day with my two small children; it’s gym-speak for lying flat on my back.

The lights are dim, there’s trance music wafting. Frankly, I could nod off very happily. And that, apparently, is the desired effect. For the first time in a career of failing to keep up with the rest of an exercise class, it seems that I’m actually doing the moves correctly. If you could call them moves, that is..."

Sporting Life in America: Competitive Bragging

NYT: "Honk if You Adore My Child Too."
"For a generation of successful upper-middle-class parents deeply involved in their children's development, filial pride can easily go overboard. Competitive bragging has become a new social sport, with a vast field of play that includes practically any public place, from the office coffee cart to the supermarket checkout line. The puffery is so inescapable, it has inspired a backlash: anti-brag bumper stickers, shirts and pins with slogans like 'My kid sells term papers to your honor student.'"

Monday, January 02, 2006

"Medicine has two faces..."

"...the iodine-stained, glass-splintered messy reality we all work in, and the clean, quiet, dignified prose we use to record it." Dr. Abigail Zuger, MD, in the NYT:
"No absence of order penetrates our documents of record. The journals' glossy pages - or, now, neat online screens - are serene and pristine, rational and assured. Every study has a conclusion. Every case has a diagnosis. Every necessary test is performed, without fuss or muss.

"if there has been any drama finding a vein, or cajoling a claustrophobic patient into the M.R.I. scanner, or debating a practicing pagan who is refusing his blood tests because the moon is waxing gibbous, you certainly aren't going to read about it in the literature. Yet, it all happens, all of that and more..."
(I believe that's why most medbloggers blog!)
"...I figured that once training was over, life would become as orderly as it was in the journals. It was a delusion born of sleeplessness: medical reality always diverges wildly from the printed record. Drugs often don't behave the way they do in studies, and patients almost never do. Labs make mistakes. There is an unending parade of problems for which the received wisdom holds no answers...Why not tell it the way it is, for a change? Let journals immortalize all the messes and foul-ups in print, the spurious lab results, the problems that never get solved or the ones that seem to solve themselves despite us.

"Let's hear about the patients on the placebo, and the ones who drop out of studies, and the ones who can't get in to begin with. Let's see an article on infection illustrated not with nice boxed tables and graphs, but with pictures of, say, a wildly agitated, preternaturally strong patient burning with fever, drenched in iodine and blood, lurching off his rolling gurney and taking his doctors and nurses down with him."

"Good medicine sometimes means that the customer - I mean patient - isn't always right."

"Or even happy." Dr. Richard A. Friedman, M.D., in the New York Times:
According to the business model that now permeates hospitals, all complaints must be taken at face value and assuaged, with little regard to the clinical context or to the effect on the patient.

But in good psychotherapy, it is not possible, let alone desirable, to keep patients happy and satisfied all the time. Frustration, anxiety and discomfort are unavoidable in life, and in therapy - particularly for patients with certain personality disorders.

This isn't to say that doctors and hospitals shouldn't submit to intense scrutiny of how they do things. But they can't be blind to the fact that good treatment doesn't always feel good. Conversely, sometimes patients feel good about years of bad psychotherapy that is doing little to help them.

Sunday, January 01, 2006

Happy New Year, everyone.

Best wishes to you all! We're in a fierce storm here. Winds are gusting to 45 mph. The huge Douglas firs are swaying, branches are falling, rain is swirling...rain is now horizontal.

Cut to obvious metaphors about "weathering storms"...a major theme of the past year. How did we do? How will we manage the next one?

In a few hours, we'll go out and inspect our sodden, debris-filled yard, left cluttered by the wind. We'll look at our roof - any big branches up there, any leaks?

I will also turn off my pager (someone else is covering!) and do my New Year's routine. I'll think about where I've been, and where I'm going.
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