Thursday, November 24, 2022

Electrophysiology 2nd opinion – implications for medical and psychiatric practice

 


Pandemic related inaccessibility prevented me from getting timely Cardiology appointments this year.  As a result, I ended up with my scheduled consultation and a second opinion consultation spaced just two weeks apart.  I talked with a 2nd electrophysiologist today. He had records about me dating back to 2009. I had consulted with a cardiologist who was an exercise physiologist and another electrophysiologist at that clinic. After reviewing the recent history of paroxysmal atrial fibrillation again we had a very interesting conversation.

He reviewed the issues of rate versus rhythm control again. The priority is reducing stroke risk and that is done by anticoagulation. When it comes down to trying to maintain a normal sinus rhythm and all the measures that involves the decision is based on "How much does the arrhythmia bother you". He gave many examples that I was familiar with including the person who is not aware of being in atrial fibrillation until you tell them. I have made the diagnosis many times by taking vital signs on people and noticing their irregularly irregular pulse and pulse deficit. Most of the time they have no awareness of the arrhythmia. In some cases, they have been advised of the arrhythmia but decided not to do anything about it. I am in the category of people with what I like to call "cardiac awareness". I know immediately if I am in atrial fibrillation or even having palpitations. I check my own vital signs 3 times a day-in triplicate. We had a discussion of my neurotic tendencies and how much this rhythm problem bothers me – even if I am in atrial fibrillation only a few times a year for a brief period.

This point is also critical when it comes to treating psychiatric conditions. A misrepresentation of medical and psychiatric treatment is that physicians are drumming up business and manipulating populations into unnecessary care. Either that - or the care is just automatic and dependent on a diagnosis or blood test.   One of the favorite fabrications is that the DSM is designed expand treatment and line the pockets of both psychiatrists and pharmaceutical companies. In fact, I have not seen a patient in outpatient practice that was not there because they were distressed, bothered by their current symptoms, and unable to get help anywhere else. In my conversation today with the electrophysiologist we are contemplating a 3-hour procedure under general anesthesia with significant potential complications including bleeding, stroke, the need for pacemaker placement, and death - all based on my subjective assessment of how much this arrhythmia bothers me. Based on level of risk – there are no equivalent decisions in psychiatry.

To reinforce that point, he said that cardiologists have been trying to show that rhythm control is superior to rate control for about 40 years and the evidence was very thin and possible non-existent. Based on the discussion of stroke prevention, that assumes that anticoagulation reduces stroke risk on the atrial fibrillation group to the same level as the normal sinus rhythm or rhythm group. I would give the edge to the rhythm control group on that parameter.  In terms of lifestyle measures rhythm control would potentially eliminate other nuisance rhythms like bigeminy and trigeminy if the origin was in the pulmonary veins.  Additional mapping occurs during the procedure to see if there is another focus for these rhythms.  The atrial flutter would need to be eliminated in a procedure on the right side of the heart. A concern that we did not discuss is a sudden worsening of the atrial fibrillation or atrial flutter to the point that a different antiarrhythmic would need to be used.  I have seen amiodarone added at that point and there are many complications with that medication – including death from pulmonary complications.

We got into a discussion about phenotypes based on the recent New England Journal of Medicine review. The focal point was whether a paroxysmal atrial fibrillation pattern like mine was easier to covert by an ablation procedure and remain in a normal sinus rhythm and remain in that rhythm.  He was aware of the review, but thought that not enough is currently known about phenotypes.  That seem to be a problem with a lot or intermediate or endophenotypes that are used in psychiatry and other fields like asthma or multiple sclerosis.  On the surface there appear to be a lot of easily described apparent subgroups, but the natural history of those groups and the underlying pathophysiology is essentially unknown and considerable heterogeneity in severity, course, and outcomes remains.   

There was a brief discussion of the athlete’s heart.  He had no reason to doubt that the slightly enlarged left atrium and aortic root on my echocardiogram was due to decades of intense athletic activity and knew that was also one of many potential factors leading to atrial fibrillation.

The question of early rather than late ablation was discussed and the idea that there is progressive remodeling in the heart due to atrial fibrillation even in the case of a few episodes per year. He thought that in general, ablation prior to persistent atrial fibrillation resulted in better outcomes and earlier ablation was better than late ablation.  He emphasized that these were across group comparisons and there was a heterogeneity factor at work.  All the ablation that he does is radiofrequency ablation and the result is anywhere from 75-90% effective depending on how well the pulmonary vein isolation goes.  That is balances against a 2-3% risk of adverse effects – largely in the form of bleeding and hematoma formation at the catheter sites.  Chest pain and migraine headaches are also common post procedure.  Very serious complications during the procedure including death and the need for pacemaker placement were at about 1%.  The only death he had seen during the procedure was unrelated to the ablation.

He had a different opinion about the dose of flecainide and moving on to other antiarrhythmics like sotalol.  He thought I could take twice as much flecainide as a standard trial dose 150 mg BID), but agreed that it might not make much difference in the low frequency of atrial fibrillation.  That is quite a difference in flecainide dosing compared to the other group of cardiologists that I consult with.

In terms of recovery time give my current workout schedule he thought it would take a month to get back up to speed.  At that point I could resume my usual activities. If I decided to do that soon it would mean putting speedskating on hold for another winter.

That is where I am at after the second opinion.  Assuming that my insurance is the same across facilities – I have two to choose from and two electrophysiologists willing to try the ablation. My choice is to weigh a moderately successful procedure against the low frequency but significant complications and make the decision. And I know at this point it is an elective procedure based on how disruptive this arrhythmia is to my life. It is possible that at some point due to worsening atrial fibrillation and/or flutter and associated worsening symptoms or cardiac function that it would be less elective.

In terms of comparison with psychiatric practice and the usual critiques – these are the same choices that people would have if they were seeing me in clinic with a few exceptions. I am not treating anyone with invasive procedures or general anesthesia.  The medications prescribed by psychiatrists are generally safer that antiarrhythmics. There is a long list of absurd complaints made by antipsychiatrists that could similarly be applied to this cardiology scenario. But most importantly – in either case the treatment decision by the patient is subjectively based on how much the symptom is bothering them. I do not know how to translate 4 hours of symptoms per year into what I have been told about daily anxiety and depression symptoms every week. Some of those symptoms are also cardiac in origin.  

But I think this highlights a completely neglected dimension of medical and psychiatric practice.  Treatment is based on more than a rational informed consent discussion and weighing the risks and benefits. It is based on more than a scientific diagnosis and confirmatory tests.

It is highly subjective and based on the personal experience of the patient that is rarely know to casual observers.

 

George Dawson, MD, DFAPA

 

 Supplementary:

I thought I would add some additional observations about my recent cardiology consults and how they compare with psychiatric practice. Putting these in the main body of the post would have increased the reading difficulty.

Categorial diagnosis versus something else:  It is fashionable these days to say that medically diagnosed syndromes are a thing of the past and we should be making dimensional diagnoses or systems diagnoses.  Of course, these have been tried in the past. Contrary to a standardized approach – the diagnostic and treatment approach is highly practice dependent as can be noted by comparing the recommendations of the last 2 posts.  In addition, there is a fine structure to categories that is so detailed that it cannot be listed as criteria. Diagnostic categories in medicine have been talked about as prototypes – but it is really an indexing system for each physician to catalogue everything they know about that disease especially in the populations they are treating.

There may be objections to this conceptualization of categorial diagnosis.  Shouldn’t all clinicians be making the same diagnosis based on some sort of standardization?  That is certainly the argument many people make – but it certainly is not realistic.  Experts have seen more cases, know more variations, and have seen more diagnostic errors in the conditions they are diagnosing and treating. They have studied those conditions more thoroughly than anyone else. To suggest that a non-expert can read criteria in a diagnostic manual or administer a checklist of symptoms from that manual and get the same results is a significant misunderstanding of the process.  

Any medical category can be parsed based on severity and using that metric will lead to different assessments and treatments within the same category That is as true for cardiac arrhythmias as well as categories of depression and psychosis. A related issue on the medical side is that all the associated symptoms that might be lumped into lifestyle effects or suggest a psychiatric disorder are basically ignored if they do not show up on a PHQ-3 that is given as part of a preregistration packet.

The good news here is that subjectivity is alive and well in medicine and psychiatry as it should be.  Our biology determines unique presentations of our illnesses as well as our reaction to them.  The physicians treating us have to understand that.

 


Wednesday, November 16, 2022

A Visit To The Electrophysiologist




I have been waiting for today’s appointment since January 19th of this year. At that time I saw a cardiologist who recommended that I see an electrophysiologist for atrial fibrillation.  I have had paroxysmal atrial fibrillation - just a few episodes per year for 10 years.  It didn't start out that way.  I was having frequent episodes until the dose of the antiarrhythmic was adjusted.   It all began while I was speedskating one night and my heart rate monitor began chirping uncontrollably.  Since then I have been seen by 4 cardiologists and 4 electrophysiologists.  The first one suggested that I hold off on any ablation procedures until “the technology improves”.  I was back to seeing that doctor today.  The first time I saw him he impressed my with detailed drawings and notes about atrial fibrillation and the time he took to explain it all.  He wrote out all of the details of CHADS-VASc Score for atrial fibrillation stroke risk and tried to convince me to start anticoagulation.  I was not impressed with the addition of one point to the score just based on age so I deferred. I did start apixaban 3 months ago when I realized the systems of medical care was fragmented and if for some reason I did not come out of one of these episodes in a reasonable period of time I might run out of luck and end up with a stroke. This time the visit was a bit different – it went something like this (not a transcript):

EP:  “We have seen each other before – what brings you back?”

Me:  “A few things – the cardiologist I saw in January recommended it, I have some concerns about the Holter results, can I expect a better result from medication changes, and to get your opinion about ablation.”

EP: “How often do you have episodes?

Me:  “This year so far I have had three – one for 2 hours, and 2 for 1 hour each in February, July, and August.  Triggers may be anxiety and nightmares. Exercise is not a trigger acutely but I did have an episode the next day after I increased my pushups from 100/day to 150/day.

EP:  “That is actually pretty good considering you are 10 years out.  We generally see this as a progressive process….

Me:  “ I have been having 2-3 episodes per year for the past 10 years.”

EP:  “Even so there may be progression there.”

Me:  “What about the Holter result?  I noticed there was a brief episode of trigeminy. When this all started I had a much longer episode of bigeminy and was advised it was a benign rhythm.  Is there a ventricular component?  Does something need to be done about that?

EP:  “No this is atrial bigeminy/trigeminy and you are right it is a benign rhythm.  Your Holter shows less than 1% isolated PACs and VPCs so there is nothing to be concerned about there and I don’t think changing any medication would be useful.”

Me:  “My primary care doc called one of your colleagues about increasing the flecainide to 200 mg/day and he said the arrhythmia risk increased at the higher dose.” 

EP:  “I just don’t think it will do much in terms of eliminating 3 episodes per year.  Are you using CPAP?”

Me:  “I don’t sleep without it – my AHI is typically less than 1.  I also my check BP twice a day in triplicate and the systolic is typically in the 100-110 range.  It always seems elevated when I come here.”

EP:  “Everybody’s BP is higher here. Do you drink alcohol?”

Me:  “No.  I had a question about NSAIDS.  I have gout but have not had an attack in a long time. I know what the package insert says about NSAIDs and apixaban – can I safely use them for a few days?”

EP:  “Well I can’t tell you it is OK to use them because it is listed as a contraindication – but you would probably be OK for a couple of days.” 

Me:  “What about an ablation?  The last time you and I talked you advised me to hold off because the technology was improving at the time. Has it improved to the point it is safer?”

EP:  “It improves every year.”  [ draws a diagram of rate versus rhythm control and on the rhythm control arm antiarrhythmics versus ablation].  About 70% of people respond to ablation but in 33% of those patients it requires multiple procedures.  There is a 5% complication rate across all procedures and that includes damage to the esophagus or phrenic nerve but we monitor to prevent that. [Another diagram to show proximity of esophagus and phrenic nerve to the structures to be ablated].   There is also a risk of stroke but you are anticoagulated during the procedure to prevent this.  It is done under general anesthesia. It takes about 3 hours.  At the end of that time, you spend 2 hours in recovery to monitor the catheter sites and if you are OK – you can go home.”







Me:  “I have also had two episodes where the afib converted to atrial flutter at a rate of 130 – I understand that takes a right sided procedure in addition to the pulmonary vein isolation on the left?”

EP:  “They can both be done at the same time [demonstrates lesion and current pathway on his drawing].”

Me:  “I have seen photographs of the radiofrequency ablations and they appear to be full thickness burns….”

EP:  “We use a cryo procedure for the pulmonary vein isolation.  Any other questions?”

Me:  “On the Eliquis – my initial concern with it was ’nuisance bleeding’ described in the package insert but I noticed that I am bleeding a lot less than with aspirin.  Is that common.”

EP: “Yes.”

Me:  “Well at this point – I guess it’s up to me to decide on the ablation.  Let me think about it and get back to you.”

EP:  “OK here is my direct number.  Either way let’s get back together in about 6 months.”

That was the approximate content of the encounter. I am used to memorizing these details and summarizing them from long and detailed discussion in a psychiatric context.  I also compared the process with the first time I met this physician.  We were both wearing masks and this was significant and of course he worked through the entire pandemic and I bailed out after the first 18 months.  Both of those factors seemed significant.  The first time I saw him I was probably wearing my white hospital coat because I worked in the same hospital and would never take time off for an appointment in the building.  This time, he either forgot I was a physician or possibly had the view that psychiatrists don’t know much about medicine. At any rate the interview seemed pressured and he was running 30 minutes late.  I had advised his nurse that I thought I had dysgeusia (altered taste) from the apixaban.  That was not passed on and I forgot to ask about it again. I also wanted to ask about exercise and resuming speedskating now that I am retired but I also forgot to ask that question. But every cardiologist I have asked that question to in the past 16 years says the same thing: “Exercise as much and ask vigorously as you want to.”  I have come to realize that is not necessarily the best advice.

The overriding goals never seem to make it into medical appointments.  There always seem to be the assumption that you address a medical problem separate from your overall life.  For example, my goal is to live as long as possible and be as active as possible.  Never touched on.  With any cardiology problem there is also the issue of cardiac neurosis – will I at some point consider myself disabled from cardiac symptoms when I am not? Is it possible to do something that will make my symptoms worse? It helps to have a clear answer to that problem.  The closest I ever get is the exercise advice (that I question) – although today it seems that the episode frequency is minor and stable and the Holter results are nothing to be concerned about.

There was potentially some controversy in the appointment that I could have brought up.  The progression of atrial fibrillation irrespective of frequency seemed new and may not have been consistent with a recent New England Journal of Medicine review.  In that review it seemed like paroxysmal atrial fibrillation was a stable phenotype compared with persistent atrial fibrillation.  On the other hand remodeling at the molecular level potentially occurs every time there is an episode and for that reason my goal is to do everything possible to minimize them.

Was there another reason to post this?  There are a couple of reasons that I use my own medical experiences for didactic purposes.  The first is to illustrate the uncertainty in all medical diagnosis and treatment. Psychiatry is constantly (and erroneously) criticized for not having a discoverable lesion or testable abnormality as a cause of most non-medical psychiatric disorders. In this case, I am talking about two conditions (atrial fibrillation and atrial flutter) that seem to have a clear medical cause or do they? There are several pathways (genetics, heart disease, excessive exercise) leading to atrial fibrillation.  What is the true etiology in my case? The excessive exercise is largely based on preclinical studies in animals and observing a higher incidence of atrial fibrillation in endurance athletes. If I opt for an ablation – the first part of that will be an electrophysiology study to detect the conduction problems to be ablated. It is not a specific treatment for a lesion – it isolates the lesion or interrupts the circuit pathway.  The medication is similarly non-specific.  As the electrophysiologist said today: “Of course the medication will not cure anything. I can’t say whether the ablation will work. We can’t be certain of anything.”  Just a few weeks ago I saw a debate saying the psychiatric medications don’t “cure” anything. Cardiology and the rest of medicine seems to be in the same boat.

The other reason to use my own data is that I don't have to worry about consent and I don't have to disguise anything - although I have deidentified the ECG with respect to the physician and hospital. 

Death was not discussed as a possible outcome and I know that it happens.  Within the past few years there was a case posted in the NEJM that showed airlock in the ventricles based on and injured esophagus and air entering the heart from that pathway. There was also a celebrity who died following an ablation for atrial fibrillation.  Like most procedures, people who do them a lot are probably more successful, but there are never any guarantees.  Henry Marsh the British neurosurgeon has written about his complications and states that even in procedures where everything seems to go right there can be a bad outcome. Over the course of my lifetime I have experienced good and problematic surgical outcomes. It is a far cry from a coin toss - but they happen.

The phenomenology of the episodes was basically irrelevant today. I have them correlated with nightmares, anxiety, and other stimuli leading to increased adrenergic input.  None of the seemed relevant.  There was no discussion of sleep or how to get rid of the nightmares. Most people may have the expectation that cardiologists don’t cover this area.  Psychiatrists do and that’s why I am trying to figure that part out myself. On the other hand – I spend a lot of time talking with people about their cardiac symptoms and often tell them to call their physician immediately at the end of my session.

The nurse who got me into the room was very pleasant and professional. She went out of her way to make me feel comfortable. Her efforts were appreciated.  She was also charged with getting an ECG done before I saw the electrophysiologist.  She did this expertly and then offered me a copy of the ECG.  The electrophysiologist gave me an additional copy!  I posted a copy here (it is unremarkable) but I will add that if this had happened in a primary care clinic within the same healthcare organization – it would have elicited eye rolls, the statement: “Let me ask my supervisor if I can do that.”, followed by a rejection of that request. Again this is all the same healthcare organization presumably schooling each clinic differently in the nuances of HIPAA.  There should be no reason why you can’t walk out of the clinic with test results and I appreciate the efforts of the Cardiology Clinic.

That is where things stand today. I am playing it by ear and tracking my blood pressure, heart rate and rhythm, sleep apnea, nightmares, anxiety level, neurosis, headaches, and long COVID symptoms. I have decisions to make and will probably get a second opinion on the ablation issue as well as where to have it done.  Should it be at my local health care organization or at a larger referral center where they do a lot more of them?

But that is another story….

 

George Dawson, MD, DFAPA


References:

1:  Michaud GF, Stevenson WG. Atrial Fibrillation. N Engl J Med. 2021 Jan 28;384(4):353-361. doi: 10.1056/NEJMcp2023658. PMID: 33503344.

2:  Thomson M, El Sakr F. Gas in the Left Atrium and Ventricle. N Engl J Med. 2017 Feb 16;376(7):683. doi: 10.1056/NEJMicm1604787. PMID: 28199804.

   

Saturday, November 12, 2022

A DSM for Psychiatrists?

 


 

No matter what version - the DSM is clearly a flash point for criticism by psychiatrists and non-psychiatrists alike. There are too many diagnoses.  People don’t like certain diagnoses or complain when some categories are eliminated. There are endless debates about diagnostic criteria, reliability, and validity. Categories are a wrong approach and we need dimensions. Philosophers have a field day imagining what the DSM is and making suggestions.  In an early post on this blog, I responded to the philosophical suggestion that the DSM was supposed to be a blueprint for living. Antipsychiatrists have no problem rejecting the entire volume of course because they are stuck in the 1970s with Szasz and maintain that there are no mental illnesses. The more flexible antipsychiatrists reframe this into everyday problems in living another decades old formulation that did not stand the test of time. Others suggest that the DSM exists to make diagnoses that lead to pharmaceutical treatment and make profits for drug companies.  The more legitimate criticism from psychiatrists is focused on the criteria and whether any diagnostic categories exist. Some of that criticism comes full circle back to why a classification system was needed in the first place. Clinical psychiatrists tend to use a fraction of the available diagnoses and in most practices can recall the diagnostic codes without looking them up. In fact, most psychiatrists use the DSM as a reference, pulling it off the shelf for rarely encountered diagnoses and then typically to look up a diagnostic code for coding and billing purposes. 

The title Diagnostic and Statistical Manual – is the first clue about the original intent of the manual and it antedates the psychiatric profession and the APA in the United States by several decades. The abbreviated history is available on the APA web site and several other Internet sites.  Initially it was to determine numbers of people by diagnosis both in the varied mental illness facilities across the country and later in military service. This function was described as administrative but there was also a consensus building aspect in the early 20th century as diagnoses shifted from a unitary psychosis model to more nuanced.  The advent of the DSM-III was a turning point because it provided atheoretical definitions of disorders that were subsequently adopted by the ICD-9. Subsequent revisions in the DSM-IV and DSM 5 included revisions based on professionals and professional organizations, assigned work groups and their research, and eventually the general public. The original goal of classification and statistics has remained but it is used for various reasons by non-psychiatrists.

There are many examples of non-psychiatric use.  In the legal and political sphere, most states have rationed services for people with severe mental illnesses who are at high risk for hospitalization and other morbidities. Qualifying for those benefits depends on a  DSM diagnosis.  The same is true for state sponsored services for autism and developmental disabilities. In forensic settings experts are called upon to give diagnoses in an adversarial setting.  Disability, veteran’s benefits, and worker’s compensation are all linked to diagnoses.  All medical billing to insurance companies and government payers depend on DSM equivalent diagnostic codes in the ICD-11. Managed care companies ration care based on many of these codes by refusing to cover them. None of these functions were designed as an original intent for the diagnostic manual.

Heterogeneity – either explicit or implicit is another frequent criticism of the manual. Human biology and the biology of diseases and disorders teaches us that the etiopathogenesis of illnesses is diverse. There are many possible underlying biological and nonbiological causes.  Many genes and lesions can often lead to the same apparent presentation or phenotype.  That lead to the idea of intermediate phenotypes or endophenotypes to get a more consistent population to study but that has only been partially successful. The DSM was never designed to biologically classify mental illnesses, but DSM diagnoses are used for studies of biology and pharmacology. Other systems have been suggested for that purpose – most notably the RDoC system, but so far it has not exhibited any widespread success.  There is no reason to think that a verbally based system will accurately describe biologically based illness whether those descriptions are in the DSM or RDoC.

Apart from classification for statistical, administrative, and planning purposes what good is the DSM to psychiatrists? I recently saw it criticized for not including enough psychopathology. The criticism was bitter and partisan but apart from some very basic definitions the DSM is not a course in psychopathology.  All psychiatric residents need to be taught psychopathology to the point that they are experts in it. That will never happen from reading the DSM. It also doesn’t happen from reading a psychopathology text or taking a college course in psychopathology.  It happens from seminars, reading, and clinical experience – discussing psychopathology with colleagues, supervisors, and instructors.  It happens from learning in treatment relationships with people who have psychopathology not just a list or criteria but experiencing firsthand the interpersonal aspects. The DSM explicitly states that it is for use by trained professionals and that it can be used to facilitate communication between trained professionals.  

The DSM is clearly not a treatment manual of any kind. That is why I have always found the charge that it is a source of prescriptions for the pharmaceutical industry ludicrous.  There are roughly six times as many prescribers of psychiatric drugs as there are psychiatrists and the only medication in that category that is more likely to be prescribed by psychiatrists is lithium. It is easy to speculate that the prescribing patterns of that larger group are not contingent about what is in the DSM.

What about the diagnostic side and what psychiatrists need? Although there was some criticism that the neo-Krapelinians have had too much influence on the manual it is time to acknowledge that verbal descriptions have come to their logical limits. It is also time to acknowledge that psychiatrists need to know a lot more about medical diagnoses in general in order to function in a medical environment. If medical conditions are in the differential diagnosis – how many medical conditions do psychiatrists need to know about and diagnose?  Every psychiatrist I know has stories about medical conditions that were referred to them as a psychiatric disorder where they made the correct medical diagnosis. They are typically conditions from neurology, endocrinology, and infectious disease but also general medical conditions like diabetes mellitus, hypertension, and atrial fibrillation. Approaches I have seen in other specialties include lists of conditions that the trainee or practitioner needs to know about.  That is a useful approach but lists like that in a DSM are likely to raise objections about medicolegal risk and that a larger recipe book is being made for what it takes to be a psychiatrist. There are also many psychiatrists in settings where medical assessments are impossible, where they are referred out, or where the practitioner may feel inadequately trained. I see all of those reasons as being an opportunity to advance the quality of psychiatric treatment.   

A related issue is the diagnostic process in psychiatry as opposed to the rest of medicine.   Nassir Ghaemi, MD had a recent commentary about this on his blog suggesting that the DSM approach prioritizes comorbidities rather than differential diagnosis like the rest of medicine.  He describes the typical pattern matching that occurs early in the process and suggests that the differential diagnosis point, the DSM encourages listing all of the comorbidities rather than going through a differential diagnosis process.  In other words there is a lack of a hierarchical process. 

That has not been my experience. Granted – I may be a more medically oriented psychiatrist than most (but then again had 20 colleagues doing the same work) – but when I see a patient the universe of diagnoses are all possible both in and outside the DSM. The number one priority was making sure that a life threatening medical condition was not misdiagnosed as a psychiatric disorder.  Every physician can recall being taught about differential diagnosis and having to write an exhaustive list for the first few Internal Medicine inpatients. That process illustrated that a lot of the “rule outs” occurred as a mental exercise and really did not need to be written down. By the end of that rotation the differential diagnosis list collapse from the low double digits to the low single digits. There was also a triage element based on the more pressing problem or diagnosis.   A DSM for psychiatrists could make this process explicit, discuss the cognitive aspects of pattern matching and completion necessary for generating hypotheses in the differential diagnosis, the differences between differential diagnosis and comorbidity, and probabilistic considerations in selecting the preferred diagnosis. It would potentially have training implications because in order to optimize the pattern matching required - adequate training experiences need to be supplied to develop those skills. 

A DSM for psychiatrists needs to be much more information intensive in terms of research on validators, psychiatric genetics, multiomics, endophenotyping, drug mechanisms of action, and biological markers for each category.  A typical response to that suggestion is "Well there are no biological markers, labs tests, etc."  I don't find that to be a compelling argument when I think about what is currently being ignored.  We are on the cusp where more of that information is becoming relevant and we are past the point where much relevant information can just be dismissed. Any concern about cost of a more extensive manual can be dealt with by placing it online for subscribers. This may seem like a significant task given the accumulating information, but it is time the APA and research leaders in psychiatry to realize that the task has changed.  Psychiatrists are different from other physicians and other mental health professionals.  Psychiatrists need the technical information to provide quality care and compete against other systems that claim to know more about psychiatry and medicine than they do. Time to adjust to that reality and have the necessary internal debates first.

That concludes my suggestion for a DSM for psychiatrists, but I am open to more suggestions.  And for the record I am suggesting two different publications instead of a general manual full of qualifiers about expertise.  We need a manual for experts and another one like the current version - for everybody else.

 

George Dawson, MD, DFAPA


References:

1:  Horwitz, A.V. (2014). DSM - I and DSM - II . In The Encyclopedia of Clinical Psychology (eds R.L. Cautin and S.O. Lilienfeld). https://doi.org/10.1002/9781118625392.wbecp012

2:  Kim YK, Park SC. Classification of Psychiatric Disorders. Adv Exp Med Biol. 2019;1192:17-25. doi: 10.1007/978-981-32-9721-0_2. PMID: 31705488.

3:  Cooper R, Blashfield RK. Re-evaluating DSM-I. Psychol Med. 2016 Feb;46(3):449-56. doi: 10.1017/S0033291715002093. Epub 2015 Oct 16. PMID: 26470724.

4:  Shorter E. The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders. Dialogues Clin Neurosci. 2015 Mar;17(1):59-67. doi: 10.31887/DCNS.2015.17.1/eshorter. PMID: 25987864; PMCID: PMC4421901.

5:  Blashfield RK, Keeley JW, Flanagan EH, Miles SR. The cycle of classification: DSM-I through DSM-5. Annu Rev Clin Psychol. 2014;10:25-51. doi: 10.1146/annurev-clinpsy-032813-153639. PMID: 24679178.

6:  Grob GN. Origins of DSM-I: a study in appearance and reality. Am J Psychiatry. 1991 Apr;148(4):421-31. doi: 10.1176/ajp.148.4.421. PMID: 2006685.


Supplementary:

It has been suggested that a hierarchical approach informs the usual differential diagnosis exercise but it may be the application of the parsimony principle. To me there is an open question about how well parsimony works for complex biological systems.

Photo Credit:  Eduardo Colon, MD

 

 

Thursday, November 3, 2022

No Way To Run A Democracy.....

 



 

CBS news came out with an analysis this morning that most Republican mid-term election candidates are election deniers.  That is 308 out of 597 total.  They agree with former President Trump that he actually won the 2020 election, despite the fact that there is absolutely no evidence to support that claim.  The evidence is lacking even when analyzed by Republicans and judges and attorneys who are Republican appointees. When that claim is reported in the news these days it is characterized as a lie. Even apart from the news media, the January 6th Committee has presented direct evidence that this claim was inaccurate and had no supporting evidence and that it also formed the basis for the coordinated attack on the Capitol and an attempt by former President Trump and his associates to overthrow the newly elected government of the United States.

What should be most concerning for any citizen of the United States is that attempted insurrection. There is a good chance that if the current crop of Republican candidates – most of whom are overt election deniers become the majority in the House that former President Trump and his associates will not be held accountable for this action. That is unprecedented in any democracy and it flaunts the rule of law and political convention of the United States. If the insurrection had succeeded – the United States as we know it would cease to exist. Democracy instead would be replaced by a Republican party of moral and gun extremists.

Instead of focusing on preserving the Republic – voters seem focused on the economy and inflation – as though any group of politicians has a more favorable history in that area. Over the course of my lifetime, we have had worse inflation, much worse unemployment, 10 recessions, 2 economic crises that nearly collapsed the world economy, and 30 yr fixed mortgage rates at least twice as high as they are now.  The people who saved the economy were professional economists from the Federal Reserve who are appointed and not elected officials. Elected officials consistently have the opportunity to pass legislation to reduce financial market risk due to speculation, but they seem to lose interest every time one of these crises has passed.  In this case both inflation and the possible recession can be explained by historical events (pandemic, Russian invasion of Ukraine) affecting the supply side and driving up prices. Rising interest rates to decrease demand and reduce inflation have made increased the cost of borrowing and that comes following a long period of artificially low interest rates that included low interest rates for savings accounts. In some cases, money market and bond funds were paying negative interest.  

I present the following graph as economic evidence. It is not exhaustive but it illustrates my point. I thought about adding a timeline of Federal Reserve Chairs but ran out of time. The national debt increases substantially under all presidents. The recessions are the shaded areas. Major crises in the economy occurred with the Savings and Loan Crisis (1982-1989), Long Term Capital Management liquidation (1998) and the Subprime Mortgage Crisis of 2007-2010.  The graph extends to August of 2022 with unemployment at 3.5% and Sticky Price Consumer Price Index of 6.39%.   Republican politicians are saying this is the highest inflation rate in 40 years.  What they are not saying is that it is also the highest rate of corporate profits in 70 years and the Federal Reserve has made interest rate increases that are already taking effect in the housing market. (click to enlarge)



I say that the voters seem focused on the economy because it is hard to get valid news about voter preferences from major networks focused on either balancing one party against the other (when no such symmetry exists) or acting essentially like the public relations department of the Republican party. Viewers used to be able to turn on the news and watch reliable journalists deliver the facts, but now they have a choice to listen to a broadcaster who parrots their political ideology. The facts take a distant second place.  There is no clearer example than election denial and all of its ugly correlates like voter suppression and political violence. 

There is only one party that has multiple members endorsing both of those options.  To listen to some of those candidates today – they make it seem like the opposition party has similar problems. There were no Democrats advocating for the violent overthrow of the US government.  There were no Democrats addressing violent groups and suggesting that they “stand by”.  There were no Democrats writing and passing permitless carry gun laws at a time when gun homicides and suicides are high and school shootings continue unabated.  There were no Democrats passing laws that allow heavily armed men wearing body armor and carrying assault weapons to gather in proximity to a legislative body and intimidate them. There is no symmetry between parties on the issue of political violence, gun violence, and the orderly transitions between elections. 

I could continue but realize that this scarcely read blog and the lateness of this post will probably not change much. I will end by posting what I consider the top issues to be in order of importance. I have posted before that I am a long time small “i” independent but in the current Constitutional Crisis I don’t have much of a choice and I have already voted. The vote I cast last week required 2 forms of ID, my address had to be confirmed in an electronic database and I had to sign a registry and one of the two envelopes containing my paper ballot.  That sealed paperwork was directly observed and signed off by an election worker.  This is what I voted on:

1:  Preservation of American Democracy. No insurrection against the government can stand and none of the conspirators should go unpunished.  Any party claiming to be the Law and Order party should understand this.  That party is trying to make crime an issue and it is hard to say if the media or the GOP is the reason for this focus - but the reality is that there has not been an increase in violent crime and there has been a 30 year trend in a positive direction. 

2:  Voter Rights. The Big Lie about the 2020 election was a variation of the big lie about election problems in the United States.  That lie is used to restrict access to voters and make it more difficult for citizens to cast their ballot. Lower income Americans are disproportionately affected.  A variation on that theme is intimidating voters and election officials. That is an ongoing process and it is encouraged by politicians spreading the Big Lie about both the election process and the integrity of the voting process. There is no evidence that either has been compromised. 

3:  Civil Rights.  The unprecedented attack on Roe at the level of the Supreme Court is really the culmination of Republican activism dating back to the Carter administration. At the time a Republican activist convinced fundamental Christians that they should be politically interested in the abortion issue and it was used to attempt to protect school segregation. They created one of the most divisive issues in American politics to advance their interests and made it seem like it was a religious issue.  This is a doubling down of moral extremism.  In other words moral superiority to cover an essentially immoral act.  There are not many positions that are more cynical.

4: Gun Regulation. Gun carnage continues unabated and the GOP and their justices in the Supreme Court have no reservations about allowing it to continue.  Republicans everywhere are rationalizing it as a problem with mental illness, when the prevalence of mental illness is the same across all countries and only the United States has mass shooters shooting children on a regular basis, gun homicide as a leading cause of death in children and young black men, and extremely high levels of gun homicides and suicides.  There are currently 25 states that allow permitless concealed carry of firearms.  All of this from a politicized reading of the archaic language of the Second Amendment. That alone would probably not be enough.  It also takes the fear tactic that the "government", "liberals", etc are "coming for your guns."  The reality is that there are so many weapons in the country - finding them and rounding them up would be an impossible task for anyone. And of course - nobody is interested in doing that. 

5:  Strengthening NATO.  The Biden administration has handled the crisis in Europe and rebuilding the NATO alliance expertly and they are not getting nearly enough credit. A secondary goal should be containing terrorism with our allies that comes in all forms including state terrorism that we are witnessing from Russia, North Korea, and Iran. It is likely there would be a much different outcome under a Trump administration.

5:  Nuclear non-proliferation: Every possible effort must be made to ensure that nuclear weapons are not used again.  There is too much loose talk about how limited tactical nuclear weapons would release less radiation and that a small local nuclear war would be "winnable" by somebody. Climate change should be a wake up call illustrating that even small changes in the environment can lead to catastrophic global changes. The detonation of nuclear weapons will not determine winners and losers. Mankind will lose and civilization will end.  

6:  Climate Activism:  As climate change gets more and more obvious the party that denied it was happening clearly has no solutions.  The infrastructure bill passed by the Biden administration was a major step in the right direction but even that is not enough. More changes need to follow to reduce carbon dioxide emissions and remove permanent environmental contaminants from the environment.

7:  Social programs.  There are Republican legislators who want to cancel Social Security and Medicare or euphemistically review it every 5 years and decide whether or not to cancel it.  Every person who has paid into those programs needs to be assured that they will get the agreed upon benefits.  Republicans use socialist rhetoric to impress upon their followers that the “socialists” want to take over the government and restrict their freedom.  In fact, social democracies are some of the fairest systems in the world and the United States has had social programs for a long time. Social programs in a democratic republic have nothing to so with a socialist government.

8:  Public health Initiatives: COVID-19 denialism was a major factor in unnecessary mortality and morbidity from that pandemic and there is no doubt who the most significant players in that denialism were. As the climate deteriorates and mankind is in closer proximity to millions of novel viruses in the wild – we need to infrastructure to assess those threats and either contain them or treat the outbreaks. We need people who understand science as a process and what needs to happen in this area.  Instead we have Republican politicians bragging about ignoring public health measures.

9:  A Coherent Immigration Policy:  Building walls and playing games with the lives of undocumented immigrants is not a coherent policy. It will take more comprehensive planning and aid to countries in Central and South America.  In addition the United States has a lower percentage of foreign born citizens than many European countries and Canada as well as a labor shortage so that increasing the number of legal immigrants each year can potentially decrease the number of people seeking political asylum. 

10:  Simplified Tax Policy:  Taxes are always a political football. Promise of no new taxes and tax cuts are not realistic, especially considering the current national debt.  A better plan is to make taxes more transparent and easier to complete. Business taxes should not be eliminated and should be consistent year-to-year and not a disincentive to doing business in the United States.

That is what I voted on.  It does not come down to a single issue for me.  It does not come down to voting for myths rather than reality.

But it does come down to a single party.

 

George Dawson, MD, DFAPA


Extremely relevant late breaking stories relevant to the above post:

1: Election deniers in Minnesota are training some election judges. Link - there are widespread efforts with various levels of organization by election deniers to interfere with the election process. This is a story from 2 days ago.

2:  What Fortune 500 Companies Said After Jan. 6 vs. What They Did.  Link - major US corporations said they would suspend political donations to election deniers and insurrectionists following January 6 - but those donations have resumed to the tune of $13 million.

3:  A message from Billie Eilish on the importance of voting. She describes the top issues highlighted above and I hope her followers and fans are able to follow through with her advice:  https://www.instagram.com/p/Ckj-ihtLw3G/?utm_source=ig_web_copy_link

4:  Charles Blow.  Dancing Near the Edge of a Lost Democracy.  New York Times November 6, 2022   https://www.nytimes.com/2022/11/06/opinion/midterms-democracy.html

"America is one bad election away from being a memory."

5:  Putin ally Yevgeny Prigozhin admits interfering in US elections.

They are obviously not interfering in the direction of more democracy.

6:  Bill Maher's analysis on the even of the election. Certainly hope he is wrong but if he isn't these are a few more reasons:

Democracy's Deathbed | Real Time with Bill Maher (HBO)

7:  Office of Intelligence and Analysis Operations in Portland April 20, 2021

Remember all of the reports about Antifa - the secret left wing terrorist organization that was supposed to be fighting the police and causing general unrest in the riots following George Floyd's death.  At the time is was pretty clear it was a myth to rationalize right wing militias showing up heavily armed to maintain law and order.  This mildly redacted report shows how US intelligence failed to show that any such organization existed.

8:  Democratic upset in U.S. midterms could roil markets, options mavens say

Nothing like last minute pro-GOP economic propaganda.  Three things:
1.  The current polls are based on the 1% of people using land lines who agree to take the poll.  With that level of sampling don't be too surprised if polls are wrong as they have been in the past.  There is no "upset" in that context only inaccurate polls.
2.  Why would the average voter be remotely interested in what "options mavens" have to say. Anyone who has followed financial news knows that it is often created to move markets in a favorable way and not to favor the casual investor or little guy
3.  See more objective data from the St. Louis FRED below.


Written by professional economists and not politicians.  Was this expansion due to another tech bubble?

"If this rise is driven by another asset bubble instead of the reasons mentioned above, then this trend is likely to cause another recession. Unfortunately, it is difficult to identify an asset bubble until after it has burst."

The current state of economics.

10:  Election workers brace for a torrent of threats: ‘I KNOW WHERE YOU SLEEP’:

And let's be honest - these threats are the direct result of the Big Lie, The Insurrection, and the fueling continued political violence by the GOP.  There are no Democrats threatening election workers.

11:  Voting Machine Problems in Arizona Fuel Right-Wing Fraud Claims

Trump spreads voter fraud claims on this election day, despite Republican official stating that there is no problem.

12:  John Oliver on Election Subversion:



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Monday, October 31, 2022

Incident Atrial Fibrillation and Intoxicants



I remain very interested in the cardiac and brain complications of medications and substances that are commonly used to get high or create altered states.  I am also very interested in the popular trend to characterize cannabis as some previously undiscovered medication that can cure everything ranging from anxiety to obstructive sleep apnea.  I was naturally interested when I saw this paper (1) looking at the issue of incident atrial fibrillation and common intoxicants.

The authors examine a very large database in California that included anyone who had been seen in an emergency department, ambulatory surgery center, or hospital over a period of 10 years (2005-2015).  After they eliminate minors, subjects with persistent atrial fibrillation, and subjects with missing data they had a total of 23,561,884 people. 998,747 of those people had incident atrial fibrillation (defined as the first encounter for atrial fibrillation).  Since their study design is a retrospective observational study they also recorded substance use was considered present if Substance use was considered present if there was coding for any indication of use of methamphetamine, cocaine, opiates, or cannabis.  Knowing the atrial fibrillation and substance use diagnoses – the authors calculate the hazard ratio for each of the substances of interest.

Hazard ratios are basically the ratio of the people exposed to intoxicants who developed atrial fibrillation over the unexposed who developed atrial fibrillation.  So any number greater than 1 means that the population exposed to intoxicants had greater risk.  The corrected hazard ratios were noted to be 1.86 (methamphetamine), 1.74 (opioids), 1.61 (cocaine), and 1.35 cannabis. The authors adjusted for common atrial fibrillation risk factors and ran an additional negative control analysis and looked at the scatter of data pints for these 4 substances and hazard ratios of developing appendicitis, connective and soft tissue sarcoma, and renal cell carcinoma and showed no consistent pattern for these illnesses.

There are a couple of interesting considerations relevant to this study.  The first is the mechanism of action in each case. With stimulants there is a direct hyperadrenergic effects and depending on the individual and dose of the drug varying degrees of tachycardia, palpitations, and hypertension.  Long term users frequently end up with cardiomyopathy from these effects and in some cases ventricular arrhythmias and congestive heart failure. There can also be acute vascular effects like ischemia either due to the increased cardiac demand or pre-existing arteriosclerosis. Atrial fibrillation has not typically been placed in that group of morbidities from stimulant use. Patient with atrial fibrillation often notice emotional precipitants for discrete episodes or atrial fibrillation although a recent study showed that the only reliable precipitant was alcohol use (2). There were significant limitations with that study with attrition and length of the study although I generally agree that alcohol is a clear participant.  Precipitants need to be carefully approached and I suspect that attentive physicians have noted variable phenomenology on an individual basis. 

The high hazard ratio for opioids is a little puzzling. Hyperadrenergic states can occur with the euphorigenic effects and withdrawal effects as well. Direct comparison with stimulants may be difficult due to rapid dose escalation and some degree of tachyphylaxis.  Cannabis is not surprising to me at all. Many initial cannabis smokers notice that their heart is pounding and don’t know why.  They find it unexpected given the conventional wisdom that cannabis is supposed to be a benign substance. Many initial users also get increased anxiety and, in some cases, have a panic attack that may be due to the cardiac sensations. The primary heart pounding sensation is because cannabis causes hypotension and they are experiencing reflex tachycardia. The effects may be less predictable because cannabis use can affect both sympathetic and parasympathetic pathways that can potentiate arrhythmias. A case report of cannabis induced atrial flutter (3) was described as occurring in a woman with a history of hypertension that eventually had to be terminated by an intravenous antiarrhythmic.   

Atrial fibrillation and other cardiac arrhythmias are another good reason for avoiding intoxicants including alcohol (in the supplementary analysis alcohol had a Hazard Ratio of 2.37).  It could be argued that it is basically a numbers game – since most people who use these intoxicants do not develop incident atrial fibrillation.  As of this moment, even if you have had your DNA analyzed for what are known about atrial fibrillation genes – you can’t be certain that you are not susceptible to the problem. And as outlined above there are many additional cardiac problems and that are possible from using these compounds.  The safest path is to avoid these intoxicants all together.

 

George Dawson, MD, DFAPA

 

 

References:

1:  Lin AL, Nah G, Tang JJ, Vittinghoff E, Dewland TA, Marcus GM. Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation. Eur Heart J. 2022 Oct 18:ehac558. doi: 10.1093/eurheartj/ehac558. Epub ahead of print. PMID: 36257330.

2: Marcus GM, Modrow MF, Schmid CH, Sigona K, Nah G, Yang J, Chu TC, Joyce S, Gettabecha S, Ogomori K, Yang V, Butcher X, Hills MT, McCall D, Sciarappa K, Sim I, Pletcher MJ, Olgin JE. Individualized Studies of Triggers of Paroxysmal Atrial Fibrillation: The I-STOP-AFib Randomized Clinical Trial. JAMA Cardiol. 2022 Feb 1;7(2):167-174. doi: 10.1001/jamacardio.2021.5010. PMID: 34775507; PMCID: PMC8591553.

3: Fisher BA, Ghuran A, Vadamalai V, Antonios TF. Cardiovascular complications induced by cannabis smoking: a case report and review of the literature. Emerg Med J. 2005 Sep;22(9):679-80. doi: 10.1136/emj.2004.014969. PMID: 16113206; PMCID: PMC1726916. [full text]