How People Think About Escalator Malfunctions

 

What would you do if you were in your favorite shopping mall and the escalator was not working?  Would you consider it an act of sabotage and demand an investigation?  Most people would just walk up the frozen staircase and not give it a second thought. You don’t have to take my word for it.  Just go out in the wild, find a frozen escalator and see what happens. The escalator in the mall I go to is usually not working.  There is no outrage or complaints to the manager. People just walk up and down it using the stair function.  That is what most people know about escalators from personal experience.  This post will examine how you could think about that problem.  But first – a few facts about escalators.

There are about 35,000 escalators in the US. Escalator density varies widely from state-to-state from much higher number in large metropolitan areas to only 2 escalators in the state of Wyoming.  Performance metrics are available for systems where they are used extensively like transit systems. Systems are rated on availability and how long they operate before failing.  The engineering metric is Mean Time Before Failure (MTBF).  An example from one metro transit system of 588 escalators measured availability at about 92% and MTBF of 153 hours (6.4 days). The average time to repair those escalators was 14 hours.  Of all the maintenance work done only 32% was scheduled.  The remainder was due to service calls, safety repairs, and customer incidents.  Interestingly service calls included escalators that turned off unexpectedly. All this data indicates that escalators are high maintenance devices compared with other commonly used devices like your automobile.

There are an estimated 10,000-17,000 escalator related injures per year.  75% of those injuries are from falls and slips (1).  Risk factors include advanced age and alcohol use. Many of those injuries are severe enough to require admission to a trauma center and in rare cases can result in death.

If you encounter a frozen escalator or one working erratically you could tell yourself: “Well I know from my personal experience that escalators will not be working from time to time. This is a little annoying but I can walk up the escalator or find an elevator like everyone else. I assume the next time I am here it will be repaired.”  If you know more about escalators you might think: “I know escalators have a high failure rate and about one in ten may not be available on any given day – this is to be expected.  I will just work around it”  After all the escalator was put there for the convenience of customers and the public.

These lines of thought are the collective reality that we experience. In considering a probability model of thought our collective experience creates a high probability that when we encounter a broken escalator, we will consider it a routine occurrence and quickly move to a work around.  A thought experiment illustrates this fact.  If I poll 100 people on how they handle a broken escalator – most of them will give the expected responses.  The outliers may be people who know about escalator maintenance or how these situations need to be handled.

But there are outliers.  Outliers could have phobias about escalators.  Escalators have well known safety hazards of falling and slipping. They have an awkward motion for many people and a person with vertigo or other balance problems may find it difficult to use them.  These people may have had a mishap on an escalator and sustained an injury.  There is a term for escalator phobia that I will not use here because I don’t think it adds much. People who are phobic of escalators may tend to avoid them.  That is easier to do in shopping malls than transit systems.  Not having worked in escalator dense areas I have never encountered a person with that phobia but have seen many people with phobias about crossing bridges and railroad tracks. 

Are there other ways to think about a broken escalator than just inconvenience.  As I was writing this, I thought of Jason Bourne one of my favorite fictional movie characters.  In the famous escape from Waterloo Station the scene begins and ends with escalators.  Fortunately for Bourne they were working in both cases.  But if they were not working, we can speculate he would probably be seeing the problem though his usual combination of situational awareness that would include alternate routes and what could be used to his strategic advantage.  The bottleneck created is an example of potential strategic use.

There are outliers beyond the outliers.  Folks with unique interpretations of everyday situations at a frequency of one person in a thousand to ten thousand.  They may have never seen an escalator or how it works.  But if they were born and raised in a modern society that is not very likely.  One recent interpretation was that the escalator was not working because it was sabotaged.  Where does sabotage fit in to a probabilistic model of everyday thought?  Sabotage is an unlikely explanation of everyday events.  People who I have professionally encountered over the years have told me about how the electricity in their home, their health, their food, their pets, their automobile, their work, their spouse, their legal status, and their finances were sabotaged by several methods.  Some of the methods were incredible like beams from satellites or delivery vans parked outside on the street using some kind of electronic device.  Others seemed more possible like “they came in the middle of the night and replaced my wife while we were sleeping.  She looks sounds, and acts the same but I know she is not real.”

Note the operative term they in the above scenarios.  They are a possible or imagined enemy causing the real or imagined problems. They can easily be a scapegoat.  Rod Serling was an expert in looking at how this dynamic plays out in society.  Slightly after the McCarthy era – he wrote an episode of the Twilight Zone called The Monsters are Due on Maple Street.  The entire plot focuses on what happens when there is a power outage on a residential street and people start looking for a scapegoat.  The final narrative is a comment on human nature and how we can be counted upon as a group to get the probabilities wrong.

What happens if the sabotage explanation persists and cannot be explained by groupthink, spycraft or reality?  Fixed false explanations and beliefs about action or delusions come to the attention of psychiatrists as paranoia on an individual level.  There are various disorders and those diagnoses depend on other features but one of the central features is the delusion.  There are also many people living in the community who are hypervigilant and suspicious without false beliefs who function normally.  Paranoia can be a personality feature or a delusion.

The ability to modify delusional beliefs by psychotherapy has been suggested since 1952.  Aaron Beck – one of the founders of cognitive behavior therapy published a case report (1) on the successful treatment of delusional thinking is a patient with schizophrenia.  Since then, techniques have been discussed in many supportive psychotherapy texts (2-5).  The common elements of psychotherapy including the therapeutic relationship, therapeutic alliance, and specific interventions necessary to discuss delusions are all covered in detail.  A detailed phenomenological interview and discussion are necessary focused on the onset of the thought.  This is necessary to explore emotional elements and how they potentially lead to a delusion.  Anxiety is a common initial state with many delusions being an explanation for the anxiety.

In the case of escalators – it is easy to imagine a person anxious and rushing to an appointment or trying to complete their shopping and they discover the escalator they use for that purpose is broken.  They may express frustration: “Why today?”, Why me?”, “Today of all days!”, etc.  But it is unlikely that they would think the escalator is sabotaged to prevent them from completing their task. Having an established set of delusions prior to the incident would increase the probability of thinking about sabotage.     

If I was seeing a patient with escalator paranoia telling me about how the escalators he was using were sabotaged – I would proceed with preparation for the therapy with the basic steps outlined above.  At some point we would need to discuss alternate explanations for the escalator malfunction.  That list may look like this and this list is not exhaustive:

1:  Need for service or maintenance/mechanical failure

2:  Power outage and other random events

3:  Imagined sabotage by a real or imagined enemy

4:  Control by a government agency

5:  A sign from a deity – a curse or a message

6:  Telekinesis – the person observing the malfunction believes he is causing it telepathically.

That discussion would examine whatever theories a person has with the goal of moving toward numbers 1 and 2 on the list.  That conversation as psychotherapy may take several months before there is any significant progress. It could involve gathering much evidence for and against the hypotheses and beliefs.  The contrast with politics and the Twilight Zone episode is interesting because it potentially works in the opposite direction. Direct evidence against the hypothesis is never considered since it is based on a political theory of persecution.  The message is reinforced by loyal followers and affiliated media.  These days that involves significant amplification through social media. The press in general does a very poor job of fact checking and refuting the process that Rod Serling correctly characterized in 1960 (6).  That group dynamic is difficult to stop and we currently watching that unfold.    

 

George Dawson, MD, DFAPA

 

References:

1:  Schminke LH, Jeger V, Evangelopoulos DS, Zimmerman H, Exadaktylos AK. Riding the Escalator: How Dangerous is it Really? West J Emerg Med. 2013 Mar;14(2):141-5. doi: 10.5811/westjem.2012.12.13346. PMID: 23599850; PMCID: PMC3628462.

2:  Beck AT. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry. 1952 Aug;15(3):305-12. doi: 10.1080/00332747.1952.11022883. PMID: 12983446.

3:  Perris C.  Cognitive therapy with schizophrenic patients.  New York. The Guilford Press, 1989: 160-186.

4:  Wright JH, Turkington D, Kingdon DG, Basco MR.  Cognitive-behavioral therapy for severe mental illness – an illustrated guide.  Arlington, VA.  American Psychiatric Publishing, Inc., 2009:  99-123.

5:  Garrett M.  Psychotherapy for psychosis – integrating cognitive behavioral and psychodynamic treatment.  New York.  The Guilford Press, 2019: 194-197.

6:  Novalis PN, Rojcewicz SJ, Peele R.  Clinical manual of supportive psychotherapy.  Washington, DC. American Psychiatric Press, 1993: 138-146.

7:  Serling R.  The monsters are due on Maple Street.  Twilight Zone.  Season 1, Episode 22 originally aired on March 4, 1960. YouTube clip.

 

Graphics Credit:

Sascha Kohlmann, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons 

The FDA and the Trump Formulary or What Separates Physicians from Politicians

 

 

The difference between politicians and physicians was on full display at President Trump and HHS Secretary Robert Kennedy press conference several days ago.   It was hyped as an important announcement about autism for a month. They announced that Tylenol (acetaminophen or APAP hereafter) was a cause of autism.  In the associated hyperbole – Trump shouted not to take Tylenol and suggested that pregnant women should "tough it out".  That even though fever alone is a risk factor for complications of pregnancy and there are no safer analgesics.  Kennedy suggested that this was somehow “transparency” about science at the FDA, CDC, and HHS, praised their cooperation and suggested that past research was somehow flawed because of a focus on genetics.

The news media had a field day with the press conference.  Twenty-four-hour news channels were playing it every half hour. Controversy rather than accuracy is how they get views. What better way to describe science as pushback on the Trump Kennedy statements.  Real science is now pushing back against political rhetoric that claims to have essentially replaced the scientific method.  It is a case study in political black and white thinking versus the probabilistic thinking of medicine and science.

The purpose of this post is to look at the science and the rhetoric around this conference. Acetaminophen (APAP) has been FDA approved since 1951.  The first Tylenol product was an elixir for children marketed in 1955.   It was approved as an over-the-counter medication in 1960 using an FDA monograph procedure that allowed drugs to be grandfathered in if they were in general use prior to the stricter regulations that began in the 1970s. These monographs are updated with new information including risks in pregnancy. 

The Trump-Kennedy Autism Press Conference (TKAC) suggests that physicians may not be aware of APAP toxicity as much as they should be.  The reality is that physicians are highly aware of that problem. As interns, most physicians are involved in treating APAP overdoses and preventing severe hepatotoxicity and death. APAP toxicity is the second leading cause of liver transplantation worldwide. Only half of the overdoses are intentional with the remainder either accidental (due to mixing APAP containing products or not following the directions) or taking APAP with alcohol use, alcoholic liver disease, liver disease, nutritional compromise, or herbal supplements. It is critical that APAP toxicity is recognized as soon as possible to prevent irreversible liver damage and death.  It is the reason why OTC bottles of APAP have the following warnings:

On the warning for pregnant or breast-feeding women, the FDA has risk categories in the approved labelling.  APAP is listed as a Category C drug defined as shown in the slide below.  In 2015 the FDA stopped using the category system and started using the Pregnancy and Lactation Labeling Rule (PLLR) – a more detailed narrative form. Despite a letter to physicians from the FDA on the APAP in pregnancy issue and the standard advice physicians have used for years I can find no new FDA package insert and no detailed PLLR language from that agency. 

This post will discuss these issues is to look at the history, rhetoric, and epidemiology in this post and then depending on how much information I think is relevant to post on the genetics, pathophysiology, and toxicology of autism in subsequent posts.  I will touch on a few of those points here to address the rhetoric.

The TKAC conference characterized autism as a “crisis” and cited an unexplained increase in the prevalence of autism over the past 20 years.  By unexplained I mean they were taking it at face value as a real increase rather than reading the research and what those authors had to say about the reasons. The reality of the prevalence numbers and the design of these studies need to be examined. I have previously posted that variation in prevalence estimates for psychiatric disorders depends a lot on methodology.  That includes the study design, how the subjects are recruited, the assessments used to make the diagnoses, and the data analysis.  There are also cultural effects over time on the same culture and in comparisons of different international cultures.

In the United States there has been a marked increase in awareness of autism.  That awareness has increased significantly with the advent of the DSM 5 autism spectrum disorder diagnosis.  It is common to hear people declare that they think that either they or someone they know “is on the spectrum.”  That includes celebrities.  Increased awareness can increase early identification programs that can increase the prevalence.  The expansion in prevalence also reflects the inclusion of people with less severe symptoms.  An example comes from the ADDM CDC study that looks at autism prevalence between selected states.  Cases are identified through educational and medical records.  California had the highest 4- and 8-year-old autism rates of any state and it was thought to be due to a program that trained hundreds of pediatricians to identify cases early and refer them to local centers for intervention.    

The diagnostic criteria for autism have also evolved as shown in the diagram below.  From very few criteria applied to more disabled populations (Kanner, Rutter) to more elaborate criteria that went from a syndrome (DSM-IV) to a spectrum (DSM 5) encompassing milder forms of the disorder (7,8). That expectedly increases the prevalence of the disorder.  The smaller graphic illustrates that 3 DSM-IV syndromes were collapsed into a DSM 5 autism spectrum disorder.  I am on record that the term spectrum makes no biological sense to me.  It is merely a convenient way that humans have to deal with very complicated biological processes.  In this case nosological convenience has blurred the boundary between people with mild forms of the disorder and no disorder.  The DSM deals with that like it does with all disorders by including a necessary significant impairment in functioning term.

Very few prevalence studies look at cross sections of all the patients with that diagnosis in the community (12). In acute care psychiatry it is common to see 50- to 70-year-old adults in crisis situations because the parents they were living with have been hospitalized or died. These same people will not be in a medical or educational database with the studied diagnoses and will not be counted in those prevalence estimates.  I have been able to locate only one study (12) showing that using the same criteria at the same point in time - the prevalence of autism in the older population is the same as it is in the younger population.

Another consideration of prevalence is that is the diagnosis of autism is not an easy one.  It assumes the clinician has expertise in making the diagnosis and has adequate time to gather and consider all the necessary information. A paper by Fusar-Poli et al (13) highlights typical errors of misdiagnosis, the lag between first presentation and the accurate diagnosis, and reasons behind those misdiagnoses in a large sample of people presenting to specialty clinics for a diagnosis of autism spectrum disorder (ASD). That same paper begins with a vignette of a middle-aged man living in the community with some assistance to illustrate how autism can present in the older undiagnosed population.    

An interesting footnote about criteria. Like all psychiatric disorders at one point in time only psychological causes were considered as etiologies for the disease.  In the case of autism it was the refrigerator mother hypothesis.  Cold, distant mothers were considered the cause of autism.  Folstein and Rutter’s 1977 genetic study of autism helped to reverse that line of thinking and bring the likely cause back to genetics and biology.  

That biological cause was a focus of criticism in the TKAC conference.  Secretary Kennedy went on record stating that genetic research is unproductive and produces no “actionable” information.  Throughout most of my career the same was said about Huntington’s Disease.  When the genetic tests for Huntington’s came on the scene, we used them like everyone else but there was still not much optimism about an effective treatment that addressed the pathophysiology of the disorder. All of that may have changed a few days ago when a report about a therapy for Huntington’s (10) that may slow progression was made public. (9) There are currently several papers about the potential for using gene therapy for autism and other developmental disorders(11).

With all the criticism of current research at this news conference a couple of major actionable research discoveries were not covered.  The first are studies that show paternal and maternal age are risk factors for autism in offspring (14-21).  Increasing age of the father and mother are both risk factors for offspring with autism.  Paternal age greater than 50 years old doubles the risk of a child with autism compared with 20-29 yr old fathers. (20).  Spontaneous mutations in DNA are a likely mechanism but several others are hypothesized.

DNA effects would also suggest that environmental factors leading to mutations may be important.  The work done at the NIH (22-25) on this issue was not mentioned at all. One of the researchers in this area announced that her lab was terminated by the Trump administration.  She was working on the effect of environmental toxins on parental DNA and her research showed an effect for maternal solvent exposure, pesticide exposure and low fatty acid intake, and occupational exposures to phenols, ethylene oxide and pharmaceuticals.  All these exposures are actionable by a government interested in protecting people from environmental and occupational toxic exposures.

Coming back to the rhetoric of the TKAC conference the overall goals seem clear – to persuade the American people that there is a crisis, that politicians rather than scientists are best equipped to solve that crisis, and that politicians can give you medical advice but at the same time you should consult with your physician.  This is typical authoritarian rhetoric and if you really believe it – there is no longer any need for science or medicine. The “crisis” in terms of increased prevalence is explainable by broadened diagnostic criteria, inclusion of less severely disabled individuals, and increased awareness. The statement about the toxicity of acetaminophen is also exaggerated since in the end – despite the President declaring that nobody should use acetaminophen – both he and the HHS Secretary walked those statements back to the current recommendations to “consult your physician.”  The criticism about the lack of actionable research suggests a lack of awareness of what has been done – including work by government scientists who were fired by this administration.  I have illustrated this with a small fraction of the autism research that is currently out there.

As a final preliminary comment – politics and rhetoric occur both inside and outside of medicine.  I have seen similar statements made by researchers over the years that in the end did not pan out.  They did not pan out because those hypotheses were exhaustively investigated and disproven by other researchers attempting to replicate that research.  There is no similar political process. In medicine especially in some epidemiological research - a clear answer at the margins is often not possible. That is why medical treatment does not guarantee a result and involves a detailed informed consent discussion of potential risks and benefits.  In politics - all it takes for a new hypothesis is somebody winning an election.  And when that happens it is more likely to be a declaration than a hypothesis.

Do the American people really want to make health care decisions based on who won an election?    

 

George Dawson, MD, DFAPA

 

References:

1: Rosen NE, Lord C, Volkmar FR. The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. J Autism Dev Disord. 2021 Dec;51(12):4253-4270. doi: 10.1007/s10803-021-04904-1. Epub 2021 Feb 24. PMID: 33624215; PMCID: PMC8531066.

2: Brugha TS, McManus S, Bankart J, Scott F, Purdon S, Smith J, Bebbington P, Jenkins R, Meltzer H. Epidemiology of autism spectrum disorders in adults in the community in England. Arch Gen Psychiatry. 2011 May;68(5):459-65. doi: 10.1001/archgenpsychiatry.2011.38. PMID: 21536975.

3: Kanner L. Autistic disturbances of affective contact. Nervous child. 1943 Apr;2(3):217-50.

4: Folstein S, Rutter M. Infantile autism: a genetic study of 21 twin pairs. J Child Psychol Psychiatry. 1977 Sep;18(4):297-321. doi: 10.1111/j.1469-7610.1977.tb00443.x. PMID: 562353.

5: Murphy D, Glaser K, Hayward H, et al. Crossing the divide: a longitudinal study of effective treatments for people with autism and attention deficit hyperactivity disorder across the lifespan. Southampton (UK): NIHR Journals Library; 2018 Jun. (Programme Grants for Applied Research, No. 6.2.) Chapter 17, Improving outcomes through better diagnosis: the effects of changes in DSM-V on clinical diagnosis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK518676/

6: Shaw KA, Williams S, Patrick ME, et al. Prevalence and Early Identification of Autism Spectrum Disorder Among Children Aged 4 and 8 Years — Autism and Developmental Disabilities Monitoring Network, 16 Sites, United States, 2022. MMWR Surveill Summ 2025;74(No. SS-2):1–22. DOI: http://dx.doi.org/10.15585/mmwr.ss7402a1.

7: Arvidsson O, Gillberg C, Lichtenstein P, Lundström S. Secular changes in the symptom level of clinically diagnosed autism. J Child Psychol Psychiatry. 2018 Jul;59(7):744-751. doi: 10.1111/jcpp.12864. Epub 2018 Jan 29. PMID: 29377119.

8: Avlund SH, Thomsen PH, Schendel D, Jørgensen M, Clausen L. Time Trends in Diagnostics and Clinical Features of Young Children Referred on Suspicion of Autism: A Population-Based Clinical Cohort Study, 2000-2010. J Autism Dev Disord. 2021 Feb;51(2):444-458. doi: 10.1007/s10803-020-04555-8. PMID: 32474837.

9: Tabrizi SJ, Flower MD, Ross CA, Wild EJ. Huntington disease: new insights into molecular pathogenesis and therapeutic opportunities. Nature Reviews Neurology. 2020 Oct;16(10):529-46.

10: Kaiser J.  In a first, a gene therapy seems to slow Huntington disease.  Science, September 24,2025.  doi:10.1126/science.zbkgxvm

11: Sahin M, Sur M. Genes, circuits, and precision therapies for autism and related neurodevelopmental disorders. Science. 2015 Nov 20;350(6263):10.1126/science.aab3897 aab3897. doi: 10.1126/science.aab3897. Epub 2015 Oct 15. PMID: 26472761; PMCID: PMC4739545.

12:  Brugha TS, McManus S, Bankart J, Scott F, Purdon S, Smith J, Bebbington P, Jenkins R, Meltzer H. Epidemiology of autism spectrum disorders in adults in the community in England. Arch Gen Psychiatry. 2011 May;68(5):459-65. doi: 10.1001/archgenpsychiatry.2011.38. PMID: 21536975.

13:  Fusar-Poli L, Brondino N, Politi P, Aguglia E. Missed diagnoses and misdiagnoses of adults with autism spectrum disorder. Eur Arch Psychiatry Clin Neurosci. 2022 Mar;272(2):187-198. doi: 10.1007/s00406-020-01189-w. Epub 2020 Sep 6. PMID: 32892291; PMCID: PMC8866369.

14: Hultman, C. M., Sandin, S., Levine, S. Z., Lichtenstein, P., & Reichenberg, A. (2011). Advancing paternal age and risk of autism: New evidence from a population-based study and a meta-analysis of epidemiological studies. Molecular Psychiatry, 16(12), 1203–1212. https://doi.org/10.1038/mp.2010.121

15: S. E. W. Sandin et al., "Autism risk associated with parental age and with increasing parental age difference in a population-based cohort of 5,766,794 children," Molecular Psychiatry, 2015

16: Wu, S., Wu, F., Ding, Y., Hou, J., Bi, J., & Zhang, Z. (2017). Advanced parental age and autism risk in children: A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 135(1), 29–41. https://doi.org/10.1111/acps.12666

17: Reichenberg, A., Gross, R., Weiser, M., Bresnahan, M., Silverman, J., Harlap, S., Rabinowitz, J., Shulman, C., Malaspina, D., Lubin, G., Knobler, H. Y., Davidson, M., & Susser, E. (2006). Advancing paternal age and autism. Archives of General Psychiatry, 63(9), 1026–1032. https://doi.org/10.1001/archpsyc.63.9.1026

18: Wood, K. A., & Goriely, A. (2022). The impact of paternal age on new mutations and disease in the next generation. Fertility and Sterility, 118(6), 1001–1012. https://doi.org/10.1016/j.fertnstert.2022.

19: McGrath, J. J., Petersen, L., Agerbo, E., Mors, O., Mortensen, P. B., & Pedersen, C. B. (2014). A comprehensive assessment of parental age and psychiatric disorders. JAMA Psychiatry, 71(3), 301–309. https://doi.org/10.1001/jamapsychiatry.20

20: Sandin, S., Hultman, C. M., Kolevzon, A., Gross, R., MacCabe, J. H., & Reichenberg, A. (2012). Advancing maternal age is associated with increasing risk for autism: A review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 51(5), 477–486.e1. https://doi.org/10.1016/j.jaac.2012.02.018

21: Ye Q, Apsley AT, Hastings WJ, Etzel L, Newschaffer C, Shalev I. Parental age at birth, telomere length, and autism spectrum disorders in the UK Biobank cohort. Autism Res. 2024 Nov;17(11):2223-2231. doi: 10.1002/aur.3258. Epub 2024 Oct 30. PMID: 39474987.

22: McCanlies EC, Gu JK, Ma CC, Sanderson WT, Ludeña-Rodriguez YJ, Hertz-Picciotto I. The effects of parental occupational exposures on autism spectrum disorder severity and skills in cognitive and adaptive domains in children with autism spectrum disorder. Int J Hyg Environ Health. 2025 Jul;268:114613. doi: 10.1016/j.ijheh.2025.114613. Epub 2025 Jun 28. PMID: 40582232; PMCID: PMC12415903.

23: McCanlies EC, Gu JK, Kashon M, Yucesoy B, Ma CC, Sanderson WT, Kim K, Ludeña-Rodriguez YJ, Hertz-Picciotto I. Parental occupational exposure to solvents and autism spectrum disorder: An exploratory look at gene-environment interactions. Environ Res. 2023 Jul 1;228:115769. doi: 10.1016/j.envres.2023.115769. Epub 2023 Mar 31. PMID: 37004853; PMCID: PMC10273405.

24: McCanlies EC, Ma CC, Gu JK, Fekedulegn D, Sanderson WT, Ludeña-Rodriguez YJ, Hertz-Picciotto I. The CHARGE study: an assessment of parental occupational exposures and autism spectrum disorder. Occup Environ Med. 2019 Sep;76(9):644-651. doi: 10.1136/oemed-2018-105395. Epub 2019 Jun 27. PMID: 31248991.

25: Schmidt RJ, Kogan V, Shelton JF, Delwiche L, Hansen RL, Ozonoff S, Ma CC, McCanlies EC, Bennett DH, Hertz-Picciotto I, Tancredi DJ, Volk HE. Combined Prenatal Pesticide Exposure and Folic Acid Intake in Relation to Autism Spectrum Disorder. Environ Health Perspect. 2017 Sep 8;125(9):097007. doi: 10.1289/EHP604. PMID: 28934093; PMCID: PMC5915192.

26: Pernia S, DeMaagd G. The New Pregnancy and Lactation Labeling Rule. P T. 2016 Nov;41(11):713-715. PMID: 27904304; PMCID: PMC5083079.

Reference Credit:

h/t to Tyler Black, MD @tylerblack32 for reference 12.

Graphics Credit

1:  DSM-IV and DSM 5 graphics are from the respective DSMs copyrighted by the American Psychiatric Association and reproduced here only for educational purposes.  

2:  FDA package insert information is reproduced here and considered in the public domain.

3:  The detailed ADDM graphic of ASD prevalence by state is form the Mortality and Morbidity Weekly Report (MMWR) (see reference 6 and is in the public domain).

Commentary on the Trump Kennedy Press Conference Commentaries with time points in the transcript: 

1:  Trump at 4:43

“Which is basically commonly known as Tylenol during pregnancy and can be associated with a very increased risk of autism. So taking Tylenol is not good. All right, I'll say it; it's not good. For this reason they are strongly recommending that women limit Tylenol use during pregnancy unless medically necessary. That's, for instance, in cases of extremely high fever that you feel you can't tough it out; you can't do it. I guess there's that. It's a small number of cases, I think. But if you can't tough it out, if you can't do it, that's what you're going to have to do. You'll take a Tylenol, but it'll be very sparingly. It can be something that's very dangerous to the woman's health. In other words, a fever that's very, very dangerous and ideally a doctor's decision because I think you shouldn't take it, and you”

Trump simultaneously skirts the issue of the potential dangers of acetaminophen in pregnancy while walking back that recommendation to the current package insert statement (see graphic above). 

2:  Trump at 36:59

“I understand it's maybe 10% of the women that are pregnant would perhaps be forced to use it, and that would mean you just can't tough it out. No matter what you do, you can't tough it out. So that's up to you and your doctor.”

Trump seems to confuse the analgesic effect of acetaminophen with the antipyretic effects important to prevent complications of pregnancy.  

3:  Trump at 40:12

“Don't take Tylenol. Don't give Tylenol to the baby after the baby's born. Every time the baby gets a shot, the baby goes, gets a shot, they say, "Here, take a couple of Tylenol." I've heard that for years. Take Tylenol. Don't take Tylenol, don't have your baby take Tylenol. Now, Tylenol is fine for people that aren't pregnant, that aren't in the situation that we're talking about one very specific situation. If you're pregnant, don't take Tylenol. When you have your baby, don't give your baby Tylenol at all unless it's absolutely necessary. Don't do it.”

Trump clearly states not to take acetaminophen if you are pregnant - with no package insert qualifier. He also suggests that it is dangerous for infants. 

4:  Trump at 44:03

“And the other things I told you about, just… The word, tough it out. It's easy for me to say tough it out. But sometimes in life with a lot of other things, you have to tough it out also. Don't take Tylenol. Don't give Tylenol to the baby. When the baby's born, they throw it at you, "Here, give them a couple of Tylenol." They give them a shot. They give them a vaccine. And every time they give them a vaccine, they throw in Tylenol. And some of these babies they're long born, and all of a sudden they're gone. And it doesn't hurt not to do it. It doesn't hurt. There's no downside. There's no downside at all.”

Trump persists with his "tough it out" message missing the point of acetaminophen use in pregnancy.  He also suggests that vaccinations lead to more acetaminophen use in infants. 

5:  Kennedy at 14:10

“NIH research teams are currently testing multiple hypotheses with no area off-limits. We promise transparency as we uncover the potential causes and treatments, and we will notify the public regularly of our progress. Today we are announcing two important findings from our autism work that are vital for parents to know as they make these decisions. First, HHS will act on acetaminophen. The FDA is responding to clinical and laboratory studies that suggest a potential association between acetaminophen used during pregnancy and adverse neurodevelopmental outcomes, including later diagnosis for ADHD and autism. Scientists have proposed biological mechanisms linking prenatal acetaminophen exposure to altered brain development. We have also evaluated the contrary studies that show no association. Today, the FDA will issue a physician's notice about the risk of acetaminophen during pregnancy and begin the process to initiate a safety label change. HHS will launch a nationwide public service campaign to inform families and protect public health.”

No mention of the research program cancelled by the Trump administration as noted above. Not clear who he means when he talks about "we" evaluating studies.  Does he mean him and Trump?  Is there anybody left at NIH, CDC, HHS who can do those evaluations?

6:  Kennedy at 15:28

“The FDA also recognized that acetaminophen is often the only tool for fevers and pain in pregnancy, as other alternatives have well-documented adverse effects. HHS wants, therefore, to encourage clinicians to exercise their best judgment and use of acetaminophen for fevers and pain in pregnancy by prescribing the lowest effective dose for the shortest necessary duration and only when treatment is required. Furthermore, thanks also to the politicization of science. The safety of acetaminophen against the risk of neurodevelopmental disorders in young children has never been validated.”

Kennedy takes credit for the longstanding advice on the package insert of acetaminophen - namely discuss with your physician. 

7:  Kennedy at 52:13

"But also it's just common sense, because you're only seeing this in people who are under 50 years of age. If it were better recognition or diagnosis, you'd see it in 70-year-old men. I've never seen this happening in people my age. I've never seen a case of full-blown autism, and that means profound autism, I want to be very careful, head banging, stimming, toe walking, nonverbal, non-toilet trained. I've never in my life seen a 70-year-old man who looks like that. You're only seeing it in kids. It's an epidemic"

Kennedy simultaneously displays his lack of knowledge about the historical development of the autism diagnosis (DSM-IV restricted age of onset to 3 years) and perpetuates a stereotype of a person with severe developmental disabilities who would typically require institutional care.  There are many older individuals with ASD living in the community - some may be your neighbors. And as noted in the above post - the expansion in prevalence has occurred primarily due to milder cases that were included in new diagnostic criteria.

How To Fail A Sleep Test...

 

“Xi – Kah – Vah” 

“Xi – Kah – Vah” 

“Xi – Kah – Vah”  ….

I kept repeating this mentally hoping my old Transcendental Meditation mantra would send me off to sleep. That was after I had repeated the US Army relaxation technique that was guaranteed to bring on sleep.  It was 3AM and I was still wide awake.  Still worse – I was in a sleep lab trying to find out why my AHI has been pegged for the past 3 months.  AHI is the Apnea-Hypopnea Index and according to the manufacturer of my CPAP machine is measure the number of apneic episodes per hour that last longer than 10 seconds.  For the 20 years I have been on CPAP – the number has been 1-3, but 3 months ago it started going up to 10+ with no good explanation - other than possible central sleep apnea in addition to obstructive sleep apnea.  

My body weight and general life style have not changed at all.  I continue to get good overall scores on my CPAP machine despite the AHI.  I consulted my sleep medicine doc and he decided to increase the pressure and see if that worked.  It did not - so we decided to do another sleep lab test or polysomnography. It is a big deal since you are observed and filmed, connected to electrodes (EEG, ECG, OCG, laryngeal vibration, chest and abdominal respirations, legs (for RLS), and masseters for bruxism.  You are also sleeping in a strange place.

An unsettling factor in the mix is that according to polygenic risk analysis – I am loaded for Amyotrophic Lateral Sclerosis (ALS) genes.  And by loaded, I mean I am in the 100^th percentile for risk.  I am not aware of central sleep apnea being the initial sign of ALS and neither was my sleep medicine doc – but I do not want to be the first case report.  So, I am hoping those genes remain quiescent and do not express themselves. 

I showed up at the lab at 8PM.  A technician explained their protocol and that after I was connected, I needed to contact her via the intercom if I needed to get up at night.  Under no circumstances was I supposed to get up by myself because it would endanger all the electrode connections.  I told her I was ready and she came back in and hooked me up over a period of about 20 minutes and then tested the connections. She also explained that I was not going to be started on CPAP - it would be added later in the night only if I needed it and then BiPAP would be added on top of that if I needed it.  Since I already had a diagnosis of obstructive sleep apnea (OSA) – that did not make a lot of sense to me.  But I was not upset and wanted to proceed with the ordered protocol.  I watched TV for about 20 minutes and it was lights out by 10PM.   

It did not take long to realize that I was just laying there thinking.  I recalled my first polysomnography in a sleep lab that was built in the Neurology Clinic of the hospital where I worked.  I had the feeling at that time that I did not sleep a wink but the tech said – “Oh no you slept all right and you have severe sleep apnea.” (AHI>50).  Since that time, I have been 100% compliant with CPAP.  I use it every night – no matter where I am. 

I checked my watch and it was 1AM.  Three hours of laying there thinking and no sleep in sight.  Time to try my sleep reverie trick.  Sleep reverie is a reliable sign of sleep onset being very close and, in my case, it takes the form of vivid and often nonsensical mental images.  For example – the image of a man walking down metal stairs from a loading dock.  A man working on an outboard motor.  A futuristic gray pickup truck driving down the road.  A 500 ml beaker in front of a small flat screen TV.  These images flash for a few seconds and I am asleep.  Some time ago, I thought I could speed sleep onset by recalling the early states of sleep reverie.  What did it feel like in the body and brain just before the images started?  I tried reproducing those sensations several times and almost had it.  I generated a brief flash of sleep reveries and it was gone – I was still wide awake.

I checked my watch and it was 3AM.  Still wide awake.  Flash on my mantra, muscle relaxation, breathing exercises, mindfulness exercises – all the tricks of the trade and I got nothing. My mind is wandering to far away places.  I am back in Africa in 1974 traveling up into the Aberdare Mountains to visit friends.  I am 25 years old and traveling with a young woman who is 23.  We are travelling in a high-speed taxi called a matatu.  They come in various forms but this one is a small Toyota pick up truck with a metal enclosure over the back.  My travelling companion and I are crammed into that enclosure with a dozen villagers trying to get up into the mountains.  Every time I got out of one of these things - I kissed the ground.  Many people were killed in matatus every year. I remember how we both looked.  We did not say much.  We knew we had to get to that school before dark and were focused on making good time.  I see us walking the final 1/2 mile along a dirt road like it is a movie.  I flash ahead to hiking in the bamboo forest with her future husband and a mutual friend.  I flash ahead to getting overrun by soldier ants at his house up in the mountains and wondering if we were going to survive that night.  In the end we were saved by a paraffin refrigerator -  ants do not cross a line of kerosene.  I think about a good friend who lived on my school compound and what it would have been like to talk regularly with him over the past 50 years - like we talked back then.

I checked my watch again and it was 5AM.  The technician’s voice came over the intercom: 

“You are not sleeping.”

“I know – I came close a few times – but never fell asleep.” (referring to the aborted sleep reveries).

“Do you want to just get up and leave?”

“I suppose”.

The technician came in and took about 10 minutes to disconnect all the electrodes.  I had 6 piles of salt and electrode paste on my scalp. 

“It should come off with just shampoo. Your doctor will look at the study.  He may decide to have you come back and give you a sleeping pill.”  

I thought about what happened on the way home calling on my years of studying sleep. I have had insomnia since I was a little kid with night terrors – but I only stayed awake all night long when it was necessary for my role as a physician. The first time was covering the coronary care unit as an intern and believing that another intern and I were responsible for a person on a balloon pump who was actively bleeding. Even as a psychiatrist there were the occasional all-nighters – typically catatonic patients who had questionable intake or agitation and aggression that did not respond to the usual measures.  And of course, complicated medical problems that always seemed to end up on my unit.  It got worse with the electronic health record because I could see almost everything from home.  But none of that is a problem in retirement.  My sleep is generally normal and I have no problem getting at least 6-7 hours per night.

The behavioral aspect of sleep provides some clues.  We all learn to fall asleep in a certain environment.  The environment I am used to is hooked up to a CPAP machine.  It has a certain sensation and noises.  The air splint from the pressure creates a certain internal sensation. Even though I was not bothered by trying to sleep without it – the lack of those sensations may have been the reason I could not sleep at all. 

A second issue was the bed.  I was handed a remote control and advised I could adjust the firmness of the mattress with the remote.  I did it at every time check dropping it by 30 percent each time.  By 5AM I was down to 30 (where 100 is the firmest).  I recently changed my home mattress and it required a trial before I could find an exact replacement.  There is a literature on mattress qualities and sleep that looks at firmness, temperature, and materials.  Most of the studies are interested in sleep but some look at spinal alignment and pain.  The results are generally mixed probably due to patient characteristics.  For example, although one review (1) finds that a medium firm mattress may work for most people – there are still are those at both ends of the spectrum that sleep better with very firm or soft mattresses.  I purchased my last mattress based on a study that I think was in the British Journal of Medicine (BMJ) suggesting that pillow top mattresses may work the best. With the replacement I tried a firm orthopedic mattress that resulted in back pain every day.  A new pillow top worked very well.  The sleep lab bed did not seem to change at all with the remote control and that may also have been a factor.  

So how do you fail a sleep study?  The short answer is by not sleeping but there are complicating factors.  I am waiting to find out if there will be a modified protocol and watching my AHI.

George Dawson, MD, DFAPA

 

1:  Caggiari G, Talesa GR, Toro G, Jannelli E, Monteleone G, Puddu L. What type of mattress should be chosen to avoid back pain and improve sleep quality? Review of the literature. J Orthop Traumatol. 2021 Dec 8;22(1):51. doi: 10.1186/s10195-021-00616-5. PMID: 34878594; PMCID: PMC8655046.     

A Primer on How to be Your Own Unity Messiah

 

I just finished a 9-hour road trip through Minnesota and Wisconsin last night.  No matter where I turned, I kept hearing the same stories.  The news was saturated with stories about what people have been calling the Charlie Kirk assassination.  Until that happened, I had no idea who he was and I ended up listening to too many descriptions.  From there it shifted to the alleged shooter.  I learned that despite turning himself in he was not cooperating with the police. The media continues to obsess about motivations and my only observation about that is that they must not watch much true crime TV. In true crime TV if you are not holding somebody up or trying to do away with your spouse – the most common motive by far is a) you are angry about something and b) you have a gun. That is all that it takes.  The myth that all gun owners are rational actors is just that. And that is the dilemma of easy and widespread availability of guns. 

After moving on from the analysis of personalities – most stories end on a provocative note.  I almost said poignant there but that would be a big mistake.  Reporters want to end in a flourish that involves a lot more than sadness.  To do that they portray the current situation as a modern-day crisis for which there is no apparent solution. A few examples:

“I can’t ever remember American politics being this divided.”

“There are people talking about a civil war – just like the Kirsten Dunst movie.”

“You can’t really lay down your arms for peace if the other side (meaning a political party) does not.”

“Some politicians are trying to tone down the rhetoric but good luck with that.”

It is very easy to get sound bites from politicians especially on the right to illustrate these points.  If the program is an interview format the question is asked “Well, how do we solve these and get people taking again.  How do we make American politics safe again?”  The guest typically has no answer. I listened to one show that had a recording of Bobby Kennedy speaking about race relationships after the Martin Luther King assassination.  It was a good unifying speech – but at the end of the clip the guest said: “Unfortunately we have no Bobby Kennedys today.”  Well, we have one but that is another story.

All these shows are portraying the current situation as hopeless. Unless there is some kind of Unity Messiah out there, we are all doomed. To that I say – are Americans really that dumb?  Granted we have proof by the current administration that the electorate is by no means a brain trust – but getting agitated about more political fiction is a whole new level. 

Let me break down what is happening here.  Since practically everything I heard was focused on the shooting incident I will start there. And I will start with statements made by prominent Republicans about the incident.  From what I heard Mr. Kirk was considered a favorite of President Trump and other prominent Republicans.  Without any evidence they began blaming the shooting on the “radical left”.  Some have claimed the shooter was “radicalized” by a semester preparing for an engineering major?  Others have made overt threats – going as far as saying that in a shooting war over the incident they will prevail.  There is no objective basis for any of these remarks.

As a psychiatrist – I am interested in reality - rather than sound bites, fomenting political unrest, or profiting from being an influencer or advertiser.  I am interested in helping you through this political and media crisis unscathed.   How do you deal with one party and the news media fomenting violent conflict and “Civil War.”  Here are a few tips:

1:  Ignore them – social media and its algorithms get credited a lot for funneling sensational content that you want to see directly and persistently to you.  All you must do is ignore it and it is easy to do.  I can say that it works very well.  I have all the major online retailers trying to sell me things every day and they are wrong 95% of the time.  That occurs just based on me ignoring their certain offers and algorithms.  I do the same thing on social media sites where people attempt to troll me.  They are as easily blocked or ignored. Staying engaged with trolls is the best way to end up in an escalating situation and a potential civil war.  An added benefit is that trolls typically have no useful content or logic. 

2:  In addition to falling for a false narrative – the same people producing these narratives are trying to produce bogeymen.  Bogeymen in this case are people that do not respond in a way that the creators of the false narrative want them to respond. That results in additional rage and threats.  The most obvious example so far are people who dare to comment on the situation, even by using Kirk’s direct commentary and in many cases recorded voice. Any hard conclusions about this language is condemned as “insensitive” or “hate speech” by representatives of the current government.  I will refrain from citing any examples here but there are many out there.  They are the direct result of years of conditioning from news that is entertainment and the idea that it has to be produced as provocatively as necessary.   

3:  Teach yourself about rhetoric – rhetoric has always been implicit in American education.  There is a debate team in high school – but formal exposure to rhetoric is unlikely even at the college level.  Learning how people are persuaded in one direction or another is a critical skill – especially at the level of analyzing how people are trying to manipulate you.  Americans seem generally clueless about this. In today’s reality there is no way that anybody should accept what a politician says at face value.

Here is a common example.  A shooting occurs and a politician states with no evidence that the shooter is from the radical left.  Subsequent information not only disproves this premature conclusion but that the shooter was a strong supporter of the politician making that remark.  Shooting number 2 occurs and the same remarks are made with no evidence.  At what point does that rhetoric become a conspiracy theory? The commonest forms of political rhetoric are designed to appeal to emotions.  You find yourself angry about something and a politician suggests not only a quick and easy explanation – but coincidentally suggests that they are the only one who can solve the problem and protect you. The next step is suggesting that to offer you the best possible protection you will need to give something up.  That may include your vote, personal freedoms, money, or the financial security of future generations.

4:  Recognize that when the suggested solutions are all based on rhetoric rather than on science, logic, and moral reasoning we are weaker as a country.  It makes real progress impossible. It makes it much easier for our enemies to influence our day-to-day life and interfere with elections. I heard only one story about how Russia, China, and Iran are involved in massive misinformation peddling about related conspiracy theories. We know it happens from the analysis of the 2020 election.  It is likely that your social media is influenced by these foreign actors trying to amplify emotional political differences. 

5:  Use your own emotions as a cue -  if you find that you are reading, listening, or watching some content that has you angry, agitated, worried, or sad just shut it off.  You are probably being manipulated for some reason.  Events can be truly sad and we have all experienced them.  But these days events are politicized and used to generate secondary emotions that may be unrelated to the reality of the situation.

To give a final example consider the internet argument.  Let’s say you are in your favorite social media venue and arguing with someone about investments, politics, a scientific paper, or any topic really.  The argument goes on and on and it gets more emotionally heated. Suddenly it shifts to personal attacks about qualifications, IQ points, or moral character. Neither party feels like they can stop until they “win” the argument. This is what I would call a rookie argument on the Internet.  Any more experienced person in this kind of debate would have truncated it immediately and walked away. 

That is where we are at in American politics today.  We have a party that is clearly interested in rhetorical rather than scientific, logical, or moral solutions.  They are quite eager to put up an endless stream of groundless arguments for consideration and have gone as far as announcing that is their political strategy.  They repeat these groundless arguments forever.  They seem to have an endless stream of people willing to engage in the rookie argument.             

The solution to the problem is not some Unity Messiah coming down the pike. It is following the steps I have outlined above.  In politics these days since the Supreme Court has equated free speech with money it would also involve not sending any of them a dime. But most importantly – just shut it down before it bothers you.  You will not be missing a thing.

On a neuroscientific basis – the importance of emotions in decision making has been known for decades.  Human decision making is not a strictly rational process but you can use rational processes to reel it in. There has never been a better time to train yourself to do it.  The truth is never enough if people are appealing to your emotions.   

 

George Dawson, MD, DFAPA

Projection Writ Large in American Politics.....

 

Recent events lead me to the conclusion that I should comment on them with the hope of breaking up the current pattern.  I see a lot of “hopes and prayers” commentary and “we need to unite like we did after 911” – but I don’t think that gets us very far.  What might help is recognizing the pattern, what it means, and using that knowledge to move ahead.    

Let’s start with the pattern.  To me it looks something like this. 

1:  Gun extremism for the past 20 years (as previously defined).  This results in no adaptive solutions for the problem for one of the major parties.

2:  Normalization of name-calling, blame, and rage by the President.  I don’t think any footnotes or references are needed at this point.  He posts something on almost a daily basis on his social media platform consistent with these activities. As Robert Jay Lifton said in 2017 commenting on the Trump Presidency as a descent into darkness “With Trump of course malignant normality becomes the rule because he’s President and what a President does tends to normalize potentially bad, evil, or destructive behavior.”

3:  Secondary spread of these patterns of behavior to everyone in his party – reinforced by mandatory compliance with his wishes using direct threats.

4:  Attributing all of the bad behavior to other people and another political party and acting as if that is true. 

In psychiatric parlance, 1 -> 4 above is referred to as projection.  I notice today that it is also used by commentators who are not psychiatric professionals.  A basic definition of projection is: ‘’Feelings and desires are not seen and admitted in oneself, but excluded from one’s experience and attributed to another.” (1)  In dealing with a person who uses that defense – it is common to feel like you are being blamed for something you are not responsible for and experience the associated anger.

But it can get even more complicated.  Kernberg writes:  “In contrast to higher levels of projection characterized by the patient’s attributing to the other an impulse he has repressed in himself, primitive forms of projection, particularly projective identification are characterized by: 1) the tendency to continue to experience the impulse that is simultaneously being projected onto the other person, 2) fear of the other person under that projected impulse, and 3) the need to control the other person under the influence of this mechanism.” (2)  In other words, the accuser in this case may be doing the same behaviors that he is accusing the other person of doing. In the cases I am referring to another party or member of another party is being accussed of radical politics that leads to political violence by a party or member of a party that has advocated and conducted radical and violent politics for years.

Before anyone invokes the Goldwater Rule here – let me say that I am not making any diagnosis of any individual.  I am simply observing patterns.  Observing patterns at a macro level is different from observing them in an individual patient in an intersubjective setting.  That field is profiling and it was invented by Jerrold Post, MD.  Post observes that in the case of paranoia projection distorts reality (3).  More specifically:  “Attempting to discredit Clinton’s popular victory in the 2016 election, he claimed massive voter fraud by illegal aliens.  As the 2018 midterms approached Trump expressed his concerns that the ‘Russians would be fighting very hard for a Clinton victory’.  So in his fevered imagination, there was a real basis for voter fraud.  And this suggests, given his reliance on the defense mechanism of projection that he would consider voter fraud.”  He subsequently refused to consider any polls that did not show him leading and called them fake news. (4).  Given his role in concessions to Putin and uniting China, Russia, and North Korea – the original suggestion of voter fraud was not consistent with reality.           

Sure you can say it’s just entertainment.  You can say like a recent District Court Judge that it is just rhetorical hyperbole that no reasonable person should take seriously.  You can say that Trump is “just joking” and that nobody takes him seriously but that misses two critical points.  First, this pattern of thought had to start somewhere.  Most of us are familiar with it from early to mid-adolescence when it is a developmental stage.  We can recall when it ended and we made a conscious decision to take responsibility rather than blaming other people for our problems.  Second, there are obviously many people who take this pattern of thought seriously and who can blame them?  I have seen trained mental health professionals fooled and reacting to it.

It is at the point where it cannot be ignored.  If you “do your own research” all the facts are out there. The current situation is the result of a decades long process that values gun extremism and political divisiveness – all leveraged by one party.  As long as you are caught up in that process – things will only get worse.  The results of future violence will be predictable and the soonest anyone can hope for change is 3 more years.  Stop the problem now by seeing this for what it is – a pattern of thought and behavior that most people grow out of.

Are there concrete steps you can take?  I suggest the following.  First, recognize what is going on. I am an old man and I have never seen a President behave like Donald Trump before.  All the projection going on needs to be ignored.  When you see news stations and social media sites trying to amplify his rage and name calling – just shut them off or ignore them.  You will not be missing a thing.  Think of the good old days when we had Presidents from both parties that did not demand our constant attention and outrage.  Presidents that acted in good faith for all of the people.  Presidents you could criticize and it would be taken seriously.  The government ran quietly in the background.  It was never perfect but it was a lot better than what we currently have.  Second, recognize that one of the provocative strategies associated with projection is to devalue some and overidealize others.  Civil servants, scientists, military officers, veterans, women, the disabled, low income people, and minorities have all been devalued while Confederate Generals, dictators, and white supremacists and neo-Nazis are praised and idealized.  It is a consistent dynamic over time.  Third, projection is a mechanism for producing bogeymen. One good example is the alleged left-wing organization Antifa.  Whenever I encounter that trope, I typically ask for evidence the organization exists and find none.  The Wikipedia page suggests there have been more hoaxes than action. For comparison, I was in college during the time of the Weather Underground and a collection of other radical underground left wing organizations were responsible for 2,500 domestic bombings in 1971 and 1972 (5).  That included attacks on universities and munitions plants. There is no possible way that any organizations like those exist today.  Fourth, recognize that the mechanisms I am referring to are intertwined with rhetoric and a distorted sense of reality. The best example I can think of is the constant accusation that you must hate a politician because you disagree with them. That is a recent development in the political landscape and it is a direct product of projection. You attribute hate to someone else if you really hate them and (per Kernberg) may experience it at the same time, fear the person you are projecting onto, and feel the need to control that person.  You also don’t have to think about it too long to see that the person(s) doing this has to see themselves as being extraordinarily important in your life.  That is also not consistent with reality.

There has never been a time in my life when ignoring rhetoric and focusing on reality has been more important.  I hope that I have provided a few pointers on how to get there and am confident that most mature adults in the country can do this.  When that happens it will be the unifying factor we are all looking for.  

 

George Dawson, MD, DFAPA

 

 

 

References:

1:  PDM Task Force.  Psychodynamic Diagnostic Manual.  Silver Springs, MD.  Alliance of Psychoanalytic Organizations. 1980:  p. 643.

2:  Kernberg OF.  Severe Personality Disorders: Psychotherapeutic Strategies. Yale University Press, New Haven.  1984: p. 16-17. 

3:  Post JM.  The Psychological Assessment of Political Leaders. University of Michigan Press.  Ann Arbor, MI. 2003: p. 96.

4:  Post JM, Douchette SR.  Dangerous Charisma: The Political Psychology of Donald Trump and His Followers.  Pegasus Books, New York. 2019: p. 222.

5:  Burrough B.  Days of Rage: America’s Radical Underground, The FBI, and the Forgotten Age of revolutionary Violence.  Penguin Press, New York. 2015

6:  Lifton RJ.  The Nazi Doctors.  Basic Books, New York.  1986.

The Unspoken Punchline...

 

The American promise—that you can be anything you want—is a mantra we internalize from childhood. It's the foundation of every commencement speech, the hopeful message on every career guidance poster. But what if the whole thing is a setup for a punchline? Comedian Chris Rock delivered it perfectly: "As long as they are hiring."

It’s a funny line, until it isn’t.  As someone who grew up in a blue-collar household, I found it to be a devastatingly accurate summary of the modern American condition. It captures the humor, the tragedy, and the stark reality all at once. For years, I have used Labor Day as a moment to reflect on the deterioration of the physician's work environment—a topic that, for those of us in the field, feels more hopeless with each passing year. But this year, I find myself thinking less about my own profession and more about the foundation on which it all rests: the simple, hard-won dignity of work itself.

My own trajectory began in a family of five children, where my father was a railroad fireman, then an engineer. In my earliest memories, he was a figure of physical toil, shoveling coal into steam locomotives. Then he became an engineer on diesel locomotives.  His schedule was chaotic, defined by the whims of the railroad's system. He would take a train 180 miles south, sleep on a station bench, and turn around the next day. We would often have to pick him up in some distant town, 30 or 40 miles away, a small sacrifice for a man who seemed to belong to his work more than to us.

The railroad was a union shop, governed by a ruthless seniority system. The most tenured engineers got their choice of routes and hours, leaving the newer men like my father with stretches of unemployment, even while he was still officially on the company's books. He hated the union dues and the men at the top who seemed to prosper without working very hard. He was, in a way, his own harshest critic, constantly engaged in home improvement projects that were more like feats of engineering than weekend hobbies. I remember a day when seven of his friends showed up to help bend a warped 16-foot plank of wood into a sill plate. The conversation, as they worked, was a symphony of railroad stories, a shared language of labor and hardship.

The values of that world were rarely spoken but deeply embedded. We were taught to mind our own business, which meant a steadfast refusal to gossip or, more importantly, to ever speak of what happened within the family. It was a kind of principled isolation. We were expected to work hard and to be rewarded for it, yet my family lived paycheck to paycheck. The meals were predictable, built from a half-pound of ground beef. Good grades were a given, but a future beyond high school was an unwritten page. Nobody in my family had ever gone to college. I ended up there on a football scholarship, and even then, in the early years of my studies, I tried to get a job on the railroad. The men who interviewed me knew my father's name, even though he had been gone for six years. I didn't get the job. It was one of the best things that ever happened to me.

 I look at that world now and see a profound contrast with the one we inhabit today. The honesty, the direct exchange of labor for value, seems to have been replaced by a system of ever-increasing abstraction and exploitation.

The promise of American capitalism—the idea that free-market competition drives innovation and success—feels more like a myth. We no longer buy products; we license them, signing up for a lifetime of monthly payments that invariably increase. There are minimal guarantees, but a large extended warrantee business where you can purchase one.  The company that employed my father, a place of hard work and honest wages, is now nothing but a ruin. In its place, we have a system where businesses compete not on the quality of their product, but on gimmicks designed to guarantee a perpetual revenue stream.

This is a world defined by stark, growing inequalities. The gap between the richest and everyone else has widened dramatically. Just in the past 10 years the number of billionaires and their net worth has doubled. Tax cuts for the wealthy, deregulation that degrades our environment—these are not accidental byproducts of the system but deliberate mechanisms for concentrating wealth. We see the rise of a managerial class that seems to exist solely to siphon value from the real producers of goods and services. The largest managed care company in the U.S. is a behemoth with a gross annual revenue that rivals the GDP of a small country. They produce nothing but profit, denying care to their subscribers while extracting billions from the system. It is a world where a billionaire, who surrounds himself with other billionaires, can convince working people he represents their interests.

The most unsettling change, however, is the erosion of fundamental values. The robber-baron mentality is back, with CEOs and corporations shamelessly pursuing power with no regard for the environment or the well-being of the working population. The truth itself has become a flexible commodity. It is now routine for a President to lie to and troll the American people, a new norm that has been embraced by those who claim to represent the very people who value honesty above all else. This particular form of ad hominem is most frequently used to attack the work done by other politicians and government workers.  Expertise is openly mocked, and the social contract with workers has been grossly violated.

Perhaps the most visceral example of this new ethos comes from a quote by a current director of the Office of Management and Budget. He stated, “We want the bureaucrats to be traumatically affected…We want them to not want to go to work because they are increasingly viewed as the villains.” He talked about starving them of funding and putting them "in trauma." As a man who grew up watching my father work, I cannot comprehend a world where a manager openly declares his desire to inflict trauma on his employees. Here is a novel concept – your employees are working hard enough already and most are struggling to get by.  The idea that a manager could view the very people who do the work—the civil servants who keep the country running—as villains is a profound moral failure.

 Labor Day was created to honor the accomplishments of the American worker. It was a recognition that we needed a social contract to ensure job security, a share in prosperity, and freedom from exploitation. In the last seven months, that progress has not just been halted; it has been violently reversed. The contempt for workers, the willful destruction of their professional and living environment, and the disregard for their security is palpable.

How can this possibly end well?

George Dawson, MD, DFAPA

References:

1:  Abelson R, Rosenbluth T.  Medicare Plan Would Let A.I. Companies Determine What Is Covered: [National Desk].  NYTimes, August 29, 2025  https://www.nytimes.com/2025/08/28/health/medicare-prior-approval-healthcare.html

2:  Nehamas N.  DOGE Put Critical Social Security Data at Risk, Whistleblower Says.  New York Times.  August 26, 2025. https://www.nytimes.com/2025/08/26/us/politics/doge-social-security-data.html

3:  Wikipedia.  Mass federal lay-offs.  Accessed August 30, 2025. Link.

4:  Malakoff D. How Trump upended science. Science. 2025 May 8;388(6747):576-577. doi: 10.1126/science.ady7724. Epub 2025 May 8. PMID: 40339033.

“Many fear that in just 14 weeks, Trump has irreversibly damaged a scientific enterprise that took many decades to build, and has long made the U.S. the envy of the world”.

5:  Kaiser J. NIH under siege. Science. 2025 May 8;388(6747):578-580. doi: 10.1126/science.ady7725. Epub 2025 May 8. PMID: 40339032.

“The atmosphere is one of “chaos and fear and frustration and anger,” said a senior scientist with NIH’s intramural research program who, like others, spoke on condition of anonymity to protect themselves and others from retribution. This scientist added: “It’s this feeling of utter powerlessness and repeated insults.”

A former top NIH official who was forced out believes that’s the intent. “I think the plan is to sow as much chaos as possible. … I think they want a dispirited workforce at NIH so people will just say ‘to hell with it’ and leave.””

6:  Jacobs P.  Trump administration quashes NIH scientific integrity policy.  Science.  2025 April 3; https://www.science.org/content/article/trump-administration-quashes-nih-scientific-integrity-policy

7:   McNicholas C, Sanders S, Bivens J, Poydock M, Costa D. 100 ways Trump has hurt workers in his first 100 days.   April 25, 2025   https://www.epi.org/publication/100-days-100-ways-trump-hurt-workers/

8:  Greenhouse S.  ‘He’s brazenly anti-worker’: US marks the first Labor Day under Trump 2.0.  Advocates say Trump has hurt workers in many ways, often by cutting their pay or making their jobs more dangerous.  The Guardian.  September 1, 2025.  https://www.theguardian.com/us-news/2025/sep/01/labor-day-workers-trump

9:  Borosave RL, Steffens S.  Trump’s War on Workers. Buried beneath the bluster is a systematic assault on labor. Nation.  August 29, 2025.  https://www.thenation.com/article/politics/trumps-attack-workers-labor/

10:  Su J, West R, Stettner A.  Trump’s Department of Labor Continues Its Onslaught against Workers.  The Century Foundation.  July 22, 2025.  https://tcf.org/content/commentary/trumps-department-of-labor-continues-its-onslaught-against-workers/

 I truncated the references at this point.  Any Google search will show hundreds of references about how Trump has attacked and derided workers and degraded the work environment.  

Graphics Credit:

The background for the photo is a blueprint of railroad yards and the Chicago and Northwestern Railroad in my hometown.  If you look closely at the right lower corner you can see the turntable where locomotives were turned and directed into the roundhouse for repair.  This was posted by the Ashland Wisconsin Historical Society.  I still have vivid recollections of accompanying my father to this complex, the smell of diesel fuel, and the constant loud thrumming of the engines making everything else inaudible.