Preventing Dementia and Blood Pressure Control

 

A paper came out last week (1) that showed blood pressure control was an effective way to prevent dementia.  One of the most effective ways to prevent stroke is to control blood pressure.  Elevated blood pressure also causes blood vessel damage that can lead to dementia – even in the absence of a clearcut stroke. In one of my clinics, we assessed people with various forms of dementia and it was striking how many people had these kinds of changes on their CT or MRI scans and were unaware of them. In some cases, there was a history of uncontrolled blood pressure like eclampsia during pregnancy that probably resulted in brain changes seen decades later that was not investigated at the time.  Substance use problems, undiagnosed forms of transient hypertension, and substance use problems with intoxication and withdrawal associated hypertension are other possibilities.

The study in question was an interventional study across 163 villages in China and a total of 33,995 research subjects. Inclusion criteria into the study was ≥40 years of age with a mean untreated SBP ≥140 mm Hg and/or a DBP ≥90 mm Hg (or ≥130 mm Hg and/or ≥80 mm Hg among those with clinical CVD, diabetes or chronic kidney disease) or a mean treated SBP ≥130 mm Hg and/or a DBP ≥80 mm Hg, based on six measurements taken on two different days. Additional details are available in the paper on online supplementary information.  Patients were treated across the study by physician supervised non-physician community healthcare providers (NPCHPs).  Research subjects were randomized into treatment as usual (TAU) or non-protocol-based treatment for hypertension and protocol-based care. In the protocol-based care patients received first line antihypertensives like angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and diuretic or diuretic-like medications. The treatment group also got free blood pressure medication, lifestyle coaching, and home blood pressure monitors but the TAU group did not.

The primary outcome measures for this intervention study were the presence of dementia and cognitive impairment no dementia (CIND).  Both diagnoses were made by expert panels of neurologists using standardized criteria.  Screening tests were administered at clinic visits to assess cognition, instrumental activities of daily living, and symptoms of dementia in a standard way. 

On the main outcome measures the blood pressure intervention group had a 15% lower risk of dementia and a 16% lower risk of CIND compared with the TAU group.  Those numbers are consistent with an additional meta-analysis done by the authors of similar trials and a previous meta-analysis of blood pressure interventions to prevent dementia.

Strokes are the usual obvious consequences of blood pressure problems and they come in two forms – hemorrhagic and ischemic. Hemorrhagic strokes generally occur through a ruptured blood vessel in the substance of the brain or the subarachnoid space.  Because blood is under very high pressure in the brain that jet can cause additional damage.  In many cases clots form and they can be associated with edema and pressure in the brain. Symptoms can vary from an intense headache to signs of cerebral edema or coma and death.  Ischemic strokes consist of blood vessel occlusion or reduced blood flow to the point that there is inadequate blood supply to neurons. This can occur as the result of ruptured plaques, emboli, or mechanical disruption of the blood vessel.  The emboli can be the result of plaque formation in blood vessels as well as blood clots due to other diseases like atrial fibrillation.  Atrial fibrillation can also be caused by hypertension.

During my teaching seminars on dementia and vascular subtypes – I generally taught about vascular subtypes as cortical or parenchymal infarctions due to major blood vessels (yellow areas on the above diagram), lacunar infarctions due to damage to long perforating arteries to the striatum (pink area), and small vessel ischemic disease or Binswanger’s Disease (BD) due to deep arterioles supplying the subcortical white matter (blue area).  Although BD was described in 1895 it has been a controversial diagnosis that has not been clarified by modern brain imaging and the presence of white matter changes ofet referred to as “white matter ischemic changes” by radiologists.  The diagnosis is also complicated by the fact that many patients has features of both Alzheimer's Disease (AD) and BD and in some cases AD, BD, and small infarctions at autopsy.  If there is any confusion about the diagnosis, a history of hypertension, previous treatment for hypertension, a review of all previous brain imaging, and the clinical pattern of changes in cognition and functional capacity should all be described.   

I am restricting my comments in this post to how hypertension results in dementia so I will not comment on the differential diagnosis of stroke.  Elevated blood pressure can also cause blood vessel damage that is not due to a rupture or embolism.  Prolonged hypertension can cause inflammation in long blood vessels supplying the striatum and periventricular white matter in the brain.  The specifics of that process are being actively studied at this point but damaged is hypothesized to occur because of endothelial cel dysfunction as well as compromise of elastin a connective tissue protein in blood vessels leading to inflammation and narrowing or expansion of blood vessels.  The inflammatory process can lead to further changes and result in a compromised blood-brain barrier and progressive narrowing of those blood vessels.  Eventually the circulation is compromised resulting in the death of neurons visualized as volume loss and white matter changes on imaging studies.   

There seems to be very little work done on the actual pressure signaling at the level of the blood vessel.  Many physiological studies and reviews are focused on overall blood pressure effects and the effect of pressure waves within the vascular system. There are other determinants of endothelial dysfunction including the effects of aging, toxins like tobacco smoke, intercurrent diseases, and metabolic/nutritional factors like blood glucose, lipids, and uric acid.  Epidemiological data supports resting blood pressure and pulse pressure as being significant factors leading to endothelial dysfunction and atherosclerosis.

The modern approach to treating the problem of endothelial dysfunction leading to cardiovascular and cerebrovascular disease is to address all the risk factors.  Hypertension, smoking, diabetes mellitus, metabolic syndrome and obesity, dyslipidemia, and substance use including alcohol all need to be addressed. Many psychiatrists might see this as a primary care problem – but given the way health care is rationed these days a psychiatrist may be the only physician that the patient is seeing on a regular basis.    

That provides the opportunity to collect data like weight, blood pressure and pulse, as well as metabolic parameters if needed. One of my previous posts discusses the issue of blood pressure parameters and white coat effect, and white coat hypertension. The previous thinking was that a lot of people get hypertensive just from the stress of being in a physician’s office.  Some research backed that up showing no difference in outcomes. That research had the same design problems as research about the safety of alcohol.  The control group contained people with cardiovascular diseases and treatment for hypertension. The practical way to address this issue is to advise the patient to check their blood pressure at home with an approved device. Many of these devices can download data into a smartphone app for easy storage.  Home blood pressure monitoring is also useful to detect Transient blood pressure increases due to physical or emotional stress. Although it has not been well studied – this kind of blood pressure reactivity probably needs to be addressed since acute and chronic increases irrespective of etiology are a problem.  

Age is one of the most significant risk factors for dementia. As the incidence of dementia increases with more survivors into old age – there are early interventions that can prevent it from happening.  Good blood pressure control happens to be one of them. 

George Dawson, MD, DFAPA

Supplementary on Binswanger:

Otto Binswanger (1852-1929) was a Swiss physician.  Like many brain specialists of the day he was variously described as a psychiatrist, neurologist, and neuropathologist. He identified as being a psychiatrist primarily but in those days before board certification psychiatry was a much broader field. Both Freud and Meyer had similar qualifications. He is sometimes confused with his nephew Ludwig Binswanger (1881-1966) who was one of the leading researchers of the existential psychiatry movement.  He described “encephalitis subcorticalis chronica progressive” while attempting to differentiate types of dementia from dementia caused by tertiary syphilis that was called general paresis of the insane or GPI at the time.  GPI was a very common reason for institutionalization at the time accounting for 20% of admission and 34% of the death in asylums in the 19^th and early 20^th century before the advent of antibiotics.

Binswanger’s description was controversial up to modern times and I will try to capture that in the graphic below.  The original description was published in 3 issues of a trade paper rather than a medical journal.  It is often critiqued as being long, rambling, and not publishable by today’s standards.  I think that criticism has the benefit of the retroscope since most papers at the time would have similar difficulties.  

Supplemental references on the Binswanger graphic according to those dates:

1894:  Blass JP, Hoyer S, Nitsch R. A translation of Otto Binswanger's article, 'The delineation of the generalized progressive paralyses'. 1894. Arch Neurol. 1991 Sep;48(9):961-72. doi: 10.1001/archneur.1991.00530210089029. PMID: 1953422.

1910:  Dening TR.  Stroke and other Vascular Disorders – Clinical Section.  In: A History of Clinical Psychiatry. Berrios G, Porter R (eds). New Brunswick.  The Athlone Press. 1995: 72-85.

1910:  Nicolson M.  Stroke and other Vascular Disorders – Social Secition. In: A History of Clinical Psychiatry. Berrios G, Porter R (eds). New Brunswick.  The Athlone Press. 1995: 86-94

1986:  Esiri MM, Oppenheimer DR.  Diagnostic Neuropathology. Blackwell Scientific Publications, London, 1896.

1994:  Hansen LA. Pathology of Other Dementias.  In:  Alzheimer Disease.  Terry RD, Katzman R, Bick KL (eds). New York. Raven Press. 1994: 167-196.

The discussion of neuropathology in this text and the subsequent edition is superior to what is seen in general pathology texts and some neuropathology texts.

Román GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JH, Amaducci L, Orgogozo JM, Brun A, Hofman A, et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology. 1993 Feb;43(2):250-60. doi: 10.1212/wnl.43.2.250. PMID: 8094895. 

2025:  Bir SC, Khan MW, Javalkar V, Toledo EG, Kelley RE. Emerging Concepts in Vascular Dementia: A Review. J Stroke Cerebrovasc Dis. 2021 Aug;30(8):105864. doi: 10.1016/j.jstrokecerebrovasdis.2021.105864. Epub 2021 May 29. PMID: 34062312.

 

References:

1:  He J, Zhao C, Zhong S, Ouyang N, Sun G, Qiao L, Yang R, Zhao C, Liu H, Teng W, Liu X, Wang C, Liu S, Chen CS, Williamson JD, Sun Y. Blood pressure reduction and all-cause dementia in people with uncontrolled hypertension: an open-label, blinded-endpoint, cluster-randomized trial. Nat Med. 2025 Apr 21. doi: 10.1038/s41591-025-03616-8. Epub ahead of print. PMID: 40258956.

2:  Supplementary Information for Reference 1 (see Supplementary Table 7. Meta-Analysis of Randomized Controlled Trials of Antihypertensive Treatment on Dementia) for results of 5 additional RCTs of hypertension treatment in dementia.  https://www.nature.com/articles/s41591-025-03616-8#Sec23

3:  Franklin SS, Thijs L, Hansen TW, O'Brien E, Staessen JA. White-coat hypertension: new insights from recent studies. Hypertension. 2013 Dec;62(6):982-7. doi: 10.1161/HYPERTENSIONAHA.113.01275. Epub 2013 Sep 16. PMID: 24041952.

4:  Lockhart SN, Schaich CL, Craft Set al. Associations among vascular risk factors, neuroimaging biomarkers, and cognition: Preliminary analyses from the Multi-Ethnic Study of Atherosclerosis (MESA). Alzheimers Dement. 2022 Apr;18(4):551-560. doi: 10.1002/alz.12429. Epub 2021 Sep 5. PMID: 34482601; PMCID: PMC8897510.

Listening with the Third Ear….

 

I joined a group co-teaching a resident seminar in psychotherapy a few weeks ago.  It is an interesting exercise blending didactics and experience.  The format is an hour of psychodynamic focused didactics followed by an hour-long discussion of a transcript by everyone in attendance including residents and 4 faculty. That is an interesting discussion of the technical aspects of therapy as well as individual differences in interpretation and intervention.

Today’s session was about listening and how listening in therapy may be different from what people consider to be typically focused or unfocused listening.  There was some discussion of how you listen to friends as opposed to strangers.  There was a secondary discussion of the depth of listening with a focus on unconscious determinants.  It led me to reflect on a couple of things during the session.

The first was focus.  Very early in my discussion with patients I was focused on what they were saying.  My focus was the same focus I would have with friends or family even though none of my patients would ever enter that sphere. People knew that I was serious and took them seriously.  As I thought about the way I interacted with people over the years – it was apparent that even though patients are technically not friends within a very short period, I would know more about them than I knew about most of my friends.  In some cases, I was more worried about them and spent more time worrying about them than I ever worried about most of my friends. The difference was in the relationship.  With friends there is a mutual affiliation and expectation of support.  In the case of patients – the relationship is for the benefit of the patient. Apart from payment, the gratification of doing good work,  and the occasional thank you -  the therapist should expect nothing back from the patient. 

The focus in both diagnostic interviews and psychotherapy was meditative to me.  I felt extremely comfortable in that setting.  I looked forward to seeing people.  It was the place in life where I felt the most comfortable. I was not particularly interested in one problem compared with another – just hearing every unique story.  When you get to a certain point in your career you are full of confidence.  You no longer have to worry about running into an issue that you don’t know how to address. You know that most people will leave your office feeling better than when they entered – even if it is an initial evaluation. 

Focus in a psychiatric interview is multifaceted.  It involves hearing both the content of what is being said and whether it makes any sense.  Do all the elements hang together in a cohesive picture or not?  If not, the job is to immediately clarify what is happening.  That always leads me back to think of an Otto Kernberg seminar that I attended 30 years ago.  Kernberg described the process of confrontation as exactly that – an indirect inquiry that would facilitate bringing these seemingly disparate elements together.  An extreme example that I frequently use is from acute care settings.  In those settings, my first task of the day was to interview people who had been admitted on involuntary holds.  They were often very angry to be hospitalized and demanded to be released. Their first words were typically: “I want you to discharge me.  You have no right to hold me in this hospital and I want to be discharged.”  The reality is that I had never seen the patient before.  I had nothing to do with how they came into the hospital or the fact that they were on an involuntary hold. Restating those facts to the patient was the type of confrontation Kernberg discussed and it most frequently led to a more productive reality-based conversation.

The focus for me always has the elements of attention, testing what is being said against my internal knowledge of reality and doing the same with any emotional content, and thinking about underlying theories for what I am seeing. At times I will explicitly ask the patient for their theories about what is happening to them to see if they have any and if they do whether they are plausible.  It is generally important to try to figure out the meaning of certain patterns of thought and behavior including dreams fantasies, and other potential unconscious content.

There is also a focus of kindness toward the patient.  The relationship is one of beneficence.  It always reminds me of Jerry Wiener’s comments about the essence of psychotherapy “Be kind and say something useful to the patient.” When I bring that up – many therapists bristle at the apparent oversimplification.  Kindness does get directly to the point that the therapeutic relationship is different from the patient’s perspective in that they should experience the therapist as unique relative to the common experiences in their life. Some therapists I have encountered over the years have talked about “reality therapy” to mean that the therapist should be reacting to what the patient does just like everybody else.  This misses one of the main advantages of psychotherapy as an opportunity to examine what is really going on in those other relationships and correct it if necessary.        

I addition to attending to the primary problem in sessions the therapist must also have a focus on the relationship and empathic responses to communicate to the patient that he had an adequate understanding of the mental problem that the patient is describing and what all the elements may be.  The relationship aspect may include the stimulus value of the therapist and how that varies with age, sex, physical appearance, and communication style.  To cite age as an example – it is common for early career psychiatrists just out of residency to be greeted with: “You are too young to be a psychiatrist.  I have never seen a psychiatrist as young as you are”. Those statements come with varying degrees of enthusiasm and carry several implications that can be explored.  On the other end of the spectrum I have not had anyone comment on my advanced age directly – but have heard comments that some doctors are so old “they did not know I was in the room.” 

Transference and countertransference are obviously relevant here but I want to stay with the focus in interviews and sessions.  In the seminar today, a paleontology metaphor was described about mining the different layers of the unconscious and how to get there.  That suggests a lot of heavy lifting to me. I see it as a much more dynamic situation.  After all – here I am extremely comfortable and interested listening to people and editing their comments for plausibility, cognitive and emotional content, defensive patterns, and their own theories about what may be happening to them.  Together we are defining what brought them in to see me along with all the relevant cultural, social, biological, and developmental factors.  This is all unfolding in the context of a specially defined relationship.  Throughout that session I am switching between listening mode and an interventional mode that involves supportive, clarificatory, and interpretive remarks.  That switching needs to be dynamic, context based, and is not the same for any two patients.  There is also the practical or real relationship including payment arrangements, appointment times, call instructions, and emergency contact instructions.

There is a check that must happen during or between sessions. Every therapist has to ask if they really understand what this patient is saying and if the patient is being helped.  That check can occur as early as the first interview.  In some cases, the therapist may consider the patient’s problem to be outside of their field of expertise. This can also happen after prolonged therapy where the benefit to the patient is uncertain – but they want to continue the therapy.

The title of this blog post refers to a famous book called Listening with the Third Ear by psychoanalyst Theodor Reik. I purchased the book in 1986 on the recommendation of one of my psychotherapy supervisors.  The subtitle of the book says it all: “the inner experience of the psychoanalyst.”  Reik was one of Freud’s first students.  In the chapter “The Third Ear” he describes attending to various cues of the unconscious life of the patient as well as what may prevent the analyst from perceiving them. He illustrates how the subjective reaction of the analyst to the patient can be one of those clues.

Reflecting on this essay so far – the one dimension that needs additional commentary is the non-linear nature of listening and the interview process. It is easy to think of the process as a matrix dependent on focused attention and a long sequence of questions.  That is the format of a structured interview. In many cases these interviews are algorithmic based on hierarchies and inclusion and exclusion criteria.  In a clinical and psychotherapy setting the focus is more on all aspects of the presenting problem. What the patient brings in to the session and the continuity over multiple sessions is more of a priority. Reik describes a patient who caused him to feel annoyed, two different patients walking by a mirror outside his office and how they react to the mirror, and the way a patient looked at him as well and what that meant for their unconscious life. 

In a subsequent chapter he goes on to describe how the analyst must avoid selective attention to what they might want to hear and how they must attend to everything.  He points out that Freud used the term gleichschweben  that has the connotation of equal distribution and revolving or circling (p. 157).  He suggests the terms freely floating and poised attention.  He adds Freud’s rationale for this type of attention as being two-fold.  First, it avoids exhaustion since it is impossible to attend to anything for an hour.  Secondly, it avoids biasing the interview or session toward a particular aim or goal.  The session after all is directed at what the patient is deciding is relevant.

As I revisited my technique, this captures what I tend to do in interviews and sessions. Since I read this book nearly 40 years ago – I cannot claim to have invented it.  I can add a little to what Reik and Freud have to say especially in diagnostic interviews.  It is possible to incorporate free-floating attention and transition to a more structured interview as necessary. Most psychiatric practices these days require that psychiatrists seen anywhere from 2 to 5 new patients per day.  Most of those patients will not be seen in either psychoanalysis or psychodynamic psychotherapy. But most of those patients will benefit from the listening techniques and interventions that can be attributed to the early analysts. It is also possible to add a psychotherapy component to practically every patient seen by a psychiatrist over time – even in relatively brief appointments.  

 

George Dawson, MD

 

References:

Reik T.  Listening with the Third Ear. Farrar, Strauss, and Giroux. Toronto. 1948: 144-172.

 

Supplementary 1:  Both Drs. Otto Kernberg and Jerry Wiener in the above essay are psychoanalysts with extensive teaching and publication experience. They are both medical doctors.  I left the qualifications out for the sake of brevity. I heard Dr. Wiener’s remarks at one of the Aspen Psychotherapy Conferences organized by Jerald Kay, MD.   

Supplementary 2: According to Reik, The metaphor listening with the third ear was borrowed from Nietzsche -  Beyond Good and Evil, part VIII, p.246.  A partial excerpt follows:

"What a torture are books written in German to a reader who has a THIRD ear! How indignantly he stands beside the slowly turning swamp of sounds without tune and rhythms without dance, which Germans call a "book"! And even the German who READS books! How lazily, how reluctantly, how badly he reads! How many Germans know, and consider it obligatory to know, that there is ART in every good sentence--art which must be divined, if the sentence is to be understood! If there is a misunderstanding about its TEMPO, for instance, the sentence itself is misunderstood!..."

The Demon Haunted World – A Survivalist Counterfactual

 

The Demon Haunted World – A Survivalist Counterfactual

 

I found myself watching survivalist videos last night.  I had just completed a blog post and was working on another (that is becoming a thesis rather than a blog) and decided to take a break.  I have dabbled in that literature on and off over the past 30 years and found that it does not add much. The end games are typically played out in popular movies and fiction. You either find yourself in an impregnable underground shelter or wandering semi-aimlessly over a barren and hostile landscape.  Both scenarios have their problems.

In the impregnable fortress there are the inevitable power struggles, equipment breakdowns, outside attacks, functional and dysfunctional alliances, and lack of planning.  Good recent examples include The Silo and Fallout.  In the wandering scenario there seem to be a plethora of hazards including violent psychopaths, cannibals, various zombies, diseases, natural disasters, and the ever-present lack of food and water.   Examples include The Road, The Walking Dead, and The Last of Us.

Survivalists are more realistically focused. The brief series that I watched emphasized escaping detection by any means.  The implication was that you were in a secure remote location with adequate food and water.  The assumption is that there are many people who were not prepared for when the shit hits the fan or WTSHTF for short.  Four days of starvation is enough to make most people desperate and at that point they cannot be trusted.  A corollary is that once they get skilled at taking what they need from others – you may be the next target.

The first video discussed the importance of smoke. A poorly constructed fire can lead to a smoke signal for people to see for miles.  That signal translates to shelter, warmth, food, and resources to any desperate person who sees it.  The author emphasized methods to minimize smoke production. Elaborate underground survival shelters not only minimize smoke but also heat signatures to avoid infrared detectors and missiles.

 The second avoidable signal to the post-apocalyptic miscreants is gunfire. You might be thinking hunting, but the emphasis was on interpersonal conflict rather than hunting.  There may be better ways to resolve a dispute and secondarily gunfire WTSHTF is not necessarily a red flag. It is a sign out there that somebody has food and resources they want to protect.   The zombie mindset is “even if you do not have a gun – you might be able to hang around in the darkness long enough to get what you want.”  No other ways were discussed about how to avoid gunfire.

The final avoidable signal was light.  Even as little as a candle represents somebody with enough resources that they can and want to see in the dark. It represents the last vestige of civilization.  For that reason, it must be blocked at all costs. Curtains were emphasized as a practical measure but black out screens were preferable.  It reminded me of the subtitle to Carl Sagan’s classic book The Demon Haunted World (TDHW).  That subtitle is: Science as a candle in the dark.  It seemed like a perfect metaphor for what is currently happening in the world. To anyone who has not read the book – the subtitle is from Thomas Ayd’s 1655 treatise on witchcraft A Candle In the Dark where he described witchhunts as a way to delude the people about what was otherwise unexplainable.  Sagan sums up the progress against witchmongering this way:

“Microbiology and meteorology now explain what only a few centuries ago was considered sufficient cause to burn women to death.” (p. 26).

The title is a metaphor for reason and truth in the context of dire superstition and this is captured by Sagan’s summation.

Many reviews of TDHW suggest that Sagan’s views are formulaic – a few rules about how to assess facts and be skeptical along with listing logical fallacies. That minimizes the context he provides about the founding fathers and how they were impacted by The Enlightenment and science. Sagan’s thesis is more complex. He is the first to acknowledge that science is not perfect but that the method of science encourages and produces self-correction. To capture reasoning that is strictly outside of formal science, Sagan suggests that all matter of human endeavor like politics, economics, and even specific policies can be subjected to scientific reasoning and scrutiny and it will result in better results and prevent primitive biases.    

Since the beginning of the COVID-19 pandemic there has been an almost continuous attack on science and scientific experts.  The first Trump administration attacked public health officials, physicians, scientists, and anyone affiliated with them.  They promoted ineffective and potentially harmful treatments for COVID, suggested vaccines were problematic, said that COVID-19 was no worse than the flu, and that case and death rates were overstated.  Several conspiracy theories were promoted suggesting that HIV was a planned bioweapon, that NIH officials were corrupt, and that the “planned” HIV epidemic was paralleled by the “planned” COVID epidemic.  If the COVID epidemic was not planned it was supposed to have originated from a lab leak in China despite all the evidence pointing against that.  The problem is not merely a lack of training in science and the scientific method.  The problem is that we have a large segment of the population that really does not care about their ignorance of science and a large segment who seem to happily take advantage of that on social media.

Sagan has a famous quote that is considered prophetic by many:

“…Science is more than a body of knowledge; it is a way of thinking.  I have a foreboding of an America in my children’s or grandchildren’s time – when the United States is a service and information economy; when nearly all the key manufacturing industries have slipped away to other countries; when awesome technological powers are in the hands of a few, and no one representing the public interest can even grasp the issues; when the people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what’s true, we slide almost without noticing, back into darkness and superstition.”   (p. 25).   

Much has been made about manufacturing in the US and there is an active debate.  Specifically – is it a feasible solution for whatever economic problems you claim it will solve?  I have seen business experts interviewed who say it is not and others who have their own specialized supply chains within the country as being a solution. How will it be compounded by tariffs and an attempt to resuscitate the coal industry? The technological power is concentrated at the monopoly level according to several court decisions.  And what about artificial intelligence? There are daily predictions that AI will replace not only truck drivers and assembly line works but also doctors and teachers.  There are grandiose claims that AI will "cure all diseases" in less than the time I have been writing this blog.  Those aspects of Sagan’s prediction seem too uncertain to be useful.

The lack of knowledge in both the general population and at the highest levels of government is also on display.  Scientific knowledge and thinking is lacking and that it is not enough.  Any reasonable analysis of population wide policies needs to include a scientific dimension, a rational thinking dimension, and a moral/ethical dimension.  This is the real current failure.  As an example, the divisive rhetoric used around the COVID-19 issue.  There was a lot of uncertainty about the best way to stop the pandemic. As physicians and public health officials were learning about this and saving lives – the counter response was that no measures were necessary including vaccinations.  In the end public health officials were being blamed for lockdowns and school closings that could only have been done by local elected officials. That rapidly evolved to conspiracy theories that led to threats of physical harm and legal action against some of the top scientists.  The culmination of this rhetoric was recently evident when the Trump administration replaced a government webpage providing scientific information on COVID-19 with one that presents a combination of conspiracy theories and pseudoscience.  None of this sequence of activity included science, rationality, or ethics.

This is what Sagan is referring to in his quote. The current web page on COVID is emblematic of sliding into the modern version of darkness and superstition. Like the old version the new one is as out in the open and accepted by many. There is an army of celebrities, podcasters, media networks, social media bots, and writers supporting it. Some of the wealthiest people in the country claim they were “censored” because they opposed some suggested COVID measures or supported anti-science rhetoric – even though there was no formal censoring. The dark narrative is very present and it continues to take its toll in terms of cabinet appointees who promote it and some who seek vindication against scientists and officials who were making a good faith effort.

As far as science goes, whether that is hard science or the dismal science of economics – we have a choice to stay in darkness and superstition or move toward the light of science and facts.   Not caring about the smoke is the difference between surviving and living.

 

 

George Dawson, MD, DFAPA

 

 

Graphics Credit:

Campfire in the forest by Crusier, CC license BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0&gt https://commons.wikimedia.org/wiki/File:Campfire_in_forest.jpg

References:

1:  Sagan Carl.  The Demon-Haunted World – Science as a Candle In The Dark.  Ballantine Books 1997.

2:  Ayd Thomas.  A Candle in the Dark.  Smithfield, London. 1655.

Cannabis and Psychosis in the 1980s - and since...

 

I thought I would commemorate one of the first papers I read on this issue when I became an acute care psychiatrist in 1988 (1).  It was my third year out of residency.  I started working on an acute care unit at St. Paul-Ramsey Medical Center in St. Paul, MN.  It was the highest acuity setting I have seen anywhere since then.  It was a combined unit that treated all forms of acute psychosis including affective psychoses and drug induced states.  There was also a forensic component so there was a lot of aggression and violence. There was no shortage of street drugs and even though it was 37 years ago – I have not seen more cases of hallucinogen and stimulant induced psychosis anywhere. I had the occasion to treat a patient who had a pocket full of PCP.  There were the more typical cases of alcohol and sedative withdrawal.  It was where I started to observe the connection between cannabis use and acute psychosis.

Like any compulsive psychiatrist fresh out of training – I was taught to study my patients’ conditions and find current literature. The very first paper I found was an observational study of Swedish army conscripts, their psychiatric conditions, cannabis use, and long-term psychiatric outcomes (1). It was also my introduction to registry studies that happen in Scandinavian countries.  Everyone in the population is on the same database so it is easy to follow them over time and look at outcomes.  In this case 45,470 draftees in the Swedish army were followed for 15 years.  Two questionnaires were administered at baseline – one to look at psychosocial determinants and risk factors for mental illness and the other for substance use history. The sample who refused to complete the substance use history were eliminated from the study. 

All the subjects were given an unspecified structured interview, psychological tests, and were seen by a psychologist.  Any subject with psychiatric symptoms were seen by a psychiatrist and any diagnosis determined was per the ICD-8 nomenclature.  The cohort was followed through a national registry of psychiatric care from 1969/1970 to 1983.  Psychiatric admissions and deaths were followed per the respective databases.   Cannabis consumption was documented as number of episodes of use with subjects using cannabis 50 or more times classified as heavy users. 

 Relative risks were calculated for estimated number of uses compared with a nonuse group and higher risk was noted at both the low and high ends. One lifetime use conferred a risk of 2.4 relative to no use.  For heavy lifetime use, the risk was 6 times greater than no use.  There was a dose dependent increase in cases of schizophrenia for the intermediate levels of use in between.

Of the other variables that were examined, several were noted to increase risk including psychiatric diagnosis at baseline, general childhood adversity, and school adjustment. 

In their discussion, the authors review possible explanations for the association with a schizophrenia diagnosis including cannabis use as causal, cannabis use as non-causal but psychiatric disorder causing cannabis use, and cannabis use as precipitating schizophrenia only in that subgroup of the population who are genetically and developmentally predisposed. They cite their own findings that show of the total number of schizophrenia cases – only 21/274 were in the high consumption group and only 49/274 had ever tried cannabis.  They conclude that cannabis was “an additional clue to the still elusive aetiology of schizophrenia.”  In their references, the authors have 12 case reports or series of cannabis induced psychosis dating back to 1972.

That was my introduction to the literature on cannabis, psychosis, and schizophrenia back in the late 1980s.  I had the good fortune to work with people who were admitted to my units for psychosis who were heavy cannabis users over the next 22 years.  I observed several patterns:

1:  Cannabis induced psychosis – this was probably the easiest to diagnose.  The patient is acutely intoxicated on cannabis and that resolves with detoxification.  The only further treatment that may be required is if the patient has a substance use disorder.

2:  Repeated episodes of psychosis that eventually do no resolve with detoxification -  these are generally heavy cannabis users and they typically have cannabis use disorder or uncontrolled use of cannabis. There have no pre-existing psychiatric diagnosis or family history of severe psychiatric disorders.  The most sensitive marker of heavy use was generally daily use but the specific method of use (blunts, spliffs, dabs) was also a sign.  These patients require treatment for psychosis for stabilization.  The duration of that treatment had to be individualized.

3:  Pre-existing psychiatric disorders exacerbated by use – recurrent episodes of psychosis in patients with a pre-existing diagnosis of schizophrenia, bipolar disorder, or depression with psychosis preceded by cannabis use is a very common problem.

As a clinician the practical approach to sorting out where cannabis fits into the scheme for psychosis and schizophrenia is a detailed evaluation and often getting to know the patient over time through repeated clinic visits or hospitalizations. The short-term goal is stabilizing them enough for hospital discharge with a plan to minimize or eliminate recurrent episodes.  If they can abstain from further cannabis use, gradual reduction and discontinuation of any medication required for stabilization is indicated. Educating the patient and their family about the psychotogenic potential of cannabis and referral for substance use treatment is also required.  That general outline is always dependent on other factors like severity of the episodes and patient preference.

One of the pieces left out of the debate on psychosis and cannabis use is the Naranjo scale.  This scale was developed in 1981 (2,3) to give the probability of an adverse event based on certain parameters. Just looking at the sequence of events I have described here – the relationship between cannabis and psychosis is probable to definite according to this scale.  The relationship to schizophrenia is less certain based on the fact it is a longitudinal diagnosis.

The treatment of cannabis induced disorders has been confounded by the widespread hype about cannabis in the American culture.  As an example – there are people who insist that you cannot develop uncontrolled consumption of cannabis, that it cannot cause psychosis, and that it is good for your mental health. There is scant evidence that any of those statements are true. After I changed to a strictly outpatient practice for the last 12 years, it was obvious that anxiety, depression, and insomnia were frequent problems related to cannabis use. At that time I was seeing a population with substance use problems.  The argument could be made that both major populations I treated over the course of my career had significant selection biases.  I would be the first to acknowledge that is true.  Those selection biases do not negate 35 years of very close observation often corroborated by many team members and collateral history. 

The issue of cannabis toxicity is highly politicized.  Like most things in the US, there are special interests set up to make a lot of money off cannabis and related compounds.  They have expected political and media influence. The idea that cannabis was a “medical” intervention was ultimately the rhetoric that led to legalization – even though there is negligible evidence that it is useful for any medical application.  I used to say that cannabis has been used by humans for over 6 centuries – what are the odds that there is an undiscovered miracle medical application?  I am willing to say that most people can probably smoke it and get high with the usual risks of any other intoxicants that includes accidents, injuries, and death.  The cannabis defenders will always say it is safer than alcohol. That is an argument based on low prevalence use.  As cannabis use picks up to the point where it is used as much as alcohol or more – the adverse outcomes including health outcomes will multiply.  I consider psychosis, exacerbations of pre-existing psychotic and other psychiatric disorders, addictions, lung disease, and cardiovascular disease to all be potential adverse outcomes.

Those are all the hard lessons I learned working with people who had these adverse effects over 35 years.  It all started for me with reference 1.

 

George Dawson, MD, DFAPA

 

References:

1:  Andréasson S, Engström A, Allebeck P, Rydberg U. Cannabis and schizophrenia a longitudinal study of Swedish conscripts. The Lancet. 1987 Dec 26;330(8574):1483-6. Full Text

2:  LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Adverse Drug Reaction Probability Scale (Naranjo) in Drug Induced Liver Injury. [Updated 2019 May 4]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK548069/

3:  Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, Janecek E, Domecq C, Greenblatt DJ. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981 Aug;30(2):239-45. doi: 10.1038/clpt.1981.154. PMID: 7249508.

Image Source:  English: CC 2.0 Attribution: please credit "Elsa Olofsson" and attribute a link to the original source of the image at: CBD Oracle.

Date   4 October 2020, 13:46:42

Source: https://www.flickr.com/photos/189516854@N06/50610714018/

Author:          elsaolofsson

 

Supplementary 1: There have been hundreds of references to cannabis induced psychosis in the literature since I first read this one.  I may take that on at some point - but I do not expect much modification to the initial results.  Human biology requires one to think probabilistically. Some people - even if they have the genetic constituents that make them vulnerable will not develop the condition being studied or they will develop it at a later time.  And of course without the vulnerability the probability of developing the condition is much lower to non-existent.  Those observations from genetics and biology can apply to the original study making the etiology of psychosis from cannabis less "elusive." 

Supplementary 2:  My go to interview questions for heavy cannabis use involved asking about daily use and type of use (how the smoke was delivered). Many of those questions were subsequently validated in a structured research interview for cannabis use.

Supplementary 3:  Naranjo scale for estimating the probability of an adverse drug event (see reference 2 for details).

The Tech Bros Want to Replace Your Teachers and Doctors

 

 

Just last week I was contacted by an acquaintance about Viagra.  He was not a physician and got the prescription through an online business that specializes in dispensing hair loss, erectile dysfunction, anxiety, and depression medications. When I see these businesses advertising that combination of medications it always piques my interest. Why these medications? Comparing them with the most prescribed drugs in the US – 3 antidepressants are in the top 20 - sertraline, trazodone, and escitalopram.  They can double for anxiety medications.  Viagra (sildenafil) is 157 and Cialis (tadalafil) is 172.  Finasteride can be used for both hair loss and prostatic hypertrophy and it is number 72.  Topical minoxidil is not on the list. It is not like there is a shortage of prescriptions for any reason.

My contact person had talked with one of the online prescribers and was not sure about how he was supposed to take the medication. Should he take it every day or just on the days he was going to have intercourse?  Reading the prescription label and the information he was sent was not helpful.

More of these online prescribing services seem to be advertising every day.  They promise cost effectiveness, the same medications that your physician would prescribe, ease or use, and no embarrassment.  How many times have you been in line at your clinic or pharmacy and had a staff person belt out some information about you that you preferred stay private?  That line on the floor separating you from the other patients is not enough distance to muffle a receptionist shouting through plexiglass.  The online service promises to send you the medication in a plain brown wrapper. 

The real downsides to this new relationship are never mentioned. No access to your records to check for contraindications, drug-drug interactions, pre-existing medical conditions, the status of your liver and kidney function, or allergies. No access to your physician who may know you so well that they can say if taking a new medication would be advisable or not. No detailed discussions of risks, potential benefits, and unknowns. For me that discussion has taken longer than most of the telemedicine visits I have heard about.  And most importantly – no access to somebody who knows your situation if something goes wrong.

There is a real issue about how much information these rapid online prescribers keep on file and what it is used for.  Do they list your major medical conditions?  Does that lead to marketing? Does that lead to data mining to develop sufficiently large programs to make more money off you?  Recall that wherever your data is on the Internet, somebody is trying to profit from it.

That brings me to a stark conclusion about capitalism that I discovered too late in life. Growing up in the US, you are sold on the idea that capitalism and democracy are the mainstays of the country.  We are special because of both and we do both better than anyone else in the world.  The wealthy are idealized and everyone aspires to be wealthy.  If you can't get wealthy maximizing your material possessions seems to be a substitute.

American products are good because our environment producers entrepreneurs and competition among entrepreneurs produces superior products.  Think about that for a second.  The entrepreneur gets all the credit.  Forget about all of the science and engineering behind any product.  The faceless people laboring behind the scenes are hardly ever mentioned. If you are industrious enough, you might be able to find out who holds the patents but in the end they are all property of a large company.  And that company is there for one reason – to make as much money as possible.

In a service industry like medicine corporate profits were initially hard to come by because it was a cottage industry of private physicians.  Even as the corporate takeover began in the 1980s, physicians resisted to some extent as a powerful mediating class between corporate interests and the interests of physicians and patients. The end run around that physician mediation was hiring them as employees.  Initially corporations proposed that they were going to make primary care more accessible and minimize specialists.  In the end that was merely a tactic and they acquired specialty care as well as primary care.  Today most physicians are employees and have minimal input to their practice environment.  They are essentially told by middle managers how to practice medicine.  They work by default for companies like managed care companies and pharmacy benefit managers that waste physician time to rubber stamp their rationing procedures. 

The profits from the corporate takeover of medicine are high.  It is after all a recipe for making money.  There is a stable subscriber base fearful of medical bankruptcy and the corporation can decide how much of those funds it wants to spend. In thinking of new ways to make more money, telemedicine is the latest innovation. Convenience is a selling point. It has been used for decades to reach people in rural areas who would have a hard time travelling long distances to clinics.  But the current model is more like Amazon online shopping.  If you have condition x, y, or z – contact us and we will get you a prescription. Better yet, let’s take the pharmacy middle man out of the picture and prescribe and sell you the medication at the same time.    

A recent commentary in the NEJM pointed out the potential problems of the new relationship between pharmaceutical companies and telehealth firms (1). It is as easy to imagine as the following thought experiment.  Suppose you are watching a direct-to-consumer ad about a weight loss drug.  You go to the suggested web site where it tells you to make a telehealth appointment the same day for a nominal fee. One study showed that 90% of patients referred through this sequence got a prescription for the advertised drug.  The pharmacoepidemiology, quality of care, and legal ramifications of these arrangements are unknown.  The scrutiny is nonexistent compared with the claims that physicians were being influenced for decades by free lunches.  That matches my suspicion that the physician conflict of interest hype was more a political tactic than reality to suppress any objections to the political and corporate takeover of medicine.  

That brings me to the Bill Gates (2) comment.  Expectedly he is an unabashed promoter of computer technology and the latest version – artificial intelligence or AI.  His thesis is that AI will commoditize intelligence to the point that humans will not be necessary for most things including teaching and medicine. No mention of the conflict of interest.  The company he founded – Microsoft is currently heavily marketing computers with an early version of AI. A couple of years ago they also changed to a license for life model.  In other words when you buy a Microsoft computer or software package – you no longer own it outright.  You must pay a monthly licensing fee if you use it or if they decide not to support your computer any more – you must upgrade it to continue paying monthly fees for a long as you use your new computer.  Or until they tell you again that you have to buy a new one.  Even though intelligence is “free” Microsoft and all of the other major tech companies are not really giving it away – they have a recipe for making money off of you for the rest of your life.   

There is a reason that doctors don’t know much about business or politics. Both are highly corrupting influences. Medicine is a serious profession that is squarely focused on mastering a large volume of information and technical skill and keeping that current. Businesses on the other hand are focused on every possible way they can get your money and they are very good at it. If it comes down to an AI program providing medical care that is all you really need to know.

 

George Dawson, MD, DFAPA

 

References:

1: Fuse Brown EC, Wouters OJ, Mehrotra A. Partnerships between Pharmaceutical and Telehealth Companies - Increasing Access or Driving Inappropriate Prescribing? N Engl J Med. 2025 Mar 27;392(12):1148-1151. doi: 10.1056/NEJMp2500379. Epub 2025 Mar 22. PMID: 40126465.

2:  Richards B.  Bill Gates Says AI Will Replace Doctors, Teachers and More in Next 10 Years, Making Humans Unnecessary 'for Most Things'.  People Magazine March 29, 2025.  https://people.com/bill-gates-ai-will-replace-doctors-teachers-in-next-10-years-11705615

 

Graphic Credit:

Click on the graphic directly for full information on the Wikimedia Commons web site including CC license.  It is used unaltered here. 

 

 

Sore feet, Biomechanics, and Orthotics...

 

 I am a big believer in biomechanics. That belief is rooted in my personal experience with physical therapists and sports podiatrists.  That experience all started about 25 years ago.  At that time I had been cycling 150-200 miles per week for over a decade, speedskating, and doing resistance training. That all sounds like a high level of activity and it is.  But what is hidden in all that activity is the effect on biomechanics.

Cycling involves a flexed position at the hips and mainlining that position for hours at a time. The result is significant strengthening of lower leg flexors, hip extensors, and some hip flexor strengthening if you actively pull up on the pedals.  These patterns are recognizable in the hypertrophy pattern in the legs of cyclists.  At the same time, not a lot of energy is expended in muscles needed to maintain antigravity posture.  As a result cycling is one of the few exercises where energy expenditure can nearly match cardiac output – since not much additional energy is used for postural muscles.

Skating is a more strenuous combination of energy required for maintaining a flexed posture while translating lateral falling movements to forward propulsion and maintaining an unnatural posture. That also involves external to internal hip rotation under pressure as you move from the outside edge of a flat ground skate blade to the inside edge and then pushing off that inside edge.  Another critical point during skating is the hip hinge – a maneuver that I was never taught - to maintain the lumbosacral spine in a flat rather than flexed position when the spine is in a flexed skating position.  All of these movements combined with tight fitting skates, gravity, and centripetal forces while cornering puts tremendous pressure on the feet.

It only took a few years of this level of exercise to create a significant amount of foot pain. I remember deciding to try to walk off the pain one day at work. At the time I was employed by a large medical center.  Walking around the complex was probably about ½ mile.  On my first few attempts I could barely make it due to severe foot pain and back pain.  I could skate 10 miles or bike 150 miles but I could not walk around the block.

My first attempt at addressing this problem was to see a sports podiatrist right at the medical center where I worked.  I also had Haglund’s deformity of the calcaneus bones on both feet and was concerned about possible hallux valgus or bunion formation on the right. The podiatrist examined my feet, took the history and determined he needed to make a pair of orthotics.  After wearing them for 1 day – my foot pain was nearly gone and it resolved completely over the next week.  The orthotics were expensive so I had to transfer them from shoe to shoe.  That could not be done with my custom molded skates but they did fit in my cycling shoes.  I wore them successfully for at least 10 years before they started to fall apart.  I did not develop a bunion and the Haglund’s deformity did not get any worse and improved with just the orthotics. When I called the sports podiatrist's office again, I was advised they no longer did custom orthotics because of inadequate reimbursement. They had no ideas about where I could get another pair.

The theory of orthotics is that they restore the normal arch anatomy of the foot.  I was presented today with the additional theory that they also condition the intrinsic muscles of the foot to maintain those arches.  Both of those theories are somewhat controversial probably because of the diverse methodologies used to study the biomechanics of the foot. The main arches of the foot are shown in the diagram below as the medial longitudinal arch (MLA), lateral longitudinal arch (LLA), anterior transverse arch, and posterior transverse arch.  The bones that make up the MLA are colored pink and the bones that make up the LLA are colored green.

Over the past 10 years my exercise routine has changed to focus more on treadmill workouts. I use typical Bruce protocol parameters to vary the workouts from 3 -12 METS and typically do 90-120 minutes per day with additional weight training. The feet have become a serious problem again with soreness at the insertion of the right Achilles tendon around the entire perimeter, sharp shooting pains through the right arch, and excessive pressure and callus formation of the second toe on both feet.  I have Morton’s toe – a condition that occurs due to a short first metatarsal so the second toe is longer than the first.  At first I thought that this could be remedied by buying longer shoes. Even though I had worn 10.5 for 50 years – I went up to a size 11.  The problem was unchanged.  I tried running shoes that felt spongier than my typically runners.  Things were worse and I got some additional knee pain. I tried several weeks of not elevating the angle on my treadmill and that was also not helpful.

I finally went into an orthotics store today to get new orthotics. There was no medical staff around. The person who assisted me identified himself as a mechanical engineer who decided to change professions after he experienced significant relief from the orthotics he was currently selling. He had a measurement system used to estimate force distribution around the feet that produced the image at the top of this post.  He explained the orthotic system consisting of three different shoe inserts and demonstrated how this system resulted in a different weight distribution than standard shoes.  He had a checklist of other points such as pain in the back or at various joints that he said would be useful for follow up. He educated me in how long I could expose my feet to the three different orthotics and how it needed to be titrated over time. He said that none of what I purchased could be refunded – but I could get a different fitting in the next 60 days and he would call me from time to time to see how things were going. I walked out wearing the orthotics that I could use 24/7 and was reassured that I could use them starting today.

I will post how this goes over the next few months.  I am hopeful that I will get the same amount of relief that I got from my original orthotics 25 years ago.  I am also hopeful that it will correct additional biomechanical problems like my right foot inverting (rolling out) as I walk and an associated clunking sensation in the right knee as well as hip soreness and clicking during exercise.  I will be very pleased if the right Achilles pain resolves because it has become a chronic problem that I experience 20% of the time.  I decided some time ago to exercise through that pain and it does work.

So far, the cost is high.  Each of the orthotics costs three times what I paid for the originals 25 years ago.  That seems like a lot but considering inflation that is about right.  The only difference is the recommended three different sets.  There is no guarantee and all sales are final.  If they do work, this business keeps all of your specifications on record and service is possible at any of their stores.  I can’t help thinking about the economics of this situation and what it implies for health care in the United States. Orthotics have become a commercial product that you can purchase at a strip mall. I don’t know the range of sizes available or how that is determined, but I know they were not custom fit like the first pair I got from a sports podiatrist.  The retail procedure is much more expensive. At the same time, the podiatrist I was seeing could no longer afford to make them because of inadequate reimbursement.  I guess this is one way we contain health care costs in the US.  Making it retail for much higher reimbursement as opposed to rationing it at the expense of licensed health care providers.  It took me a long time to figure out that American capitalism is not about superior products.  Most of the time it is just about making money and how you can get advantages to do that.  The true test will be in the results that I will revisit over the next several months.

 

George Dawson, MD, DFAPA

Supplementary 1:  A biomechanics approach is also useful because pain can be addressed without any additional measures like medications or injections. At least that is the best case scenario.  It makes little sense to take over-the-counter pain medications when orthotics or physical therapy work for the pain. The previous orthotics I used corrected my foot and ankle pain and low back pain.  It also resulted in improved posture.  All of that from subtle (1-2 mm) changes in the position of my feet.  If these orthotics also work for strengthening the intrinsic muscles of the foot that is also an advantage over having to do specific exercises for those muscles along with wearing the orthotics.  I never found the exercises for the intrinsic muscles of the foot to be very effective.  

Supplementary 2:  Practically all of the running and athletic shoes these days have an insert in the bottom of the shoe.  This appears to provide some arch support - but it does not.  The staff person I was assisted by referred to it as a sock liner.  By definition it is typically a foam layer that your foot rests on and it is not designed to provide much support. There can be a very uncomfortable coarsely finished inner shoe surface below the sock liner.  An insole by definition is designed to provide support and an orthotic is a specifically designed insole to provide more support.  Numerous examples are available on any Internet search.    

References:

1:  Venkadesan M, Yawar A, Eng CM, Dias MA, Singh DK, Tommasini SM, Haims AH, Bandi MM, Mandre S. Stiffness of the human foot and evolution of the transverse arch. Nature. 2020 Mar;579(7797):97-100. doi: 10.1038/s41586-020-2053-y.

2:  Asghar A, Naaz S. The transverse arch in the human feet: A narrative review of its evolution, anatomy, biomechanics and clinical implications. Morphologie. 2022 Dec;106(355):225-234. doi: 10.1016/j.morpho.2021.07.005.

3:  Wang H, Wu Y, Liu J, Zhu X. Investigation of the Mechanical Response of the Foot Structure Considering Push-Off Angles in Speed Skating. Bioengineering (Basel). 2023 Oct 18;10(10):1218. doi: 10.3390/bioengineering10101218.

4:  Chauhan HM, Taqi M. Anatomy, Bony Pelvis and Lower Limb: Arches of the Foot. [Updated 2022 Nov 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK587361/

5:  Collier R. Orthotics work in mysterious ways. CMAJ. 2011 Mar 8;183(4):416-7. doi: 10.1503/cmaj.109-3802. Epub 2011 Feb 14. 

 

Image credit:

1:  Foot impressions at the top are from the retail store and are from my feet done today 3/29/2025.

2:  Anatomical images of arches are from reference 4 – reproduced here without alteration per the CC license as follows:  This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Trump Derangement Syndrome - Will It Become a Mental Illness in Minnesota?

 

It came to my attention yesterday that a bill has been proposed in the Minnesota Legislature to declare Trump Derangement Syndrome a mental illness.  Anyone unfamiliar with the mental illness statutes in Minnesota might ask why there are definitions like that in the law in the first place. The purpose of these definitions is threefold as far as I can tell. First, they define the behavioral evidence in terms of severity necessary to meet the standard of severe mental illness.  In common parlance that is typically described as risk to self, risk to others, or inability to care for oneself because of mental illness.  No diagnostic criteria or reference to diagnostic manuals is made. The definitions are there as lay standards so that potentially any interested person can act on them. Second, they are necessary criteria for civil commitments, guardianship, and conservatorships in the state. In other words, a psychiatric diagnosis by itself is not sufficient criteria for any of those proceedings.  The statutory requirements must also be met.  Finally, the criteria also determine eligibility for additional treatment resources like case management and outreach services.     

To confirm the validity of this proposal I sent emails to both of my state representatives Rep. Elliot Engen (R) and Sen. Heather Gustafson (D). I expressed my concern that the mental health statutes in the state are for the serious business of civil commitment, guardianship, and conservatorship proceedings and therefore I needed to know if Trump Derangement Syndrome was a serious proposal and if it was – what they were going to do about it.

I have not heard back at this point but the press coverage is increasing so I will talk about it as if it is legitimate.  Where does this come from and what does it really mean?  During the previous Trump election there was a lot of controversy about whether he had a psychiatric diagnosis – primarily a personality disorder.  There was a lot of discussion about narcissistic and antisocial personality disorders. There were several high-profile psychiatrists and some academics who maintained these positions.  These criticisms still surface today.  At the time, I critiqued those positions based on the APA’s Goldwater Rule.  Psychiatric profiling was invented by Jerrold Post, MD for intelligence gathering and it was not meant to be applied to politics.  The Goldwater Rule states that a direct assessment must be done and any information released with informed consent.  Those controversies basically faded because the public criticism had no impact and it was obvious that a lay standard in the 25^th Amendment rather than public speculation is the overriding consideration:

“Section 4:

Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.”    

Even though a substantial number of Trump’s first staff disapproved of his performance or thought he was incompetent – there was no effort to invoke the 25^th Amendment.  He was subsequently rated as the worst President to date by polled historians.  We also learned that if the President or his party control the Supreme Court – it is possible that an entirely different standard applies than it does to the average citizen. It is clearly possible that the President can commit crimes and escape prosecution. 

The idea that Trump is an unlikeable person is easily explored with the following thought experiment.  How many people like liars? Trump is described as lying an unprecedented amount in the history of American politics – tens of thousands of lies.  At times the lies are characterized as bullshitting using Frankfurt’s philosophical definition.  According to Frankfurt - bullshitters have more disregard for the truth than liars.  So, pardon me if you think bullshitting is more acceptable.  How many people object to a person who routinely calls other people names and ridicules the disabled?  How many object to threats?  How many object to racism, misogyny, and white supremacy? How many object to withdrawing foreign aid amounting to less than 1% of the budget if it results in the deaths of hundreds of thousands of people (3.3 million according to a New York Times estimate from AIDs, malaria, TB, lack of vaccinations, and a lack of food).  How many people like the administrative, justice, public health, and research infrastructure of the United States being decimated on an arbitrary basis by Trump appointed designees?  How many people like loyal government employees working in non-political positions in the US Postal Service, the Veteran’s administration, and the National Park System terminated either for a completely fictional cause or without cause?  I think the point is made even though this is only a partial list of what Trump has done to cause people to legitimately dislike him.  I could probably come up with a much longer list.  For completeness sake – let me add – how many people like a President who attempted to overthrow the US government and who has continued to lie about the election for the next 4 years?

That brings me to the statute:

Subd. 28.Trump Derangement Syndrome.

"Trump Derangement Syndrome" means

2.24 the acute onset of paranoia in otherwise normal persons that is in reaction to the policies

2.25 and presidencies of President Donald J. Trump. Symptoms may include Trump-induced

2.26 general hysteria, which produces an inability to distinguish between legitimate policy

2.27 differences and signs of psychic pathology in President Donald J. Trump's behavior. This

2.28 may be expressed by:

2.29

(1) verbal expressions of intense hostility toward President Donald J. Trump; and

2.30

(2) overt acts of aggression and violence against anyone supporting President Donald

2.31 J. Trump or anything that symbolizes President Donald J. Trump.

        

On the face of it – this definition is poorly written by people who are obviously not mental health professionals. The wording can be taken as colloquial rather than technical.  That means the terms “paranoia” and “hysteria” are whatever the politicians decide to use them for and that could include name-calling. Concern about the Trump on-again off-again tariffs?  You are just paranoid. 

The idea that these meaningless expressions would cause “an inability to distinguish between legitimate policy differences and signs of psychic pathology in President Trump’s behavior” is laughable.  First, as previously noted nobody is making any psychiatric diagnoses on Trump.  That time has passed.  His party is more than willing to let him do whatever he wants.  Second, it does not take a mental health professional to decide if someone is unlikeable, or doing things that you do not like, or using rhetoric that you do not like, or is conducting themselves in an immoral or unethical way that you do not like.  We all do it every day.  We are all judged on our behavior every day and accountable in many ways.  The vague wording in the preamble in this statutory language is intentional and it gives the proponents plenty of freedom to determine what they think is “intense hostility” toward Trump.  They could at least include a scale using examples of Trump’s intense hostility to others. As hostile as Trump was to Zelensky in the tragic White House meeting or possibility some of his milder name calling incidents directed at Clinton, Harris, or Obama?  The essence of this language is that it sends the strong message that if you criticize Trump – you are at risk.  He is basically beyond criticism even though he is the most objectionable President on record.  The “overt acts of aggression and violence…” language is already illegal without this nonsensical modification.

Like most things in the Trump administration there is no scientific backing to any of this language.  The rhetoric is slightly more interesting. Anyone paying causal attention to the news has seen the pattern of outrage followed verbal aggression (mainly name calling and lying) that is a standard part of MAGA theatrics over the past several years. If you really have not - just turn on one of their news channels, podcasts, or radio broadcasts. Better yet – attend a school board meeting and witness the screams about book banning and other things that are often not even happening. More recently that has spilled over into MAGA town halls meetings to the point that the GOP has had to shut them down.  Other than the obvious appeals to excessive and inappropriate emotion in these meetings there are two additional patterns that cannot be missed.

The first is what I like to call the gangster approach to pseudo negotiation. This was evident in the meeting between Zelensky, Trump, and Vance. Before any actual content was discussed both Trump and Vance were accusing Zelensky of “not respecting them” or saying “thank you’.  This is what you will find in any rapper beef but it obviously has no place in high level diplomacy.  What were Trump and Vance trying to do here?  To anyone familiar with rhetoric, this is a standard attack on the person rather than their argument. Zelensky never got his argument out and then to add insult to injury he was told to leave the White House as if he had really done something wrong.

The second is a variation on that theme. Whenever Trump is even mildly confronted, he acts like he has been wounded.  One of his comments is “You are not very nice; you are not being very nice to me.”  He will rationalize the rest of his behavior such as refusing to talk or attacking the journalist or their organization based on that sensitivity.  He will often attack the journalist typically by calling them names or questioning their ability.  In some cases, he will suggest that the interviewer has some nefarious purpose or that they are part of a “fake news” conspiracy against him.  In more recent developments he is suggesting that the people in the media who he does not like will be prosecuted.

Both patterns are obvious in the news and in life. We typically encounter this kind of behavior as adolescents from bullies in schools. Recall that bully on the playground who likes to make up nicknames for classmates just to humiliate and embarrass them. He persists in using the nickname even though you and your friends don’t like it.   You all acquiesce because he is bigger and will beat you up if you protest too much. Occasionally some smaller kid stands up to the bully and punches him in the nose.  At the meeting with the principal – the bully and his father claim the other kid started the fight.  They are typically outraged and tearful.

That is the real reason for a Trump Derangement Syndrome statute.  It allows even more leverage against the people who protest the bully.  Now some politician can gaslight them in addition to Trump bullying them and calling them names.  

This is not a mental illness.  It is a political tactic.  It is an affront to anyone with a real mental illness, their caregivers and treatment providers. If this language is allowed to stand in Minnesota it adds to the embarrassments that this administration has placed on the American people and will result in a gaslighting defense for America’s number one bully.

 

George Dawson, MD, DFAPA          

To editors: I have a more concise 500 word version of this essay that could be published if there is an interest and the publication seems right.  Contact me if you are interested.  

Supplementary 1:  There still is a possibility that this proposal is a hoax. If that is true there will be a predictable response from Republicans suggesting that this response is just another example of Trump Derangement Syndrome.  Their rhetoric can be cancelled by pointing out that their technique of flooding the zone is really just another application of Brandolini's Law and it is unfortunate that they do not devote as much energy to serious governing.

Supplementary 2:  The parallels between patterns of authoritarian suppression in Russia/USSR and the current administration are unmistakable.  Non-medical and political "diagnoses" are widely used to suppress and detain dissidents and other targets of political oppression. In the US, the current administration is making strong initiatives to suggest any criticism of the President is illegal as well as many forms of legal protest.  

Supplementary 3:  Added on 3/28/2025 nearly 2 weeks after the original post. At this point I have not heard back from either of my elected officials. The proposed statute remains on the site at the following link - but it has been modified to show that one of the co-authors has been removed.  That co-author has been arrested for allegedly for coercion and enticement of a minor in connection to a prostitution sting.  As a result I have to conclude that it is still going forward.  

Graphic:

The graphic in this case is taken directly off the Minnesota Revisor web site – an official site of the state government.  The link I used is available below – but it disappears and gets updated to a new link frequently:

 https://www.revisor.mn.gov/bills/text.php?number=SF2589&version=0&session=ls94&session_year=2025&session_number=0