I think it's time

...to say goodbye.

Like Medpundit, I find that I don't have enough time to devote to this blog.

It's been a lot of fun.

The Forgiveness Project

"Could you forgive the unforgiveable?" Kate Kellaway, in the Observer:

"The Forgiveness Project...has no religious or political agenda. It has no agenda at all apart from the brave, unfashionable wish to turn the blame culture on its head, to share the stories of people who, in extremis, have discovered that 'the only way to move on in life is to lay aside hatred and blame'. It tells of victims and perpetrators from all over the world: South Africa, America, Israel, Northern Ireland.

"...These stories are tremendously moving but they are complicated too. Would it be unfair to suggest that Rice's sentiment sounds precariously close to revenge? Forgiveness can be uncomfortable. It may induce squeamishness, strain, disbelief in the onlooker and, perhaps, in the forgiven. It can seem artificial. It seems to involve an emotional double-jointedness, an ability to bend backwards further than an ordinary person is designed to go. And yet, at other times, something miraculous occurs. People seem to emerge into a new landscape, a clearing where negative feelings no longer consume them. I imagine that it is not an easy place to be. They are exposed, unsupported - for revenge and hatred were, in their ugly way, crutches - but they are free.

"...Adam Phillips, writer and psychoanalyst, suggests: 'Forgiveness is not an act of will, if genuine.' He is quick to see its darker aspect: 'It puts the forgiver in an immensely powerful position. There is word magic here: the belief that if you forgive, people will be absolved of their guilt. At worst, forgiveness is a tyrannical gift: your life in my hands. You'll feel better when I forgive you.'

"Marian Partington, whose sister Lucy was one of the victims of Frederick West, the Gloucester mass murderer, disengages herself from the word: 'I don't like 'forgiveness'. It is completely barnacled with aeons of piety. I prefer compassion: empathy with suffering.' If the word is to be used, she sees it as 'a verb not a noun. I get a bit suspicious of people who say "I have forgiven", as if it is something in the past...'

"After trauma, she believes, people often experience a 'frozen silence with no words. There are no words to describe this place'. Time involves a thaw and 'acceptance' and, in Partington's case, luminous words to describe her feelings, to break the silence."

Grief

Grief, originally uploaded by creativity+.

...for Pfc. Tucker and Menchaca.

"Tell me, who is the president?"

"The president?" The patient's eyes grew wide. She was ninety-two years old, and her memory was "not the best, dear."

We had just met. I'd quizzed her gently, and she'd responded with bemused indulgence...until now. She looked directly at me, and scowled. "Here it comes," said her daughter. Here it came, indeed! A stream of bitter disapproval...

It was 1998, and we had all just heard of Monica Lewinsky.

At times, we must try to learn if our patients are aware of a larger world, beyond their own surroundings and circumstances. If a patient is forgetful or disoriented, how severe is the impairment? There is a long tradition of asking, "Who is the president...and the one before him...and the one before him?" Unsurprisingly, the question can bring the larger world thundering into my office. The interview stops, and I learn exactly what the patient thinks of the old so-and-so, even if they can't quite remember his name.

When Clinton was president, people tended to forget the elder Bush. It was "Clinton, Reagan, Carter..." That changed when Bush, Jr. assumed office. It became "Bush, Clinton, Bush's father." Now, people are unsure about Ford and Carter. The younger the patient, the greater the confusion about where to place Nixon and Johnson. But the quality of memory depends on the nature and context of the information. (A man with mild Alzheimer's could not recall Clinton's name, but called him "the sex guy.")

In the last few months, the emotional impact of this question has again intensified. I don't need polls to tell me what our community thinks of its leaders.

I do have to be careful, though. One elderly lady unleashed a torrent of opprobrium about the president. But her son stepped in: "Mom, what president are you talking about?" It was Herbert Hoover. Now, that's an impressive long-term memory...

When pain meds make pain worse

Michele G. Sullivan, in Clinical Psychiatry News:

HENDERSON, NEV. — Treating medication overuse headache involves a three-pronged approach of patient education, teaching pain coping skills, and addressing psychological issues that put patients at risk for relapse, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

Most patients don't understand that excessive use of opioids can actually make them hypersensitive to pain, said Dr. Lake of the Michigan Head Pain and Neurological Institute, Ann Arbor. “They believe the pain is stronger than the medication, not that the medication is actually making them worse.” This thought process can be the root of ever-increasing medication use, as the patient experiences “pain anxiety” and attempts to forestall pain by premedicating.

The first step is to teach patients how medication overuse exacerbates headache pain, he said. Only when they have a clear understanding of this relationship will they be open to adhering to medication limits.

Sustained opioid use downregulates opioid receptors and upregulates excitatory receptors. This results in increased synthesis of excitatory neuropeptides. “Opioid tolerance is a red flag for induced abnormal pain sensitivity,” Dr. Lake said...

Simply taking away the analgesic isn't the answer, he stressed. Patients need to understand that drugs are not the only way to alleviate headaches, and that they will probably have to tolerate some level of pain. “The evidence, clinically and empirically, shows that it's very difficult for these patients to move to pain-free days. They have to find ways of dealing with headache that doesn't involve drugs.”

Biofeedback, stress management, and antidepressants all may be effective tools in relearning responses to headache pain.

Thanks for the Ethics classes

...you showed us how to cheat. Forbes.com:

Last fall, Bentley College management professor Tony Buono taught a class on corporate scandals with colleagues pitching in from finance, accounting and even the philosophy department. The four picked through the cases of Enron, WorldCom, Tyco and Shell.

At the end of the semester, the number of students in a simulated trading room who were caught in misconduct or misusing information for insider trading was significantly higher than at the beginning. The students said, "You taught us how to do it," Buono recalled.

"For those of us who've spent our careers teaching this, it's been a disappointing time," said Buono.

Buono, the Bentley professor, suspects the students in his class who got caught misbehaving in the mock trading room considered it a game.

"We're trying to tell the students there is no reset button in real life," he said.

Dinner at the Bipolar Restaurant

Joel imagines a cafe that brings diners into a "bipolar experience."

1. You would be surrounded by frowning people.
2. The food would be hospital food. If you did not eat it, they would not let you go home until you did.
3. The food would make you constipated or dizzy or wanting more and more and more...

5. The waiters would take notes on your behavior.
6. Voices would tell you that the waiters did not like you and that they wanted to poison you. Other voices would just say things like blab blab blab over and over again.
7. Whenever you lifted a fork or knife, the staff would watch you especially closely...

11. You’d leave the restaurant relieved that you were out of it. When you got home, however, you’d discover that the restaurant had moved into your bedroom.

Dilemma.

I've made a rule here: "No medical advice is given on this site."

But suppose that a commenter says: "To taper a med, do A, B, and C." Does that violate my rule? Should I delete the comment?

And if another commenter states that such a taper is unwise or even dangerous, what then? Is that medical advice?

Why does it matter? Each day, people ask Google about "stopping meds." Each day, Google leads some of them here. Note the active, growing comment thread. Baldrick says:

"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."

A crucial point...one that I wish I had made, myself! But Baldrick also says: "To taper meds, do a, b, and c." (You see where I'm going here.) Another commenter vehemently disagrees with Baldrick, and says that such a taper should not even be posted.

I'm trying to walk a tightrope. I've tried to say: "Some think A, and I've seen B, but please talk to your doctor." I believe that I'll have to start monitoring things more closely, and delete anything that might be construed as "advice."

Your thoughts are most welcome. (Add: I've republished the original post, with updates.)

Stopping Paxil.

This can be terribly difficult. But it can be done. (Note updates!)

I note Dr. Stephen M. Stahl's "dosing tips":

"For patients with severe problems discontinuing paroxetine, dosing may need to be tapered over many months (i.e., reduce dose by 1% every 3 days by crushing tablet and suspending or dissolving in 100 ml of fruit juice and then disposing of 1 ml while drinking the rest; 3-7 days later, dispose of 2 ml, and so on.) This is both a form of very slow biological tapering and a form of behavioral desensitization."

So if a dose was lowered from 20 mg to 19 mg, that would be a 5% reduction. But he's describing a 1% reduction. (As the dose gets lower, the proportion changes, of course.) He adds:

"For some patients with severe problems discontinuing paroxetine, it may be useful to add an SSRI with a long half-life...prior to taper of paroxetine."

He also notes that paroxetine inhibits its own metabolism, making tapering even more problematic for some (i.e., the effect of a dose reduction can be magnified. The patient is not only taking less, he's also eliminating it faster). -Essential Psychopharmacology: the Prescriber's Guide by Stephen M. Stahl, Meghan M. Grady (Editor), Nancy Muntner (Illustrator)

Note! Dr. Stahl and I can't tell you what to do. We aren't your doctors! (See disclaimer in sidebar.)

Why I'm posting this: I notice that I'm getting lots of hits from this site today. (5/20 update: the link has been changed, and now there's no access to this forum. There was much outrage about some psych-blogging, including mine.) There's horrific pain and anger in this thread. Obviously, for many, there's been a complete breakdown in the relationship between psychiatrist and patient. I hope that no one has to go through the pain that they're describing.

Update: related post here. And note, please: no medical advice is given on this blog! (I've come perilously close to breaking my ironclad rule, here.) Eat a healthy diet, look both ways when you cross the street, and talk to your doctor about any and all med changes! Patients should have a doc in their corner, looking out for them!

Yet another update (6/13): Baldrick has an important comment.

"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."

However, I'm afraid that I'm going to have to delete any comment that gives, or appears to give, medical advice. That includes posts that say, "Do this" (whatever "this" is). The issue of whether, and how, and when to stop meds is controversial. Each patient is different. Please speak to your doctor! No medical advice is given on this blog.

"I'm afraid I have some bad news..."

A clear winner of the Most Regrettable Bedside Manner Award. In the New Yorker:

Your husband was admitted with extreme pain in the abdomen, which is obviously not our fault...We didn’t want to rule anything out, so we opened him up.

There were no multi-hundred-pound tumors; that’s the good news.

However, it’s a real mess in there. There’s a lot of intestinal tubing squishing around—what you call “guts”—as well as an assortment of small, esoteric organs they don’t spend a lot of time on in medical school. And bear in mind that everything’s pretty much the same color, not like in the textbooks...

Falling into the "doughnut hole"

Some patients are discovering that their Medicare Part D drug coverage has a gap, and stops paying when a limit is reached. For some who qualify, coverage resumes later. The gap in coverage is called the "doughnut hole." Timely advice from OnThePharm:

"Yesterday I had my first customer come talk to me about his medicare coverage. He spends quite a bit of money in the pharmacy, but he had opted for a plan which had the “doughnut hole.” Now. the details of each plan’s doughnut hole vary, but basically they all revolve around the magic $2250 number. There are some common misconception about this so-called doughnut hole, and he had fallen victim to both!

"...As always, I recommend checking out the Medicare website, particularly their plan search tool. Be sure to be specific, and enter your medications, and dosages so the plan can really help you choose the plan that’s best for you. At the end, it will present you with a list of plans ordered by yearly cost that cover the medications taken. The yearly cost is what it will cost you or a loved one in terms of premiums, copayments, and lack of coverage if a donut hole is ever reached. While you can’t change which company you go with now, you will be able to after November 15 when open enrollment begins again."

Question 36

From a multiple-choice pathology exam:

36. The poet Yeats wrote:

An aged man is but a paltry thing,
A tattered cloak upon a stick, unless...

A. He finds a younger woman, has a fling,
And then yells out, 'I never will confess!'

B. He takes Viagra pills, to boldly bring
To his beloved his mighty manliness.

C. He uses Rogaine, and by next spring
Has hair regrowth that's certain to impress.

D. Soul clap its hands and sing, and louder sing
For every tatter in its mortal dress.

E. He burns his 'Path' book, and while it's smoldering,
He shouts out loud, 'I'm DONE with that B.S.!'

-Ed's Pathology Notes.

Heckling the student.

Or rather, don't heckle the student. I'm too late:

More Hawaii

DSC_0002, originally uploaded by shrinkette.

Can't let it go. Sorry.

We're back.

DSC_0059, originally uploaded by shrinkette.

...and the world can't wait to see my vacation photos, right? I thought so! This is the Napali coast of Kauai, where I completely and utterly forgot about the rest of my life...(and my blog!). A little misty, perhaps, but so are the memories.

One more: this is Maui.

Okay, back to work. I have a lot of catching up to do!

Aloha

Honolulu, originally uploaded by Mikey720.

Greetings from Oahu. We needed a break! We'll be hiding out here for about a week. Blogging will be very sporadic for awhile...

Our best medical blogging

Dr. Emer hosts this week's Grand Rounds at Parallel Universes.

Note: Pediatrics has its own weekly roundup. This week, it's hosted by Blog, MD.

And what's this? Indian Cowboy is starting a psychblogging carnival (coming June 1). Must think of something to submit. Looks like I'll be extremely busy...

A Farewell Party for Medpundit.

She's been our leader, our "doyenne," since 2002. We can't let her go without a send-off, can we? Come on in, I'll take your coat. Glad you could make it!

The guest of honor is here. (She looks...happy. Relieved, perhaps?) We have quite a gathering. DB and GruntDoc are here, and Dr. Emer is relaxing on the deck. Dr. Choi brought his lovely family. Help yourself to our lavish buffet! Can I get you a drink?

(Ahem.) All right, everyone. It's time for some tributes. Who wants to start?

Dr. RW:

"Medpundit was one of the pioneers in medical blogging. She influenced my blog in many ways and will be missed."

GruntDoc:

"I thought I'd made the big time when I got a mention in her blog in August, 2002, and I've been a long-term reader and fan of hers. She's what people think of when you say "medical blogger": she commented on medical news and ideas in a meaningful, substantive way. That doesn't mean she's been opinion-free, far from it, and that made her blog more interesting, not less so."

Dr. Robert Centor:

"I have often told interviewers that I would not have become a medical blogger without Sydney Smith as a role model. She showed me that medical blogging could work.

"When I started my blog, I always measured my success by comparing what I was doing with her blog. In my mind she was the pathfinder."

Dr. Emer:

"I do pray it is not her final decision. She gives excellent insights on almost any medical issue and current health studies. I hope she still blogs. It need not be regular. It can be once a week or even once a month.

"I won't say goodbye, Medpundit.....I'd rather say I would wait until you can blog again. Godspeed!"

Kevin, MD:

"A sad day indeed. She was one of the reasons why I started this blog. Best of luck in the future, Dr. Sydney."

At her farewell post, visitors send their best wishes. Here's Geena, of CodeBlog: "Wow... I hope you leave the blog up. There is wonderful information here. I've been reading medpundit for years! You'll be missed!!"

Aggravated DocSurg: "I completely understand your dilemma, and wish you all the best!"

PalmDoc: "Thank you for your time with us sharing your life, wit and wonderful blogs."

Difficult Patient: "I totally understand . . .maybe you can do a "once a week" like many others--just a little "check-in" with the blogosphere! ;o) Enjoy your family!!!!! (Sounds like your kids are the same ages as mine.)"

Nick, from Blogborygmi: "I'm going to miss you, too. Thank you for all your encouragement in the beginning!"

Dr. Serani: "You are going to be greatly missed."

Daily Capsule's Sue Pelletier: "Sydney, I have to add just one more, 'I'm going to miss you' to the list. Medpundit was one of my favorites, and your insights and experiences were terrific. Thanks for the memories."

Finest Kind Clinic and Fishmarket: "Bye. Will miss you. On the other hand, my blog doesn't cover medicine much anymore...too depressing..."

Dr. Ostrovsky, of medgadget: "Thank you for all your work. Perhaps you might consider posting infrequently, when something you find important comes up. Anyways, good fortunes to you."

We all thank you, Medpundit. You are already missed. Everyone join in, please:

"Happy trails to you,"
"For (s)he's a jolly good fellow" (yes, the kid is singing "he," but it's cute),
and "Happy Trails, again!"

Mighty Barry did not strike out.

Barry Bonds ties Babe Ruth's record, but there is no joy in Mudville. Mercury News:

...maybe that's the one positive we can take from this whole sordid steroids scandal. If nothing else, Bonds is a living, breathing, tortured, tormented illustration we can point to when we tell our kids, 'You know, when you cheat, you're only cheating yourself.'

Bonds has cheated himself out of the adoration and adulation that should have been his Saturday. He cheated himself out of the respect and reverence that traditionally is reserved for our greatest athletes. He may have even cheated himself out of the Hall of Fame.

NYT reports: "As Bonds crept closer to Ruth's No. 714, fans have heckled him and waved critical signs. One threw a syringe in San Diego. Another dressed as a syringe in Houston."

Medpundit says farewell.

This news is...huge.

"I no longer have the time needed to devote to (the blog). The phrase 'declining reimbursement and rising overhead,' is repeated so often in medicine that it seems a cliche, but it's also a reality. I'm spending longer hours at work and seeing more patients to support my office and my family. The 1-2 hours a day it takes to keep up the blog are no longer there. I don't have any hope of that getting better in the foreseeable future. In fact, I anticipate that in the next 1-2 years, I'll be adding even more office hours until I've reached the limits of my physical and mental capabilities."

Medpundit, you've inspired so many of us. I'm truly sorry to see you go.

But I do understand. As Dr. Dinah says,

Now I don't just write a blog, I read other people's blogs: it's like throwing Time in the fire and watching it burn.

Look, if you dare!

New Scientist Technology Blog:

How'd you like to see yourself 30 years from now? It sounds terrifying to me, but if you fancy looking at an artificially haggard and gnarled version of you then pop over to this site. All you have to do it upload a picture of yourself and they promise to use 'facial transforming software' to age you 30 years or so.

Should I try it? Er...you go first!

Are "service babies" preferable to "service goats?"

Dr. Dinah would like to blog about "pet goats and ducks, as service animals for the emotionally distraught." But she can't. She's laughing too hard! The comment thread is priceless:

...And if the service goat flies for free, then my service spouse should fly for free, too.

Roy, I'm gonna need a note.

ClinkShrink said...

Given a choice between sitting next to a service goat versus a shrieking service baby, I'll take the goat...

Sarebear said...

Those shrieking service babies really get your goat, huh? Hee.

ClinkShrink said...

As puns go, that one was not baa-aa-aaa-d...

The plight of the banana

New Scientist:

"The world's most popular fruit and the fourth most important food crop of any sort is in deep trouble. Its genetic base, the wild bananas and traditional varieties cultivated in India, has collapsed."

(Yes, yes, I know. In the last post, I was restrained. And this post is about...bananas. However, this is a pure and wholesome blog! Do you suppose that my Id is getting feisty again?)

Restraints.

Staff demonstrate for - and on - Dr. Maria. I've had this training, too. It's remarkably easy to take me down. A team of five staff can flip me like a flapjack. The leather cuffs go on, they're locked, and I'm down. (I don't try to resist!) Here's Maria:

"And so it began—and it happened much more quickly than I had anticipated (although time may simply pass faster when one is actively struggling against five other human beings). I kicked, I floundered, I wriggled, I did my best to wrest myself from their grips. Before I knew it, however, one person each had a hold of each arm and leg. Their hands were placed outside of each of my knee and elbow joints, restricting my excess flailing.

And then they picked me up off of the floor. Which sucked, because then there was nothing upon which I could brace myself. I continued to kick and jerk about—and started getting all sweaty and gross in the process."

"Where have all the flowers gone?"

...the flowers that were to be tossed at American liberators by grateful Iraqis. Dr. Stanley Renshaw, at Political Psychology Blog, observes:

The expectation that American soldiers would be greeted as “liberators,” with flowers and sweets was reasonable enough. After all, Iraqis had been savagely brutalized by Saddam’s domestic rein of torture, terror and sadism. Robert Kaplan recently wrote that, “Iraq in the 1980s was so terrifying that going to Damascus from Baghdad was like coming up for liberal humanist air. People talked furtively in Syria; in Iraq, nobody breathed a syllable of opposition. The whole country was like an illuminated prison yard. I was emotionally affected. Recent events make it easy to forget just how bad Iraq was back then. “

Still, the question remains: What happened? If Americans were truly viewed as liberators, why is it now struggling against a ferocious insurgency? Why did the good will that Americans expected seem to turn so suddenly into suspicion and resentment? These are very important questions whose answers go to the heart of American efforts in Iraq and the public’s assessment of them...

Dr. Renshaw is "a professor of political science at the City University of New York, and a practicing psychoanalyst." A thoughtful, fascinating blog!

She's back!

BigMamaDoc is blogging again. What an ordeal she had!

As I was wheeled back to my ER room, Dr. Resident said, "Well, you've had several more strokes. I count at least 8 new lesions. Maybe more. This is very interesting. Let me repeat some of the physical exam. "

Oh, so who's the faker now, buddy?

The Neuro ICU is a strange place to be when you don't feel particularly ill. Strapped down by IVs and catheters. People were nice there. I whined to Nurse Scott a bit too much about having to use a commode for a BM. He recommended I go on a walking tour of the ICU to put things in perspective. I was the only nonintubated patient in the unit. My neighbor died over the weekend. She was an organ donor. I can't stop thinking about who got her heart, kidneys, eyes...

She reports that her blog-friends have helped her morale. She also has a prayer request.

Happy Mother's Day

Mother's Day, originally uploaded by Donna C..

I'm on call again. If your Mother's Days are rough, Dr. Serani has a post for you.

Must get to work now!

Update: Dr. Flea observes that the translations are a bit mangled. I suppose it's too late for me to issue a Denial of Responsibility for accuracy in French, Portuguese, etc. It looks like some fine sentiments did not survive Google translator (or some such application). I do hope all moms are happy, anyway!

"I'm suing that doctor! I'm going to make him pay!"

The patient is furious. What should I say? Every word will be subpoenaed. Think, Shrinkette. Think some more...okay, a question:

"Why are you suing your doctor?"

"Because I needed him, and he was not there for me!"

(Afterthought: am I there for my patients? Am I there for this patient? I'm thinking about how I'm going to be subpoenaed...)

"The Secret Lives of Our Parents"

A Flickr group pool. It's filled with shots of "our parents, before we knew them."

The mystery of mom and dad! An irresistible topic (for me, anyway). Here are some moms, before they were moms:

Prettiest Bride Ever, originally uploaded by glyph hunter.

feb 1948, originally uploaded by DayDayDad.

Mom & Packard, originally uploaded by Mirandala.

Mom at the Hotel Washington, 1951, originally uploaded by Joey Harrison.

FDA approves Chantix.

It's a novel medicine for smoking cessation. Cigarettes just aren't as satisfying when you take this twice a day. From the FDA website:

"The U.S. Food and Drug Administration (FDA) today approved Chantix (varenicline tartrate) tablets, to help cigarette smokers stop smoking. The active ingredient in Chantix, varenicline tartrate, is a new molecular entity that received a priority FDA review because of its significant potential benefit to public health.

Chantix acts at sites in the brain affected by nicotine and may help those who wish to give up smoking in two ways: by providing some nicotine effects to ease the withdrawal symptoms and by blocking the effects of nicotine from cigarettes if they resume smoking...

The approved course of Chantix treatment is 12 weeks. Patients who successfully quit smoking during Chantix treatment may continue with an additional 12 weeks of Chantix treatment to further increase the likelihood of long-term smoking cessation.

In clinical trials, the most common adverse effects of Chantix were nausea, headache, vomiting, flatulence (gas), insomnia, abnormal dreams, and dysgeusia (change in taste perception).

Holding my breath for BigMamaDoc.

She's had some strokes, and she's had some procedures. The latest word from her blog:

She is doing fine, we should be heading home Friday. I will let her tell the story as only she can.

Mr. Mamadoc

What can she be going through right now? Hope she's okay...

Oops.

A blog is deleted, and its author has an insight. The Blog That Ate Manhattan is no more. (Doctor, if you ever want to guest-blog over here, just let me know!)

A million dollar chicken.

Peta Thornycroft blogs from Zimbabwe:

With Zimbabwe’s official inflation now at 913 per cent, (international accountants say it is closer to 1500 percent,) it’s a pain going shopping. A decent sized whole chicken cost nearly a million Zimdollars this week.

It’s hard getting enough money to pay for a couple of baskets of basics as there are long queues in banks, and the automatic cash machines are always 'run out of funds' or jammed. Imagine being an accountant and checking the overdraft.

Interest rates are officially about 783 per cent. Last week it was 750 percent. A medium sized engineering company had an overdraft of Z$10 billion in December. Now it owes the bank Z$65 billion. It can’t pay. In theory its trading figures should have kept its overdraft manageable as the value of the Zimbabwe dollar shrinks daily....No one knows how high these extraordinary figures - inflation and interest rates - will go, nor what will happen when they continue to climb, minute by minute.

The Reserve Bank, which runs most of the country (the army runs the other part) acknowledges without blushing that it prints trillions and trillions of Zimbabwe dollars, to keep the economy going...

Every aspect of life in Zimbabwe is in a state of collapse. Education, health care, trade, commerce, and of course human rights...

"How do you understand dread?"

Neurologist Dr. Greg P., on the Emory "Dread" study. Suppose you knew that something bad was going to happen, and that you couldn't prevent it. Would you simply wait for it? Would you suffer more, and sooner, just to get it over with? Suppose we did imaging studies of your brain, while you chose and responded. What would we learn? Is this a good model for dread, and for responses to dread?

Subjects are given a shock on their foot, after having been given a warning that the shock was coming, what its voltage will be, and what the delay is. Initially, this proceeded without any choices, as a training period.

Next, subjects were presented with a choice between receiving a certain percentage of the shock, and a certain delay, or a different percentage and a longer delay. The two voltage percentages might be the same, in which case slightly more than half the time, subjects chose the shorter delay, presumably to get the experience over with. This is what is interpreted as the Dread factor -- that subjects so dreaded the wait that they wanted to shorten the wait...

Now we have two groups of subjects, mild dreaders, who will take the early shock only when it's the same or less, and extreme dreaders, who are willing to take an earlier higher shock.

So now the neurobiologic substrate. Subjects had all this happen while having a functional MRI (fMRI) done, which can then be statistically analyzed... I still have some uncertainty about whether I can make this connection to dread. What is dread? Dread is one of these experiences that we all have, and presumably share with others.

Dictionary.com says that it is "To anticipate with alarm, distaste, or reluctance". Hard to disagree with that, but what is that really? To me it is a complex feeling that cannot be removed from its cognitive aspects, so I'm not sure that the dread identified in this study is necessarily connected to other kinds of dread, like bad news or paying my taxes, yet dread per se has all these flavors...

I'm waiting for someone to connect these findings to the "Dread factor" in politics, economics, foreign policy...and in our waiting rooms...

Meet "Shrink Rap!"

A warm welcome to the newest psychiatry blog. Drs. Dinah, Clinkshrink, and Roy have created "a cyberplace for psychiatrists to talk." Here's Dr. Dinah:

It was a hard winter. It started even before that, perhaps in October, right before I left to work in Baton Rouge-- one patient had a serious suicide attempt, several were in crisis, even the patients who were fine were having trouble getting out the door at the end of the sessions. "Treatment-Resistant Depression" had become one of my favorite terms, but there were also a few people with mania and psychosis who were having a tough time. So it continued through the winter-- one patient called at least 10 times a day (I finally told her to stop; this improved the quality of my mental health remarkably), another e-mailed, up to 4 times a day, patients called-- or worse, their relatives called-- they cried, sometimes they even sobbed.

I mentioned it to a few colleagues and they all had the same response: My practice, too! One friend told me her emergency phone line usually gets 2 calls a month, now she was getting 3 a day, including calls from a patient on another continent, all while she'd taken on 3 news patients that week and her husband was out-of-town, leaving her with their 2 young children to negotiate. She beat me out for the Most Suffering Psychiatrist award and I brought her chocolate. Something in the air? Yet one more effect of Global Warming?

I felt discouraged, overwhelmed, and I wondered for the first time if I really loved psychiatry as much as I thought...

How did things begin to turn around? She tells us, here. Go, read!

Happy birthday, Dr. Freud.

He's 150 years young today. Mind Hacks has a round-up of interpretations. Who wants to analyze Freud? Times Online tries:

Although his writings were not scientific in any rigorous sense, and although he was not the lone pioneer that he claimed to be, supposedly charting a completely unknown psychological continent, there is no doubt that it was he who made us aware, in a straightforward and coherent fashion, just how hidden and contorted human motivation could be, how little reliance we could place on our consciously avowed intentions, and how important, though also how difficult, it is for us to know ourselves.

Freud was not a great scientist, nor did he discover anything in the sense that Robert Koch discovered the germ that causes tuberculosis, and Watson and Crick discovered the double helix. He did not contribute any store of positive facts to human knowledge. Science would be deprived of practically nothing had he not lived. His theories are now universally dismissed, either as having been disproved or, somewhat contradictorily, as being incapable of disproof and therefore not scientific theories in the first place.

Yet his influence on all of us was enormous, and it would be as impossible to return to a pre-Freudian way of thinking as to return to a pre-heliocentric theory of the solar system. Freud is a little like Nature in Horace’s famous line: though you may throw him out with a pitchfork, yet he returns. It is as if he enunciated deep if unprovable truths about ourselves that had never been so clearly enunciated before...

Side effects, side effects

Trick-cycling for Beginners:

Allow me to tell you about some of the side effects I have experienced over the years.

One drug made me sleep for up to 20 hours a day.
One caused violent headaches and nausea if I forgot to take a single dose.
One made my mouth so dry that no amount of water or chewing gum could prevent my lips and cheeks from constantly sticking to my teeth from lack of saliva.
One caused restless legs. If you have never experienced this, I'm not sure that I could begin to describe the frustration of lying in bed and feeling uncontrollably compelled to shake your legs like a marionette. If you don't, it's like being tickled in restraints...

I owe those horrible pills an awful lot. I would not ask anyone to risk subjecting themselves to the potential side-effects of medication if I didn't consider it necessary. They improve many people's lives beyond measure. Anti-psychiatry opinion that psychotropic drugs do more harm than good is a dangerous myth.

My message is this: Patients - tell your doctor about the side-effects, especially if it's bad enough to make you want to stop taking the medication. I wouldn't advise following my example - don't just quit the medication without a discussion. There may be alternatives. Don't compromise your own health.

Doctors - ask your patients about side-effects, especially the embarassing ones. Most of your patients won't want to say anything about them. Have some empathy. You might think the side-effects of meds are minor in comparision to the alternative, but it is not you taking the stuff. Please listen.

Oh, and by the way - don't bother recommending prunes. They don't work.

BigMamaDoc Watch

Just posted:

"Greetings from a Friend of Bigmamadoc. I'm here to pass along an update for the good lady. Here goes:

"The procedure last night terminated early once they saw how goopy things were in those brain arteries. (Pardon my non-medical translation.) The new plan is to stent the artery on the right side Thursday and the left side on Friday or Monday. She'll be in the Neuro-ICU unit over the weekend. Her husband is with her, her child is well cared for, she's in a pretty good mood and she's receiving excellent care..."

"Which triangle appears to be suffering more?"

Dr. Deborah Serani:

"...if you're like most people, the triangle that is rotated more from the vertical position is the one that is suffering more. The triangle that is vertical, standing on point is stronger.

"In a recent study, Pavlova and her colleagues[1] found that imbalance or instability in a picture of static objects is what leads individuals to attribute emotion to them. In a psychological sense, it is as if we see ourselves as the object. Being vertical and grounded is a state that is pleasing and empowering to us. The shapes that feel off-center evoke an off-centered feeling for us."