A House of Dynamite

I watched this Kathryn Bigelow movie a couple of nights ago after anxiously waiting for it to hit Netflix.  It turns out that Bigelow and I are the same age and lived through the Cuban Missile Crisis, the Cold War, and the era of public and private atomic bomb shelters – all based on the idea that you can survive a nuclear war.  As I have written on this blog is a couple of places – it was also my job in my early 20s to disassemble the bomb shelter in the basement of our public library.  Nobody ever gave me a reason – but in retrospect it was probably because planners realized that there would be no survivors.  I am not talking about dying in the blast or even surviving the radioactive fallout and fires.  I am talking about the millions of tons of smoke, soot, and dirt blown up into the atmosphere and the effects of that blocking sunlight.  The direct smoke and soot effects are expected to last for 5 years and the resulting greenhouse gases for a century (1).  There will be climate change and an inability to grow crops for a very long time.  That would mark the end of civilization probably within a few years.

There are differing opinions on what it would take to create a nuclear winter. Over the past 30 years several groups have estimated the environmental effects of numbers of nuclear weapons ranging from 15-100 kilotons.  The simulations vary from a limited exchange to a large-scale exchange of several thousand nuclear weapons.

This movie is focused on the launch of a single missile from an unknown location and the people responsible for responding to that attack.  There is the suggestion that early warning systems may have been compromised by a cyberattack.  We see a cross section of military officials and civilians at Fort Greely Alaska, in the White House, and via telecommunications monitoring threats to the United States.  They detect a missile launch and initially think that it will splash down in the Sea of Japan.  They eventually see that it is on a suborbital trajectory and it will hit the continental United States.  Chicago is determined to be the target. 

The tension increases greatly when the staff involved realize that this is a nuclear attack on the United States.  There is some initial confidence that they can intercept the with Ground Based Interceptor (GBI) anti-ballistic missile missiles. The GBIs are used to deploy an Exoatmospheric Kill Vehicle (EKV) that is a kinetic energy weapon designed to seek out and destroy the ballistic missile by direct impact. In a tense dialogue between the Secretary of Defense and the Deputy National Security Adviser we learn that the success rate of the GBI system is only 61% and it cost $50 billion.  During these discussions Ft. Greely has 2 GBIs in the air and they both miss.

That leads to increased tension. The alert state is DEFCON 2 and none of the staff has been at that state in the past.  Everyone knows the gravity of the situation.  People are upset, tearful, and trying to contact their families.  A cabinet official jumps off the roof of the Pentagon.  One of the central figures calls her husband and tells him to put their child in the car and get out of town as quickly as possible.  Even though there is only one missile in the air headed for Chicago – the viewer knows only 20 minutes total have elapsed.  There is no adequate amount of time to evacuate most major metropolitan areas.

With the failed countermeasures we see the President in the final frames.  He is with his retaliatory strategy advisor – a Lieutenant Commander.  He has a large book of targets – all specified by certain codes.  The President is anxious and hyperventilating. He is contemplating the gravity of the situation – the human toll, not letting the perpetrator get away with it, what the American people will think of his response, the insanity of selecting military targets when he does not know who launched the missile, and the message it would send if the US does not respond.

This was a very good movie that I enjoyed a lot.  It was well written, directed and acted by some of my favorite actors. Most importantly it contains a solid message about nuclear war – don’t go there.  The anxiety, confusion, mayhem, and desperation portrayed as the product of a single missile launch may be the 21^st century equivalent of that atomic bomb shelter I closed in the 1970s.

But it turns out there is more.  The Pentagon apparently released a memo disputing the low accuracy of the GBI anti-missile system.  I have not been able to access the memo but apparently it claims a 100% success rate in stopping incoming ballistic missiles. 

I was able to see an interview of Joseph Cirincione (2) – a defense consultant with experience all the way back to the Reagan era and the Star Wars initiative.  He said there have been a limited number of tests of the system but you could claim a 100% success rate if you looked at the last 4 tests.  If you look at the life of the program there have been 20 tests and only 11 or 55% were successful.  He pointed out the technical difficulties of trying to shoot down long-range missiles and said the system was more of a sieve than a protective dome and that it could not be counted on to plan a defense.  Further, the total investment in antiballistic missile technology has been $453 billion and that technology in the form of lasers, rockets, or the GBI/EKV will not be adequate for another 30 years.  He alluded to a study of the technology by the American Physical Society (3) but it was not clear that was his reference for the estimate.  When asked about the most significant nuclear threat to the US, Cirincione said it was Russia and that in an attack of a thousand ballistic missiles – the US would be able to “intercept 1 or 2.”  In the Pentagon versus movie accuracy, he rated it: “House of Dynamite 1 and Pentagon zero.”      

Where does this leave us?  Here are a few considerations.  First, if anyone was serious about waste, fraud, and abuse it is far more likely to be found in the Pentagon than in health and human services.  The $453B spent on several antiballistic missile systems to end up with one that is as effective as a “sieve” says it all. And apparently a new contract has been signed even though physicists are saying the technology will not be ready for another 30 years.  Second, the current system is a coin toss in terms of intercepting ballistic missiles from a rogue state.  In an all-out attack by a nuclear power it can possibly intercept a trivial number of missiles.  It makes no sense to advertise it any other way or pretend that the United States is “protected” against a long-range missile attack.  Third, we are right back where we started when nuclear non-proliferation was the order of the day.  Having all the nuclear weapons in the world is a lose-lose situation rather than a zero-sum game if all of humanity goes extinct during the attacks and the aftermath.  You don't even have to be in the game to lose.  If you are a hemisphere away the resulting climate change and ice age will kill you.   Fourth, rather than being focused on non-proliferation were currently have leaders who are bragging (4-6) about weapons systems.  Fifth, there is not even a tip of the cap to cosmopolitanism at this point.  Billions of people around the world work every day and strive to get home safely to their families every night.  In the meantime, we have a handful of old men with a limited stake in the future playing a dangerous game of brinksmanship – often for no reason other than playing the game.   

When exactly are world leaders really going to work in the interests of their people?  Nuclear war, nuclear winter, and the extinction of humans is the last thing any rational person wants.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Precedents for holding your nuclear fire:  There was one brief allusion in the movie to a nuclear early warning that was ignored during the Cold War.  There were two – in both cases commanders from the USSR ignored in one case a radar error suggesting an attack by the USA and in the other a direct attack by the US Navy on a Soviet submarine.   This is interesting because the Soviets were typically considered war mongers by Americans at east that was the political hyperbole.  In fact, two of their commanders exercised good judgment under fire and probably prevented an all-out nuclear war.   

Supplementary 2: Kathryn Bigelow responded to Pentagon criticism of the movie about the accuracy of the Ground Based Interceptor missiles (7).  She described the film as realistic and authentic. In The Guardian version of this story a nuclear physicist said that the scenario was “about as easy as they come.”  That same article said the US has 44 GBICs in Alaska and California and has contracted for a new system for $13.3 billion.  Bigelow said she hopes the film will create discussion and cultural change that may produce a more rational approach to the problem - like arms reduction.   

References:

1:  Toon OB, Robock A, Turco RP. Environmental consequences of nuclear war. Physics Today. 2008 Dec 1;61(12):37-42.  https://climate.envsci.rutgers.edu/pdf/ToonRobockTurcoPhysicsToday.pdf

2:  Cirincione J.  TMZ Live October 28, 2025  Link to video

3:  American Physical Society.  Strategic ballistic missile defense. Challenges to defending the U.S.  March 3, 2025  Links to 3 different reports

4:  Wittner LS.  Nuclear arms race intensified during Trump’s presidency.  The Hill. July 5, 2024  https://thehill.com/opinion/4755721-trump-nuclear-arms-race/

5:  Cancian MF, Park CH. Trump Moves “Nuclear” Subs: Negotiating Tactic or Escalatory Gamble?  August 6, 2025.  https://www.csis.org/analysis/trump-moves-nuclear-subs-negotiating-tactic-or-escalatory-gamble

6:  Megerian C.  Putin boasts about new nuclear-powered missile as he digs in over Russia’s demands on Ukraine.  October 27, 2025.  https://www.pbs.org/newshour/world/putin-boasts-about-new-nuclear-powered-missile-as-he-digs-in-over-russias-demands-on-ukraine

7:  Shoard C, Pulver A.  Kathryn Bigelow responds to Pentagon criticism of A House of Dynamite: ‘I just state the truth’.  The Guardian October 29, 2025  https://www.theguardian.com/film/2025/oct/29/kathryn-bigelow--pentagon-house-of-dynamite-netflix

 

 

Nobody Talked About My Uncle Johnny – Lingering Questions About Adverse Childhood Experiences…

I never knew my Uncle Johnny.  He died when he was 7 years old – many years before I was born.  He was the second of 8 children born to my paternal grandparents.  They were immigrants from Croatia and Austria.  Croatia was one of several countries that eventually combined to form Yugoslavia and then became Croatia again when Yugoslavia broke up.  As I tried to follow my grandparent’s timeline in the 1920, 1930, and 1940 census my grandmother’s country of origin was listed as Croatia-> Yugoslavia-> Yugoslavia. I am trying to piece that all together from the usual genealogy sites.  Nobody in my family ever talked about Johnny.  I did not know he existed until 4 months ago.   I was trying to find information about my paternal grandfather and landed on the census that showed he had 3 children – 2 aunts familiar to me and Johnny.

We always knew that my father had a brother who died in childhood. We did not know how old he was when he died, but we knew it was a gruesome death.   I was told that “he was held over a fire by two kids and burned to death.”  I was also told that child’s name was George and my father and subsequently I was named after him.  I also heard a version of the story that he was named Nick after my grandfather.  I had an uncle who had Nick as a middle name.   

Once I found out that Johnny existed, I sent an email to the Wisconsin Historical Society to track down what happened to him and the date he died.  In Wisconsin you cannot get a death certificate unless you know the exact date of death. I was sent newspaper clippings from several Wisconsin newspapers. The basic story in those papers was that Johnny went down to a local coal dock to see an airplane with several other boys.  There was a bonfire next to the plane.  He sustained severe burns, and died 2 days later in a hospital.  In the hospital he told his father that he was pushed into the fire.  Subsequently there was another story that he was held over the fire.  The Police Chief investigated what happened.  Some of the boys were questioned. Several of them were named in the newspaper.   After the article about his death, there are no further articles about the outcome of that investigation or whether the death was ruled accidental or a crime.  At the time of his death my father was 1 year old and he had a 5 year old brother and 3 sisters ages 4, 6, and 9.  

As a physician from an acute care hospital just the thought of what happened to Johnny evokes anxiety, anger, and hopelessness.  There was no burn care in 1925.  I did psychiatric consults on the burn unit at our modern trauma center for many years.  Burn care is emotionally demanding for both the patients and their physicians. Early on, one of the burn surgeons told me that he had informed consent discussions with severely burned patients and gave them all the option to choose no care except pain relief. It is difficult to imagine what the care must have been like in 1925 for my 7-year-old uncle during his last days. There were several statements about my grandfather seeking justice – but I am not sure whether that happened or not. 

There is a story that the boys involved did not do well as adults and that one of them may have died by suicide. At this point I cannot corroborate the outcome of the police investigation.  The local police department does not have records that old. I have requested the extended fact of death certificate to see if a specific cause of the severe burn injury is listed.  Local officials were initially unable to locate that death certificate until I discovered that the names of decedents were frequently misspelled – even official records (3,4).  I located a gravestone in the local cemetery marked John Dowson.  I sent that to the Register of Deeds and she was able to locate the death certificate under the name John Dosson. Given the age, date of death, and size of the town – it could not be anyone else.  It is also the first time I saw his date of birth.  

Given the historical limitations what were the potential impacts on the family?  Trauma is an overworked word these days in psychiatry and psychology.  Recent advocates of explaining nearly all psychopathology in terms of trauma and providing trauma informed care seem to have ignored the history of the field.  To cite a few examples – sexual trauma in children has been described back into the 19^th century by psychiatrists (1).  The trauma and biological effects of being raised in orphanages (psychosocial dwarfism) was described by psychiatrists (2).  Combat related trauma and PTSD was so well described that several of my mentors were placed in accelerated psychiatric residency programs to make sure the US Military had enough psychiatrists to treat the psychiatric complications of World War 2.  It is worth noting that before shell shock or the stress of combat was not seen as an etiology.  Soldiers exhibiting those symptoms were seen as morally deficient. In other words – the soldier was seen as flawed and combat exposure was incidental. In the early days of correcting that diagnosis the most frequent diagnosis in the German army was psychopathic personality suggesting an intrinsic susceptibility to overrespond to life threatening stressors.   

Over the span of my career I taught and practiced detailed phenomenological assessments that included every possible context that psychiatric disorders or symptoms occur in.  It was quite a shock when I started hearing about trauma informed care and started to see the iatrogenic problems associated with it. In the population I was treating at the time there were a significant number of immigrants from Africa, Russia, and Asia.  I routinely worked with 15 different language interpreters.  Many of the immigrants had been exposed to war and torture.  The prevalence of torture victims was so high that there is a  Center for Victims of Torture in Minnesota that was established in 1980.   

Despite those clear correlations the relationship between stressors or trauma and psychopathology is complex.  One of the primary problems is oversimplification. It is well known that people subjected to the similar catastrophic stressors do not respond in the same way (5,6)   This is due to several biological, environmental, and psychological factors that are typically called resilience.  More resilience translated to less maladaptive stress response.  In some cases, the stress response is very transient to nonexistent.  In others it follows a predictable course and in some it does not resolve without treatment.  The emphasis on identifiable stress response syndromes – Acute Stress Disorder and Post Traumatic Stress Disorder does not capture all the effects of these events.  It is clearly possible to have your life impacted by this kind of an event and not develop these full syndromes.

There have been efforts to more clearly correlate adverse life experiences with both physical and mental health.  The Adverse Childhood Experiences (ACEs) inventory was developed by the CDC and used to look at childhood adverse experience with subsequent problems.  The checklist is listed below and it was designed to be given only to adults over the age of 18. Inspecting those questions and the scoring it is apparent the focus is on physical, sexual, emotional, and verbal abuse and neglect.  There are four items on the lack of availability of a parent due to substance use, mental illness, separation or divorce, and/or incarceration.  The adverse experiences are all originating in a parent, caregiver, or person living in the same household.  Nothing about bad accidents originating outside the family or the death of a parent or sibling.

 The original CDC study of the ACES checklist was studied in a HMO sample (6) half of the 9,408 respondents reported at least one childhood exposure and a quarter reported more than or equal to 2 exposures.  This study also looked at correlations between ACES and adult risk behaviors and diseases and concluded there was a graded relationship.  That set the stage for subsequent studies that made similar claims.          

In the case of my Uncle Johnny – what was the impact of his death on the family?  Why was his name never used in discussions with his siblings?  Did it matter if the cause of death was never adequately resolved?  Did it lead to effects that are not typically considered as adverse childhood experiences?  None of his siblings knew his name.  The names passed on to the next generation were not accurate.  Why were his death and the associated circumstances never talked about in the family? 

Every family has characteristics that family members think about.   I can think of a few for mine.  We lived an isolated existence.  A typical family outing was a drive in the countryside.  We did not socialize with anyone.  Once or twice a year my father’s brother or brother-in-law would stop by.  Once or twice a year – we would stop by to see one of my father’s coworkers or a guy he used to play baseball with.  I did not know about the baseball connection until I found a picture of his team online – 40 years after he died. 

We would visit my maternal grandparents often.  It was one of the few places my father would smile.  He was typically very serious and showed emotions only during times of stress or if he was listening to opera or a comedian on TV.  I once asked him if I could play Little League baseball and he said: “As long as you know you are playing it for you and not for me.”  I got a similar reaction when I tried to give him a fishing rod for Father’s Day: “You just want me to take you fishing.  I don’t fish because when I was a kid we had to fish every day for food.”  His family home was right next to the coal dock where I usually went fishing.  The only consistent story we heard about his childhood was what it was like to grow up during the Great Depression.  One of the last events my father attended was a banquet for my high school football team.  It was an undefeated season and I was one of four sophomores.  He was at the event and seemed to enjoy himself – but never said a word about it to me.

If things got a little out of control – my father got angry.  I remember when one of us fell down a staircase.  He was clearly upset but it was mostly anger.  At times it came across like he was blaming the person who had the accident.  I found a box of rifle cartridges in the old horse barn modified to be our garage.  I put them in the trash burning pile that he attended next to our house every other night.  I still remember him dancing around when those cartridges went off. He showed plenty of restraint when I admitted doing it and that was the end of it.  I went out the next day and found the exploded cartridges in the ashes – the brass peeled back in a flower petal design.

There were many more situations that occurred between my father and I that I would consider unusual in retrospect.  There were only 5 children in our family and I cannot imagine what it would be like with three more. We lived “paycheck to paycheck” but never ran out of food.  There was not a lot of joy in the household. I worried about him and still have the mental image of him walking home in knee deep snow from work.  I worried because he told me that deep snow could get pulled into the air intake of his diesel locomotive and kill the engines.  In that blizzard he was leaning into the wind, covered in snow, wearing a flimsy fishing hat, and no gloves.  I was the only one up waiting for him at 11PM.  He walked in smelling like diesel oil and Lucky Strikes and shook off the snow.  He was freezing.  I was happy to see him.       

As I think about my Uncle Johnny and my family of origin there are more questions than answers.  Would things have been different for all of us if he had not been killed? Would my father have been a happier guy?  Would we have been less isolated?  Would the paternal side of the family have been less fragmented?  Can a catastrophic event like that have intergenerational effects?  There are only suggestions described by statistics at this point.  Studies like the impact of violence on mothers in families and the unique stressors that immigrants experience provide that data.

In an ideal world - the people closest to the incident have the greatest ability to process it and frame it for future generations.  They may not have the ability to do that but make no mistake about it – that is a very difficult task.  

 

George Dawson, MD, DFAPA

 

Supplementary 1:  The guidelines I used to write this essay:

1:  All of the principals in the generation of interest are deceased.  The general rule that I encountered from vital statistics government agencies for less stringent access to records was deceased for 50 years.

2:  I limited my remarks to personal observations in the subsequent generations and did not speculate about anyone else’s experience.

3:  I wrote only about observed behavior and did not speculate about intrapsychic states.

4:  I did not judge or assign blame to anyone – recognizing that this is a complex problem complicated by imperfect information. 

 

Supplementary 2:  Lessons about Vital Statistics

1:  The death certificate of my uncle was requested in an attempt to resolve a longstanding family mystery.  Starting in 1910 in the US the Standard Certificate of Death was supposed to include a manner of death (see section 37 below).  The manner of death is listed as accidental, suicide, homicide, natural causes, undetermined or under investigation.  The old death certificates did not have this section.

 

From my uncle’s death certificate, the cause of death was listed as:

“3^rd degree burns”

“1/2 of body involved”

From my grandfather’s death certificate, it read:

“cerebral thrombosis”

“arteriosclerosis”

Neither of them had manner of death listed.

An additional complication for my uncle was that I was sent 2 different death certificates with different dates, different spellings of his name, and different causes of death.  There were problems with the way this data was collected and reported in the past.  

References:

1:  Esquirol JE.  Suicide in Dictionnaire des Sciences Medicales.  A Group of Physicians and Surgeons (eds).  1821: 219-220

French psychiatrist Jean-Étienne Dominique is credited with suggesting that suicide was associated with mental disorders and was not the result of moral weakness and therefore not a sin or a crime.  In this initial report he described and attempted sexual assault by the father on a 16-year-old daughter resulting in several suicide attempts.  I could not access the original Dictionnaire des Sciences Medicales - but found this interpretation in Peter Gay’s Freud – A Life for Our Time – page 95 footnote.

2:  Spitz RA. The role of ecological factors in emotional development in infancy. Child Development. 1949 Sep 1:145-55.

3:  McGivern L, Shulman L, Carney JK, Shapiro S, Bundock E. Death Certification Errors and the Effect on Mortality Statistics. Public Health Rep. 2017 Nov/Dec;132(6):669-675. doi: 10.1177/0033354917736514. Epub 2017 Nov 1. PMID: 29091542; PMCID: PMC5692167.

4:  Gamage USH, Adair T, Mikkelsen L, Mahesh PKB, Hart J, Chowdhury H, Li H, Joshi R, Senevirathna WMCK, Fernando HDNL, McLaughlin D, Lopez AD. The impact of errors in medical certification on the accuracy of the underlying cause of death. PLoS One. 2021 Nov 8;16(11):e0259667. doi: 10.1371/journal.pone.0259667. PMID: 34748575; PMCID: PMC8575485.

5:  Geoffrion S, Goncalves J, Robichaud I, Sader J, Giguère CÉ, Fortin M, Lamothe J, Bernard P, Guay S. Systematic Review and Meta-Analysis on Acute Stress Disorder: Rates Following Different Types of Traumatic Events. Trauma Violence Abuse. 2022 Jan;23(1):213-223. doi: 10.1177/1524838020933844. Epub 2020 Jun 26. PMID: 32588756.

6:  Copeland WE, Keeler G, Angold A, Costello EJ. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry. 2007 May;64(5):577-84. doi: 10.1001/archpsyc.64.5.577. PMID: 17485609.

7:  Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8. PMID: 9635069.

 

UpToDate and the Rx Transitions in Mental Health

 

For the nonphysicians reading this UpToDate is a comprehensive online resource for physicians that has essentially replaced internal medicine texts. Before it existed, most physicians who practiced adult clinical medicine could purchase a new internal medicine text every 4 or 5 years for $200-300. UpToDate (UTD) requires an annual subscription that is roughly double that cost. Many large groups of physicians provide access to their medical staff free of charge. In my last years of practice, I had an out-of-pocket subscription but I let it lapse 2 years ago. I renewed it just last week.

My rationale for the subscription comes down to several factors.  First, I need access to the best current information on complex diseases and their treatment.  The counterargument is that you can access it online – but that information is often not balanced or realistic.  UTD is carefully edited by experts in the field who often comment on what they do in their clinics.  There are several levels of editing.  Second, continuing medical education credit is available just from studying what you are interested in.  I can do a deep dive into a subject on UTD and end up with several hours of CME credit that is necessary for licensing.  The free CME credit I can access is often low in quality and requires too much time – like needing to watch an hour-long video to get 1 hour of CME credit. I really have a hard time understanding why anyone would watch or listen to a program when reading is much faster.  The only useful exception is listening while driving.  Third, there is a drug interaction program.  After extensively researching hundreds of polypharmacy combinations – I still like running those analyses.  Fourth, researching my own medical problems.  A colleague pointed out that was one of the main reasons he subscribes.  In today’s world of brief medical appointments, it is good to have some expert backup.  And if any medication is suggested I always do my own drug interaction checks and do not assume the prescribing physician or pharmacists has.  I have suggested modifications of prescriptions to my physicians on that basis.  Fifth, as a reference for my blog.  UTD references are in many of my posts.

When I renewed this time there was an option for Rx Transitions in Mental Health.  I have positively mentioned UTD in the past as a source for physicians on antidepressant tapering and transitions.  Any experienced psychiatrist has done hundreds of these transitions or tapers.  The original UTD chapters were written by senior psychopharmacology experts and they were approaches I had used many times in the past.  It was also a reminder that contrary to some recent discussions about antidepressant withdrawal – psychiatrists have been aware of these issues and have addressed them for decades.

The Rx Transitions interface is sparse. It is explicit about the intent: “to provide clinicians with information about switching antidepressant medications”.   There is a column on the left of antidepressant to be stopped SSRIs (citalopram, escitalopram, fluoxetine, sertraline), SNRIs (duloxetine venlafaxine ER) and DNRIs (bupropion ER).  After selecting the drug and the dose – a drop-down menu appears with a brief list of important information including a link to the drug interaction program.  A more expanded list of antidepressants being started pops up that includes paroxetine, milnacipran and levomilnacipran, mirtazapine, vortioxetine, and vilazodone.  Once that is checked three different schedules are provided for an immediate, rapid or standard switch.  That roughly translates to switches on day 1, week 1 or week 2 respectively.  Several paragraphs of additional information are shown and the entire summary can be printed.

I have included a graphic at the top of this post to illustrate the possible transitions. The possibilities are illustrated for the starting prescription of citalopram and ending the transition with any of the 12 antidepressants on the right side of the diagram.  That is 12 possible transitions x 3 starting doses or 36 possible transitions. If we made similar connections for all the drug and dosages on the left side of the diagram there would be a total of 346.  All would ask about immediate, rapid, or standard switches and all would show additional information about the switch is subsequent windows.

The question is whether this add on would be useful for you in your clinical practice. The first consideration is that UTD has had sections about how to do this in the main resource for years.  They are written by expert psychopharmacologists.  When I have looked at them as a reference, they back up what experienced psychiatrists do in practice.  Secondly, do you treat much depression and should you?  There has been movement in the past 20 years to suggest that antidepressant prescribing should be a function in primary care.  Both the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have guidelines about this.  Collaborative care models have been suggested but many if not most primary care MDs have inadequate psychiatric back up. Context is very important since I doubt that getting a prescription in a primary care clinic is the same as seeing a psychiatrist. As an example – if I am discussing an antidepressant transition, I have asked that patient if they have ever stopped the medication and if they have ever had withdrawal symptoms. Some primary care physicians tell me they see minimal withdrawal symptoms because people tend to just stop the medication if they get side effects.  In that case starting a new medication is starting from scratch.

In psychiatric practice it is common to see people on the max doses of antidepressant monotherapy or polypharmacy.  In those cases, I would typically see people much more often until I was sure they had made the transition without side effects or withdrawal.  That might include initial tapering and close monitoring of depressive symptoms.  A final variable is whether the person can be counted upon to self-monitor.  I always told my patients to call me at the earliest sign of a side effect and further that I did not ever expect they would get used to side effects.  That did not prevent many from not reporting side effects until they came in for the follow up visit.  That is another reason for scheduling close follow up during these transitions.

Rx Transitions in Mental Health may be useful for physicians who have not had a lot of experience making these transitions.  It is an outline for what is possible in both the time domain and end results based on the list of medications that are used.  I think the choices could be further simplified.  For example, I do not see the utility for transitioning to paroxetine – an antidepressant with the highest withdrawal and drug interaction risk from any other medication in the diagram.  Similarly, I do not see the utility in including both citalopram and escitalopram as antidepressants to transition to, especially now that they are both generic drugs. Escitalopram is preferred because it has a lower effective dosage and better side effect profile. Using this program assumes a knowledge of antidepressants in general.  There are still many prescribed for other indications like sleep, headaches, and chronic pain.  Depression specialty clinics still prescribe tricyclic antidepressants and monoamine oxidase inhibitors that require special considerations.  There are also augmenting therapies (aripiprazole brexpiprazole, buspirone) that factor into the transitions. For the basic cases listed and with all the qualifications posted in the software – many will find the suggestions useful.

An easy thought experiment is possible to assist in the decision to get Rx Transitions.  Just look at the above diagram and think about each transition listed.  If you have done it many times before without any complications and are aware of all the considerations and precautions - you probably don't need it.  

The written chapter in UpToDate (2) is more comprehensive than the antidepressant switching tool.  It discusses concepts like antidepressant equivalent doses, pharmacokinetics, antidepressant withdrawal/discontinuation, and has links to specific classes of antidepressants, general approaches to treating depression, and treatment resistant depression.   Even at that level – psychiatric training should provide the clinical psychiatrist with what they need.  If you are a psychiatrist, I would encourage you to read this chapter first if you are considering subscribing to UTD for the psychiatric content only.  I hope that you know all this information cold including how to set up the medication transitions and monitor them.  As previously stated, there are many other reasons for psychiatrists to subscribe to UTD.

Primary care physicians will probably find this chapter to be very useful – especially if you have been nominated in your group to treat anxiety and depression.  I would recommend reading the chapter (2) first.  If your group provides access, they might also consider the switching tool but I would not consider it a necessity. If you have been using UTD for years you are probably aware of this chapter.     

 

George Dawson, MD, DFAPA      

 

Supplementary:

I have had UpToDate staff comment on this blog before.  If you are an UTD staff member please post a reference to the very first chapter on antidepressants transitions in UTD.  I think the original chapter was written by Ross J. Baldessarini, MD.  I would appreciate knowing how long that content has been in UTD.  

References:

1:  Rx Transitions for Mental Health: Antidepressant switching tool. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on October 2, 2025.)

2:  Hirsch N, Birnbaum RJ.  Switching antidepressant medications in adults.  In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on October 2, 2025.)

Why Equal Opportunity for Women Is Not “Woke”

 

I encountered two media events in the last couple of days that I thought I would respond to.  The first was an interview of Dana White talking about why there is no such thing as toxic masculinity and that you can’t be too masculine.  The second was the Trump-Hegseth lecture to the commanders of the armed forces and how there would now be male performance standards and grooming standards for members of the armed forces that were consistent with the new warrior ethos. President Trump also made an irresponsible comment about nuclear weapons that I will only say was not strategic or realistic.  He seemed to imply that because we have more of these weapons and they are more modern we could intimidate other nuclear powers and win a war.  I hope that I have been clear on this blog that in even a limited nuclear war whether you are close to the explosions and fallout or not – all of humanity loses.  By loses I mean up to and including extinction of all humans.

As I was watching the Dana White clip my first thought was: “Toxic masculinity is watching two guys inflict brain damage on one another.”  I remember watching him comment early in his career about how people never get injured badly in these fights despite being knocked out by punches, kicks, and chokes. Fighters have died in boxing matches and mixed martial arts competition (MMA) but apparently not in White’s ultimate fighting championship (UFC) competitions.  Despite that distinction it is just not realistic to think there are not injuries from these sudden accelerations and decelerations to the brain in any combat sports.  All it takes is repetitive nonconcussive impacts (1).

Like most of these complex subjects – masculinity and femininity all depend on your definitions.  And in academics the definitions may come down to your field.  My initial attempt at trying to research it yielded a steady stream of papers from the fields of post modern philosophy and literature, gender studies, and English literature.  A Medline search was more productive but still vague. I narrowed it down from 19,266 references (masculinity) to 333 (masculinity AND definition) to 93 (masculinity AND definition AND review). Even then the results are sparse since they include many references to medical disorders that may be masculinizing or feminizing. 

The overall process or how we arrived at stereotype of masculine or feminine is rarely discussed.  It is usually just assumed that the universe of human traits, attributes, and behaviors segregate neatly into two categories based on biological sex. These stereotypes come into play in some assessments like the Minnesota Multiphasic Personality Inventory (MMPI).  Scale 5 on that assessment is the Masculinity-Femininity scale.  It contains subscales Mf2 Stereotypic Feminine Interests and MF3 Denial of Stereotypic Masculine Interests.  High scores on the MF2 scale indicate and interest in stereotypical occupational and pastime interests.  High score on the Mf3 scale indicate a denial of stereotypical masculine occupations and interests.  Examples of masculine occupations include a forest ranger or a building contractor). The examples of feminine occupations include librarian or nurse.  Some sources state this scale is not usually interpreted in current use and it was originally intended for use with occupational interest. From the examples given – many of us know men and women working in occupations in opposition to what used to be considered stereotypically masculine or feminine (eg. women park rangers and men nurses).

A relevant dimension that I have not seen investigated in any systematic way is how societal conventions have affected masculinity and femininity stereotypes.  In a patriarchal society, where women have less access to jobs that are dominated by men – it will appear that they chose work based on their preferences. The change in the distribution of men and women in the work environment has changed dramatically in the past 40 years. When I started in medical school there were specialties where women were actively discriminated against and their numbers were naturally low. In psychiatry – I have never worked in a department where there were fewer women than men.  That includes jobs where heavy physical work predominates. All things equal – women have demonstrated that they can perform as well in jobs that men do.  That includes professional sports.  In this previous post – I pointed out the landmark district court ruling that expanded women’s access to high school sports with the result being highly skilled professional sports teams.

This wholescale integration of women into all aspects of society has been overwhelmingly positive.  The obvious rational argument is that no society can afford to eliminate the intellectual, creative, and physical resource of half of their population without suffering.  The proof of that is in what has happened so far. More high caliber workers and researchers and overall a much more productive society.  If there has been a downside – I have missed it.  Feel free to let me know about it in the comments below.

There has been a predictable political reaction to the integration of women in the workplace. Forty years ago, the family model was the husband was the breadwinner and the wife was expected to be the homemaker.  If a woman dared to get hired into a predominately male workplace – they were criticized for taking a job from a man. Their choice was to brave that criticism or take a traditionally female job where compensation was less. There are social and political forces out there today that think that 40-year-old model was the best one.  They do not see women in the workplace as a tremendous asset, only a detriment.  That often extends to women not being seen as physical or intellectual equals or having the same basic problem as men needing to generate income for families.  The end result of that bias is a male-centric society operating on male gender stereotypes.    

Dated masculine-feminine stereotyping also works against men.  Here is an example.  Sam wants to bring one of his college professors home for a visit.  He lives in a scenic part of the state and his professor said he would like to see it.  He is concerned about how his professor will be perceived by his largely blue-collar family and friends.  He confides in another friend at college: “I am worried that my professor’s vocabulary, style, and articulation will not be accepted.  I am really worried they will think he is gay and he is not.”  This brief example points to common stereotypes used by subcultures and some of the associated problems.  In this case, the subculture demands that men exercise a very limited male stereotype and if they move too far outside of that they will be criticized or not tolerated.

Common criticism of the concept of toxic masculinity is that it is not well defined, it can be stigmatizing, and the outcomes of people who have it are not well studied.  Considering all the possible traits, attributes, and vocations it is easy to imagine that a sample of men with relatively homogeneous toxic masculinity might be difficult to find.

Some authors have attempted a definition.  Sanders, et al (3) use a dimensional approach across 5 categories: masculine superiority, domination and desire, gender rigidity, emotional restriction, and repressed suffering. The researchers came up with a 35-item scale consisting of statements that subjects disagreed or agreed with on a 5-point scale.  The entire scale is available at reference 2.  A few examples of the test statements:

6. People are attracted to men who dominate others

7. Muscles are indicators of masculinity

10. Men are superior to women

11. Gender and sex are the same thing

15. Men cheating on their partner is natural

 The only aggression noted in the scale is sexual aggression in the statement: “Men can’t rape women because consent isn’t a real thing.”  There are no statements about verbal or physical aggression. The authors conclude the scale has adequate psychometric properties but it appears form the references that it was not widely adopted. 

Rather than define toxic masculinity in terms of what it is – a better approach may be to define it in terms of what it is not. I suggest the following:

1:  Acceptance of women as equals in every possible way – entitled to the same rights, independence, and privileges as men in society.  I am sure that most people agree with this on paper – but in many applications this statement is still difficult to implement.

2:  Refusal to accept the stereotype that women and the physical appearance of woman are primarily for the sexual interest and satisfaction of men.  This is commonly referred to as objectifying women, and despite an equality revolution in the 1970s it still permeates most aspects of American society. As far as I can tell there has been no initiative to educate boys at an early age about this bias and how it can affect their sexual behavior. We are counting on men to become self-enlightened at some point in their lives.

3:  Aggression against women as either physical or verbal forms of aggression is never acceptable. Aggression in general and the potential for aggression including the use of firearms is identified by some as a masculine trait. Aggression against women is a complex construct because in many cases it involves seeing a woman as the exclusive property of a man.   

4:  All people must be accepted and not discriminated against based on masculine or feminine stereotypes.  This is more complicated than it seems. My example of the professor in a blue-collar world is one – but there are many more. It includes the idea that gender is not necessarily equivalent to biological sex.

Coming around to the introductory paragraph.  Dana White’s comment about how “you can’t be too masculine” requires context and definition.  He provided neither. If he includes encouraging people to beat people up – even if they are consenting adults and doing it as a job then I would disagree.  I notice his standard argument is that he has improved the medical and safety standards of the UFC so that nobody has died (there have been fatalities in both mixed martial arts (MMA) and professional boxing). I would not agree. Most men are not UFC fighters and don’t get into physical altercations at all.  Prevalence surveys suggest that 30-40% of adolescent males get into fights (versus 20% of females), 1/3 of adult males get into fights, 1/3 may be at risk for intimate partner violence, and about 10% of male homicides are preceded by a fight.  Substance use and intoxication are frequent correlates.  I am personally aware of 5 cases where bar fights resulted in death.  In all cases the victim was struck just once.  All these prevalence studies also investigate aggression from women and the numbers are lower but substantial.

It may be easier for some people to see aggression as a male trait pushing into a zone of toxic masculinity.  There are too many complicating factors to make that statement.  I would suggest that an attitude of needing to settle disputes no matter how trivial with physical violence or using physical violence to intimidate people or take advantage of them crosses that line.  In that case – aggression is overvalued beyond any societal norm.     

In terms of classification – masculinity stereotypes are qualitative rather than quantitative categories.  Nobody is measuring them in terms of quantity and the same thing applies at the biological level.  Testosterone levels have a cutoff between normal and deficient and is age adjusted. Having more testosterone does not make you more masculine but it may cause side effects. The same might be said of any psychological construct of toxic masculinity.

There has been a good response to the awkward Hegseth lecture from retired Generals and women who served as officers, pilots, and in special forces. The consensus of that sample at this point is that the lecture was an insult to women in the military (as well as the assembled officers) because they perform as well as the men and did not get any special considerations for promotion or placement in combat ready positions.  There has been a pattern of regulations that prevented women from serving in combat or special forces that seems to be implemented on an arbitrary basis. The women who qualified and served are proof that they can do that work like they have done every other kind of work in modern society.  There was also a suggestion that without women, enlistment quotas would not be met.  Beyond these comments there are many references on women in the military and in combat positions by country and policy.  It is not like this is a novel consideration.

These same generals pointed out why the officers in the room at that lecture would not be saying anything.  Military protocol is that they must defer to civilian authority and cannot question it.  They also pointed out the exception that they cannot follow illegal orders.  The retired generals all said this is why Trump’s comments about deploying the military in cities and using the military against civilians was wrong. 

What is the real difference between men and women fighter pilots and combat veterans? Just a Y chromosome. That’s it and there is nothing "woke" about it.

 

George Dawson, MD, DFAPA

Supplementary 1:  What about Fuck Around and Find Out (FAFO) messaging? 

This blurb from Hegseth:

“That's why pacifism is so naive and dangerous. It ignores human nature and it ignores human history. Either you protect your people and your sovereignty or you will be subservient to something or someone. It's a truth as old as time.

And since waging war is so costly in blood and treasure, we owe our republic a military that will win any war we choose or any war that is thrust upon us. Should our enemies choose foolishly to challenge us, they will be crushed by the violence, precision and ferocity of the War Department. In other words, to our enemies, FAFO.”

If you are naïve to hep Internet slang (like I am) – you might have had to look up FAFO (like I did).  As noted in the above sentence – it is aggressive language.  The type of language you can see expressed in the road rage incidents of any real crime TV show. It is not the longstanding peace through strength position that the US has taken with previous administrations.  When you spend more on your military than the next 10 countries in the world and have a large standing military it could be construed as the language of a bully trying to provoke someone into unwise action. I am sure that I could provide some quotes from Sun Tzu that would make more strategic sense.  I am also sure that is why his line fell flat with military officers who are scholars in this area.

It is not the first time the FAFO rhetoric has been used by the Trump administration. Eight months ago Trump posted a photo of himself dressed like a gangster in front of an FAFO sign on his social media.  It was a message to Columbia after they refused to receive 2 airplanes carrying deported immigrants. Trump apparently threatened tariffs and visa bans. 

In keeping with the one of the overall themes of this post – is this form of symbolism and verbal aggression toxic masculinity?  If you consider gangsters and verbal aggression to be a masculine trait – then yes, it is.  

Supplementary 2:

Commentary from retired Generals on the Hegseth speech.  All links are to transcripts or videos.

Retired Brigadier General Ty Seidule:  Retired Army brigadier calls Hegseth and Trump's military meeting 'an insult'. Link

Retired Lt. Gen. Mark Hertling:  A Retired General Blasted Trump And Pete Hegseth For Their "Insulting" And "Offensive" Remarks To Military Leaders.  Link and Link

Retired Major General Randy Manner:  Major General Takes on Trumps “Enemy Within” Comment Link

Retired Army Gen. Barry McCaffrey: Comments on Trump Hegseth  Link

Retired U.S. Army Major General Mark MacCarley: Link

Retired Lt. Gen. Russel Honoré:  Retired general criticizes Trump and Hegseth’s new military standards.  Link

Retired Lt. Gen. Ben Hodges: Link

Ret. General Wesley Clark: “A lot of the rhetoric that came out struck me as culture wars stuff.”  Link

Former Army Vice Chief of Staff Gen.  Peter Chiarelli (Ret) on This Week:  Link

CHIARELLI: "No, there's nothing unlawful about what he said. Nothing whatsoever. I'm concerned about what I considered an attack on women, and the fact that -- that there are -- there are people who say that women have been let into different combat fields and cannot meet the standards. I just don't believe that's true. I know when the Army opened up the Ranger program, the standards did not change at all. Not at all. And the fact of the matter is on today's battlefield, everybody's in combat. Everybody's in combat. We found that out in Iraq. The minute you set foot from Kuwait into Iraq, you went into harm's way. And we needed medics. And many of our women -- many of our women were assigned to medical units. So, we had to pull them out and send them up with convoys. And they did amazing."

Retired Lt. General Ben Hodges:  Face the Nation  Link

MARGARET BRENNAN: I want to pick – pick up where we left off with Senator Duckworth, who is a Purple Heart recipient for her time serving this country in combat.  Men and women have different basic fitness standards. The secretary, in his remarks at Quantico, said women – or he suggested women were being given a pass or were held to lower standards for fitness requirements. Do you think his change to the, quote/unquote, "male standard" is necessary?

LIEUTENANT GENERAL BEN HODGES: I think this is completely unnecessary. I have 38 years in the Army, and we've served with women in all sorts of different environments and deployments. And I never had a case where a female soldier was not able to do what she had to do. So, this is a – seems to me an unnecessary, almost a medieval approach that doesn't reflect the requirements that we have for women and men who are intelligent, able to operate in a modern battlefield environment.

Ret. Colonel Don Christensen:  “His speech directly attacked the values of many of the senior officers and enlisted members in the audience, and I would expect many of them to demonstrate their disgust by retiring,” Don Christensen, a retired Air Force colonel and former military lawyer who watched the speech, said of Hegseth.  Link

Retired General Tim Haugh:  Commenting on cybersecurity and being fired by Trump for being "disloyal":  60 Minutes Transcript.

Major General (Ret.) William Enyart:  On appropriate uses of the National Guard.  Link

References:

1:  Daneshvar DH, Nair ES, Baucom ZH, et al. Leveraging football accelerometer data to quantify associations between repetitive head impacts and chronic traumatic encephalopathy in males. Nat Commun. 2023 Jun 20;14(1):3470. doi: 10.1038/s41467-023-39183-0. PMID: 37340004; PMCID: PMC10281995.

2:  Graham JR. The MMPI – a Practical Guide. 2^nd ed.  Oxford, England: Oxford University Press, 1987:  136-139.

3:  Sanders SM, Garcia-Aguilera C, Borgogna NC, Sy JR, Comoglio G, Schultz OA, Goldman J. The Toxic Masculinity Scale: Development and Initial Validation. Behavioral Sciences. 2024 Nov 14;14(11):1096.

 

Graphics Credit:

Wikimedia Commons:  English: Corporal Brandy Bates, a team member with Female Engagement Team 8 and native of Ann Arbor, Mich., walks around the corner of a mud wall while supporting soldiers from the Afghan National Army’s 215th Corps and U.S. Marines with Lima Company, 3rd Battalion, 7th Marine Regiment, during a recent foot patrol through the village of Tughay, Sangin district, Helmand province. The FET supports 3/7 by bridging the cultural gap and interacting with the local Afghan women.

This image was released by the United States Marine Corps with the ID 111206-M-GF563-025 posted on December 15, 2011.

https://commons.wikimedia.org/wiki/File:Female_Engagement_Team_builds_trust,_rapport_with_women_in_Sangin_111206-M-GF563-025.jpg

 

 

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