Monday, November 19, 2018

Exploits on the Internet

I received the above at my work email address last week.....

I have always been unimpressed with the idea of computer hackers for a number of reasons, the most obvious ones are contained in the above email.  Apart from the obvious extortion, their ability reach out and ruin the day for anybody through any number of mechanisms is a major problem.  I was concerned to some degree about the threat based on me watching porn videos because it would be fairly easy to make it appear that I did it using any split screen video app.  Some online research revealed that there is a hack for Mac cameras.  It might be easy to get a video of me on the computer and then pair it with any pornography video.  

My dealing with identity thieves illustrated how easy it is for criminals to remain anonymous in our society while average citizens deal with their mischief.  I was called at work by a very aggressive person working for a collection company who claimed that I owed them $10,000.  Investigation showed that an identity thief opened a fake credit card based on my Social Security Number and ran up the charges.  I filed a police report and was advised by the local police that it was unlikely that anything would happen, but that the report was necessary in order to file an affidavit with the credit card company to avoid paying the charges.  I was eventually able to track the thief to a Florida address and called the local Sheriff to investigate.  I was told that the Sheriff would not look into it because "anybody could have used that mailbox and it would be an invasion of privacy." It became clear that identity theft was just the cost of doing business for credit card companies and credit reporting agencies - regardless of the cost and time to the consumer.

The source of my of the hacking exploitation is infuriating and that of course is poor computer security.  What is never really made explicit is the reason for the lack of security. It was certainly never really designed in.  Apple claims that it is and they have a detailed explanation about this in their literature.  On the other hand Microsoft operating systems dominate the individual and corporate PC worlds.  If you are going where the money is - it will probably involve a Microsoft OS.  It seems that every Microsoft upgrade involves a raft of new security problems and when they have a stable OS - it gets upgraded and the old stable version gets unsupported anyway.  I suppose you can't make a lot of money on a product that you never upgrade. A lot of the security problems rest with the software manufacturers.

There is the software security industry.  Large companies that make antiviruses, firewalls, malware detectors, and pass word managers.  A dizzying array of free and in some cases fairly expensive software with the guarantee that none of it is foolproof - it might not work at all.  As an example, I was looking at the new collection of password managers for keylogger protection.  The above note describes a keylogger and that is software that records your keystrokes and sends them back to the hacker so that they can discover your passwords and account numbers/logins and steal from you.  Keyloggers can also take screen shots to get similar information. The password managers may or may not protect you against that.

The average computer user seems to pay a premium price for a computer with not very good security and an additional price for software that may or may not add much security.

By default we are left with a semblance of security at our own hands.  The common advice is to not open any email from an unknown source.  Email is a common way that malware and viruses are introduced to computers in large systems with extreme results.  It may allow hacker access to information or in the extreme case hijack the entire system until a ransom is paid to unlock it.  In the case of the message sent to me - I am sitting behind a corporate firewall  that seems to intercept even benign messages and send me a report so that I can decide which one should be deleted and which should be released.  This message sailed right through! 

All of the lack of reasonable security results in the possibility of scaling the criminal enterprise.  Now instead of blackmailing a person who may be engaged in some activity that they don't want anyone to know about - the enterprising Internet criminal can send out thousands or tens of thousands of these messages - just playing the odds. The impact on the other 90% is completely ignored.   

All of the security fixes so far ignore the basic problem of who is basically creating all of this chaos. I did an PubMed search on hacker(s) and came up with 90 references dating back to 1986.  None of them were what I would consider to be scientific papers. Most were opinion pieces either warning about threats or advice on how to secure your data or network against threats. Many were from non-mainstream journals.  

I am also a member of the IEEE and when I check their web site, there are 240,000,000 references to hackersHackers psychology as a search term results in 4.182 million references.  Going to the IEEExplore digital library results in 10 hits - 4 from journals and magazines and 6 from conferences.   The professional literature available to me does not seem to be much of an improvement over what is available in the popular press.  In the popular press there are some articles speculating on who the hackers are and what their various motivations are.  For example, an article discusses how some teenage boys become obsessed with hacking and with time and a singular focus can hack like anyone.  There are stories of American teenagers hacking the American government including military institutions and Russian teenagers being praised by Putin for stealing money from American bank accounts.  An article suggests that these teenagers eventually grow out of it when they recognize it is wrong.  One story suggests that the hacking obsessed teens are on the Autism Spectrum - they have Asperger's syndrome.  There are appeals to come up with a multidisciplinary approach to studying hackers and why the social sciences are important in the effort.  There is a suggestion that some of these programs are out there in the security industry and law enforcement - but nothing very compelling.   

Hackers have a large footprint in popular media.  The average television program suggests that a good hacker has instant access to whatever information they need.  That can range from any video feed to any blueprint to any financial information in any city.  That is an obvious stretch, but that is the way things are portrayed.  A study of how many media portrayals are of white hat versus black hat hackers (the old western terminology applies) might be interesting.  My impression is that most are white hat by a large margin.  And then there are the hacker antiheroes, most notably Eliott Alderson of Mr. Robot and his sister Darlene.  Nothing in the media portrayals to suggest that cybercrime in the US costs an estimated $350-500 billion annually.

I sincerely hope that there is a vast network of concerned cybersecurity experts, that are acting rationally on these threats.  I confess that I am not very confident that there is. The idea that a private contractor can access top secret government files and send them around the Internet suggests to me that even our top intelligence agencies may not know much more about protecting their systems than I do. 

Coming back to the graphic, my overriding concern is that there are tens of thousands of people out there like the person that sent this email.  They can get close to many more people than they could walking up to them and holding them up on the street, but that doesn't mean they are any less sociopathic.  The dominant dynamic is that they will verbally, emotionally, or physically intimidate  you to get what they want.  That tone is clearly there in this email.  I think network providers and the hardware and software providers can do a lot more.  The most compelling evidence there is the disappearance of pornographic email spam from the early part of the century. At first it was up to the individual user to set up filters to get rid of it and then mysteriously one day - the inbox was free of pornography for good.  They should be able to do the same thing with emails like the example here.

For now every user must stay diligent and do what they can to protect themselves.  A home network specialist that can be consulted about the latest gear and standards helps.  Common sense helps.  At the bottom rung is the idea that not all emails need to be opened or responded to no matter how obnoxious they are.   

George Dawson, MD, DFAPA


Despite the confusing landscape my experience here highlights a couple of points.

1.  It is critical to change your password/login if a business you access on the Internet gets hacked.  In this case the hacker was able to purchase a 2013 password from an Internet site I frequented on the Dark Web and use it in the first line of the email. That password was available because the company I locked into was hacked exposing the personal information of tens of thousands of users.  This highlights the need for changing passwords immediately when there is a report that an online site has been hacked.

2.  In one of the papers I read about password changes - it turns out that frequent password changes required by many companies result in less secure passwords because employees are annoyed by the changes and the suggested complexity of the passwords. The authors of that paper suggested that frequent changes were unnecessary.


I am very interested in any scientific research on the psychology of hacking and cybercriminals.  Please post any good references that you have. 


1: Hutson M. Hackers easily fool artificial intelligences. Science. 2018 Jul20;361(6399):215. doi: 10.1126/science.361.6399.215. PubMed PMID: 30026208.

2: Waldrop MM. How to hack the hackers: The human side of cybercrime. Nature. 2016 May 12;533(7602):164-7. doi: 10.1038/533164a. PubMed PMID: 27172030.

3:  Committee on Developing a Cybersecurity Primer: Leveraging Two Decades of National Academies Work, Computer Science and Telecommunications Board, National Research Council; Clark D, Berson T, Lin HS, editors. At the Nexus of Cybersecurity and Public Policy: Some Basic Concepts and Issues. Washington (DC): National Academies Press (US); 2014 Jun 16. PubMed PMID: 25057698.

Monday, November 12, 2018

Unsane - It Sure Is

I watch TV while working out - usually Amazon, Netflix, or HBO.  It is all on the Amazon Fire interface.  Today I saw Unsane advertised and despite my aversion to the ongoing One Flew Over The Cuckoo's Nest portrayals of psychiatry - I decided to watch it on the strength of Claire Foy as the leading actor.  Could the actor save the predictable portrayal?  I was skeptical but forged ahead anyway.  The film was a Steven Soderbergh film and I later learned that he shot it on an iPhone 7 Plus.

In the introductory section we learn that the main character Sawyer Valentini (Claire Foy) has moved from Boston to Pennsylvania.  She is a financial analyst in a bank and does financial analysis and reports.  We see her in a contentious phone call with a client in the opening scene.  He coworker expresses some concern and another coworker looks and rolls his eyes.  She meets with her boss and the conversation has overtones of sexual harassment.  Later there is a computer dating scenario where she ends up at her apartment with the date and starts to react like he is assaulting her.  She ends up taking some medication out of a medicine cabinet.  Later we see her Google "Support groups for stalking victims".  She drives out to a psychiatric facility for an initial appointment and that is where the drama begins.  I am going to list the problems point-by-point.

1.  She meets with the intake staff person and describes her concerns about being stalked as well as the residual "neurosis" (her term) of being in an new city and having a tendency to see her stalker everywhere. At one point she alludes to feeling depressed at times and thinking about whether there is any point in going on.  The staff person asks her if she has ever had suicidal ideation and she goes into a detailed discussion of Therapeutic Index and how she would be experimenting with that if she was going to attempt suicide (translation - overdosing).  The therapist leaves and has her complete routine paperwork.

2.  She completes the "routine paperwork" that is also described as "boilerplate" and learns that in doing so she has voluntarily committed herself for 24 hours.  In other words she was tricked into being hospitalized and that trick was apparently irreversible.

3.  While voicing strong objections she is asked by a nurse to disrobe, be searched, and change into hospital clothing.  The nurse's tone is threatening and she complies.

4.  She is taken to a psychiatric ward of about 10 people.  It is a combination of men and women and they are all locked into a room with no supervision all night long.  She is threatened by the other patients, gets into a physical confrontation with two of them and is eventually sedated in the same 10 bed ward in full view of the other patients with no safety monitoring.  She is subsequently restrained in the same manner in full view of all of the male and female patients and not protected.

5.  She finally sees the psychiatrist the next day.  He does the world's most cursory evaluation - largely reading chart notes in between phone calls.  It lasts about 5 minutes. She makes a compelling argument to be released. He informs her that she needs to stay another 7 days based on her assaults on another patient and staff. At no point in the interview does he ask her any direct questions about depression, suicidal thinking, or the details of the incidents of aggression.

6.  She befriends another patient who has smuggled in a cell phone and convinces him to let her use it.  We learn that the patient with the cell phone is really an undercover reporter investigating the hospital.  She calls her mother who comes to the facility and demands that they release Sawyer. The psychiatrist refers her to an administrator. The administrator gives her an irrelevant sales pitch on all of the good work that is done there and passive-aggressively acknowledges that it is her mother's prerogative to contact an attorney in order to get her daughter freed. 

From a creative and artistic standpoint - it was apparent to me from the outset that Sawyer's reality testing was not impaired.  Hypervigilance is not psychosis. So when she recognized her stalker on the nursing staff passing out medications it was not a surprise.

Spoiler alert right here - if you really wanted to be surprised see another film.  If you don't want to know the ending to this predictable one stop reading right here.

A series of implausible scenes unfold that depend both on the stalker as nursing staff and Sawyer's transformation to homicidality bent on killing the stalker/staff person. The stalker gives Sawyer a "megadose" of methylphenidate a stimulant a - controlled substance. Special effects at that moment seem to indicate she has some kind of psychedelic experience from the drug.  The stalker is warned by the nurse that he has to be more cautious of "we could lose our jobs." The stalker ends up killing two patients and torturing one of them with cardioversion paddles - right out of the old action series 24.  Some reviews of the film think this was an electroconvulsive therapy device - more proof that old Hollywood stereotypes about psychiatry don't ever go away.

The stalker traps Sawyer in an isolated seclusion room and in an excruciatingly long exchange, she tricks him and ends up stabbing him in the neck.  Like most films of this genre, he survives and recaptures her outside of the hospital and kidnaps her.  During the kidnap sequence we learn that he killed her mother and the hospital staff person who he has been impersonating.  Sawyer gets another chance to kill him and apparently does in the most gruesome manner  possible.

We flash forward 6 months and see Sawyer eating at a restaurant with a friend.  She looks out into the room and see the profile of a man who appears to be the stalker. She hears him saying things the stalker would say.  She grabs a steak knife and approaches him from behind.............. 

All of the points above are what a psychiatrist would consider to be highly problematic.  By that I mean they would all merit investigation by the appropriate authorities,  legal penalties, and disciplinary action against licensed health professionals. If I was prone to discuss malpractice - the incidents could also lead to that type of civil litigation.  Anyone experiencing a fraction of what Sawyer experienced in this psychiatric hospital should contact the responsible officials or an attorney about what could be done.  In my experience health officials are quite eager to do exhaustive investigations of these complaints both in the case of licensed health care professionals and institutions.  In the film it took a dead body on the premises to get any action from the police.  In real life, a call from Sawyer's mother would be enough to get action in any state that I have practiced in.

The commitment law in Pennsylvania did not seem to be adequately portrayed.  The statute says that any interested party can initiate commitment based on an imminent dangerousness standard.  That was certainly not present in the film.  At no point was Sawyer suicidal and the brief scraps that she was in would not have required physical restraint or forced medication in any setting that I ever worked in.  The maximum period of confinement in the state of Pennsylvania without a court order is 5 days and in this case Sawyer was detained 1 day initially and then another week.  That is a violation of the law.  In the state where I work, the longest period of time that a person can be help without a court order signed by a judge is 72 hours. In cases where it appeared a high risk person would be released, attorneys have always advised me that the person needs to be released according to the law - no matter what the possible adverse outcome.   

There are some continuity problems with the film.  How is it that her stalker would happen to know that she would be inappropriately admitted to a psychiatric hospital and be able to identify and kill a prospective employee in order to work there?  Wouldn't it be much easier to get close to her in real life rather than inside an institution?  And what about Sawyer?  She has insight into the fact that she is hypervigilant and needs to avoid the stalker. Is there a better film just exploring that theme and what happens to people in these situations plus or minus the real stalker?

In the past, my standard for films has been recognizing that they are entertainment and not really about psychiatry.  This film fails at both levels.  I suppose at some point all actors might be interested in doing a horror movie - but the psychiatric hospital as horror genre is as tiresome as it gets.  How many times can you show a gun toting Dr. Sam Loomis battling evil incarnate as a former asylum patient?   How many times can you show hospital staff that are sadistic, abusive, or grossly incompetent? Apparently there is no limit. The idea that a film like this should just be brushed off as fiction minimizes the fact that One Flew Over the Cuckoo's Nest seems to have stigmatized the most effective treatment in psychiatry for two generations.

The psychiatric hospital that Soderberg is reaching for is the spooky old asylum of the late 19th and early 20th century.  What made that asylum spooky was that people were freaked out about severe mental illness.  They did not know what it was and they did not have a name for the symptoms or disorders. They knew that some of their relatives went to these places and never came back. They lived the rest of their lives there.  They were warehoused and never got better.  That was the real scary part.  Most if not all of those places are shut down and have been for a long time.

The real horror story these days is trying to get into a mental hospital when it is needed.  Contrary to Sawyer's experience in the film, nobody is trying to recruit people into hospitals.  They are rationing the beds and turning people away.  All of the beds are typically full.  The emergency department psychiatric staff will do whatever they can to discharge.  A lot of people end up waiting a day or two and just give up and go home.  In some cases if people with mental problems are brought in by the police, the choice is admission to the hospital or jail.  Jail is the most likely outcome.

Jail is the real scary place these days and it has been for at least 20 years.  That is where a diverted patient needs to worry about incompetent or nonexistent treatment, physical assaults, and encounters with the evil people that Hollywood typically, uses to populate psychiatric hospitals.

The real evil out there today - is the system of non care that exists.  That is what people feared - developing a mental illness for which there was no treatment and being sent away for a lifetime. 

That is what Hollywood needs to understand.

That and a ton about modern psychiatric treatment.

George Dawson,  MD, DFAPA

Graphic Credit:  Inked Pixels.  A ghostly figure casts a long shadow down the middle of a dimly lit passage of a dilapidated mental asylum.  Downloaded from Shutterstock per their standard licensing agreement on 11/12/2018.

Wednesday, November 7, 2018

The NEJM "Addiction As Learning And Not Disease" Article - Clinical Realities

I had anticipated posting a piece on the biological realities that were minimized in this review but I am currently waiting for a graphic that I acquired permission to use.  I have not heard back from the publisher.  In the interim, I will post some information on the clinical reality of treating people with severe substance use disorders or addictions to illustrate why learning is really an inferior paradigm to use in analyzing the problem.   It really comes down to treating all of the features of a profound loss of normal functioning.  These features are not subtle and include insomnia, anxiety, depression, cravings, compulsive use, and protracted withdrawal.  The following comments considers only those people with addiction that is defined as DSM-5 severe substance use disorder and compulsive use of any addictive substance.  By definition that means I am not considering people with less severe problems, such as the average college drinker or cannabis smoker who lacks these features, can easily stop, and invariably stops when they move on with their life after college.  I could post a series of vignettes but for brevity - I can roll all of those problems into one problem, that is generally recognized as the most significant drug problem in American today and that is opioid use disorder.

Consider the following hypothetical and all of the potential solutions and the implications for addiction as a disease or a learning opportunity.

40 year old man with chronic back pain, benzodiazepine use disorder and opioid use disorder.  Prior to admission he was using 10-16 mg clonazepam per day and 240-300 mg of oxycodone per day for 5 years.  The use disorder developed as a direct result of prescriptions of oxycodone 10 mg TID for back pain and clonazepam 0.5 mg TID for back spasm.  The patient was admitted to a residential treatment facility and detoxified with buprenorphine and phenobarbital over a period of 10 days.  On day 15 he is referred for assessment of depression and anxiety.  

He has no history of insomnia, depression, or anxiety prior to the onset of the substance use problems. Since the detox was completed (on day 10) - his anxiety is "through the roof", he is unable to sleep, and he is depressed and somewhat hopeless.  His concentration and focus are so impaired at this point that he can't retain information presented in groups or individual discussion and he feels like treatment is a "waste of money" because he has not learned anything.  He is craving benzodiazepines but also opioids to some extent.  He has drenching night sweats and has to change his shirt 2 or 3 times a night.  He describes muscle and joint pain.  He is concerned that he will relapse immediately upon discharge due to all of these symptoms.  He asks about taking trazodone for sleep, an antidepressant for depression, and gabapentin for anxiety.  He suggests that if the problem cannot be solved - he will go back to his primary care MD and get another prescription for benzodiazepines and that he will "try to control it this time."  

At this point the best intervention (s) to address these symptoms include (choose as many as you like):

a)  Continued 12-step facilitation groups
b)  Cognitive behavior therapy for insomnia (CBTi)
c)  Cognitive behavior therapy for substance use, anxiety and depression.
d)  A family program to educate the patient and his family about the relevant dynamics
e)  An NA group to deal with cravings
f)  Prescribe trazodone for sleep
g)  Prescribe an SSRI for anxiety and depression
h)  Prescribe gabapentin for anxiety
i)  Prescribe a benzodiazepine for anxiety
j)   Prescribe buprenorphine/naloxone (BUP/NAL) for opioid withdrawal and medication assisted treatment (MAT) of opioid use disorder.

Numerous learning and medical interventions for the problem and I have seen several to most of them applied in this scenario.  I have seen many applied repeatedly well past the point of failure to the point that a person may be leaving treatment more symptomatic than they came in.  That is a significant failure because the patient leaving in that circumstance is highly vulnerable.  This scenario is highlighted generally ion the movement to make sure that persons with opioid use disorder are prescribed BUP/NAL and given naloxone intranasal or injection when they make the transition from treatment setting or secure environments where they have had no access to opioids like jails.  That emphasis is important because of the overdose risk with opioids but the risk for relapse to using any substance requiring treatment is very high and potentially leads to a fatal outcome.

The other clinical consideration of addiction as disease is that it is multidimensional.  As highlighted in this case - it is not a simple question of detox, stabilization and discharge.  Significant physical symptoms of illness, intoxication, and withdrawal can persist well beyond any expected period of detox.  Significant sleep problems can persist for years beyond the detox period.  Striking psychiatric symptoms are all part of the mix and physicians not suspecting these disorders can attempt to treat them as depression, dementia, bipolar disorder, anxiety disorders, panic attacks, and even attention deficit-hyperactivity disorder.  Some treatment literature talks about a vague syndrome of protracted withdrawal symptoms that is often used to described any unusual symptoms or perception during the recovery period.  Addiction is a modern day great imposter of psychiatric disorders.  Clinicians following people with all of these symptoms can discuss general guidelines with people about how long it takes various symptoms complexes to resolve before a psychiatric disorder should be considered.   In some cases the symptoms are of sufficient severity that they need to be treated acutely and the issue of disorder versus disorder cause by the substance needs to be worked out in the long term.

A long standing debate in the treatment of substance use disorders is the role of physicians and medical treatment.  Medicine has always had a role in detoxification especially when it comes to potentially life-threatening detox or detox that involves significant discomfort.  The epidemiology of addictive disorders and psychiatric disorders points to an obvious reason to try to treat both disorders at once and a place for psychiatric treatment. Medication assisted treatment to reduce relapse has been the most recent medical innovation.  All of these roles are consistent with a disease model that seeks to correct or address a loss of normal function in the human body or brain.

I am an advocate of psychosocial therapies not just in addiction, but in just about all areas of psychiatry.  Further I am an advocate of 12-step recovery because it is cost effective, it works, and it has the realistic long term goal of abstinence.  In addiction treatment, those therapies work best if a person is detoxified, cognitively intact, all of the associated comorbid symptoms are treated, and (where possible) craving and relapse potential are reduced as far as possible to break up the cycle of compulsive irrational substance use.

Given all of those considerations what is the correct answer to the question?  None of the verbal therapy or experiential (a though e) options work, but I have seen them applied even when the person was in significant distress and no progress was being made.  There are no known talk therapies that adequately treat intoxication, withdrawal, or many of the intermediate states associated with early recovery that in some cases extend for 1-3 years.  What about the symptomatic treatment of psychiatric symptoms?  Not the best options either.  In this case, I have seen patients on multiple antidepressant, anxiolytics, trazodone, atypical antipsychotics, and even stimulants for the symptoms described.  In many cases the associated medications led to additional morbidity.  So treating this multidimensional illness as a single or a collection of psychiatric disorders is also the wrong answer.

The correct answer in this case is  j) Prescribe buprenorphine/naloxone (BUP/NAL).  In practically every case like this that I have been involved with since the advent of BUP/NAL prescribing the anxiety, sleep disturbance, depression, and physical symptoms all resolve or at least the portion of the illness that is directly attributable to opioid use.  In this case the patient was also using a benzodiazepine with a long half life and may also need to address those symptoms.  Protracted withdrawal from benzodiazepines has been described since the late 1980s and the symptoms can also last for a long time.

The clinical approach to addictive disorders provides clear information on why addiction is a disease whether you happen to accept any of the models proposed by Volkow and Koob or not. At every step of the way in the above example, the underlying systems are described in either of the main addiction texts.  There is clearly a loss of normal functioning that does not respond to talk therapy or other learning interventions.  In fact, these interventions presented to a distressed person typically create more problems than solutions. Although it is possible to insert neurobiology into any medical or talking intervention these days, learning interventions for the above problems can be expected to have little to no effect on the major problems that this patient is experiencing.    

All of those problems at any stage of addiction are a loss of normal functioning or a disease state. With addiction the loss of normal functioning is not trivial. It is disabling, severe, and life threatening. Any quality treatment program should be able to address them and not depend solely on a learning environment to assist these patients.

George Dawson, MD, DFAPA

Tuesday, November 6, 2018

Computational Aspects of the Human Brain

As part of my lectures on the neurobiology of addiction - I digress briefly to discuss the computational aspects of the brain.  A lot of that discussion is focused on on the above graphic showing that overlaps in capacity with a list of the world's ten fastest supercomputers.  At least that is the estimate of the AI Impacts group.  It is basically a computation based on edges and nodes. I include power estimates for a brain from existing hardware to the actual power estimate of the human brain that I would guess every physical chemistry student from my era had to contemplate at one time.  And then I try to stimulate some discussion of supercomputers versus the human brain and it generally falls flat.  My Socratic process goes something like this:

"OK so we know that humans can't really beat computers on straightforward calculations so what advantages do we have?"

"I will give you a hint - why do we all go thorough residency training? Why can't you learn your specialty by reading about it in a book?"

The first lesson is pattern matching.  The human brain is designed not only to match patterns but to be trained to match a lot of them.  Some research article suggest about 88,000, but when  you consider what has to be matched that has be very a very low estimate.  I quote references from 15-20 years ago and a course I used to teach on diagnostics and diagnostic decision making.  Ophthalmologists correctly diagnosing diabetic retinopathy at a much higher rate than nonspecialists.  Dermatologists diagnosing rashes faster and correctly classifying ambiguous rashes with greater precision than nonspecialists. If I am really on a roll I might digress to talk about Infection Disease rounds at the Milwaukee VA sometime during 1982.  I was the medical student on a team of residents and fellows doing a consult for possible subacute bacterial peritonitis.  As the attending listening to the presentation he was also looking at a rash on the patient's shin.  By the time we were done he had also diagnosed a strep infection in addition to the peritonitis.  When you have significant pattern matching capacity, and you have been exposed to relevant patterns you can recognize them quickly and improve the speed and accuracy of the diagnosis.

I move on at that point to illustrate that the computers are catching up.  The simple captcha is less robust in discriminating machines from humans.  Opening an account may take more that checking the "I am not a computer" box. Now you might have to look at 8 pictures and check the one that contains an automobile or a stop sign.  Some of these photos are often difficult for humans to decipher.

At that point I touch on human consciousness - both the unique aspects and computational power it takes to generate.   About a decade ago I started saying that if there are 8 billion people on the planet - there are 8 billion unique conscious states. It makes sense at a number of levels especially when I put up hard numbers on cell types, protein types, the genetic information represented, and the typical stream of consciousness that every person experiences every day.  What is the content and flow of that activity? How does it get biased in psychiatric disorders and addictions?  How much computational power does it take to generate all of this information?

My latest step is what I like to consider The Matrix observation.  If I am standing in front of a room of 15-20 residents - what does it take to generate the physical representation of all of the people and all of the objects in that room? What does it take to make all of those representations unique? There can be a general consensus about what is happening - but just looking around it is clear that there are obvious different experiences.  One person looks very interested and one semi-interested.  One person is more focused on her Smartphone and is indifferent to my presentation.  Some people look sleepy.  Others look irritated.    They also appear to be indifferent to the context.  I know that my job is to try to get this information across and make is semi-interesting.  There is no real expectation on the residents.  It is clear from the questions I ask that they really don't know too much about the brain.  There are parallel streams of information processing that allow us all to evaluate what is occurring on the fly both the information content and emotion.  In some case there are pre-existing heuristics and in other cases associative memories and biases.  All of this represents a tremendous amount of information or computational power depending on how you may want to discuss it.

I have been preoccupied myself with the computational power and estimating it accurately. I used to try to model it in terms of electrical buses and neuronal firing rates - but the numbers I got were far too low.  There really are no good equivalents in the physical world with the possible exception of the Transversed Edges per Second (TEPS) metric used by the AI Impacts group for the above graphic.  You can't really use estimates of typical audio or visual information and concluding that is what is being processed by the brain.  I have never really seen an accurate estimate of all of the sensory information that the brain is handling in real time.

I went to bed last night and waited for sleep reverie or that period of time where you stream of thinking is jumbled and illogical just before you fall asleep.  As a chronic insomniac it is one of the few reliable cues that I am probably getting some sleep.  It happened when I had a sudden image of a baby high up on a brick wall, followed immediately by a person who seemed to be me sitting in a single seat futuristic car.  The salesperson was describing it to me and suddenly the car and everything else was being swept down what appeared to be a very sophisticated hydraulic roadway. The roadway was bright orange and the salesman shifted his pitch to tell me the advantages of this kind of a roadway with this car.  The roadway was moving at about 20 miles per hour.

I shifted briefly and remembered it was 2018 and I was in my bedroom in Minnesota.

And for a minute I thought about being able to estimate the information necessary to generate that brief full color science fiction scene and the three or four more I would encounter that night.

George Dawson, MD, DFAPA

Some additional examples as they happened:

1. Dream of 11/22/2018:  I am back on my old inpatient unit.  The layout is exactly the way it was 20 years ago (the building has since been razed).  I am working with the same staff.  I walk into the examination room to look at the templates for the day.  In those pre-EHR days I had designed a template with all of the relevant features necessary for the billing and coding requirements.  At the time we were all threatened with legal action if we did not comply with these regulations even though they were totally subjective.  In those days I worked with a physicians assistant who prepared the templates ahead of time before we started interviewing patients and completing the subjective aspects of the evaluation and documenting the progress.

The templates were all stacked in two circular patterns - ten templates in each circle.  They appeared to be the exact temples that we used right down to the blurred fonts from being photocopied too many times.  The precise handwriting of my physicians assistant in the diagnostic section was exactly the way he wrote things down.  The placement of the exam table and crash cart were exactly where they were in reality.  The table we used was circular and about 6 feet in diameter with a laminated blonde wood finish and it was also exactly the way it was in that now 20 year old reality.

I looked at the templates and asked myself: "Why are they all face down?  I can't see the patient's name or identifying data.  I will have to go through them all to find the correct template when I start interviewing patients."

I felt somewhat irritated.

And then I woke up. 

2. Dream of 11/23/2018: I am in a large modern, multi-floor medical facility. It is not one that I specifically recognize, but it seem like there are elements of many that I have been in.  I am rushing around on the ground floor. The impression I have is that I am late for a lecture. It doesn't seem to be an explicit CME lecture but everyone else there (including myself) is too old to be a medical student or resident. I run into the elevator just beating the door as it closes.

I make to to the lecture.  It is basically a large room - maybe 50' x 50' and for some reason I burst through the door running at full speed.  Just before the crash into the back wall, a guy standing on the side wall grabs my arm to slow me down and stop me.

I ask myself if that was really necessary because my plan was just to stop myself by reaching out and planting my hand on the back wall.  I notice that there are several people who I assume are physicians that are standing and sitting near the back wall and they seem a little alarmed about something.

Then I am back in the elevator and headed to the ground floor.  I am walking out of the building and realize that I am chewing something metallic.  I realize that is is a collection of machine screws, nuts, and ball bearings. I realize that is purchased them on the ground floor of this building and that they are sold for that purpose.  I also know that I cannot really chew them or I will break my teeth.  I have to cautiously move them around in my mouth.  They remind me of a chap stick product that is applied with a ball bearing device at the end of the dispenser.

I wake up with a metallic taste in my mouth.

3.  Dream of 11/24/2018:  I am back in my home town. The streets and buildings are identical to the way they look in reality.  I am with a friend of mine and we are looking at a 1960s vintage Buick.  It is large and chalky white.  He tells me that his sister recently bought it and she wants to take everyone for a ride.  He thinks I should come along, but just then I remember something that his sister said to me in the last 15 years that would make me not want to go with them. He is talking about the car as though it is a great buy, but as I walk past the tail end of the vehicle, I notice that it has a new paint job and that whoever did it just painted over the decals of the previous dealers.  You can see them faintly through the paint.

I tell my friend that I can't stay around because I have to go grocery shopping. Just then one of his friends comes out and tells me that he has a lot of groceries he can just give me so that I will not have to go to the store.  I decline but he continues to insist. I reluctantly accept free groceries and sling them over my shoulder in a large garbage bag and start to walk home.

The real path home is just 6 blocks - 4 blocks south and 2 blocks east. It is all residential. But in the dream I encounter a large modern baseball park right next to the street. The game is just completed and they are interviewing the winning pitcher. She is in her mid 20s and short and compactly built.  Her uniform and short brown hair are drenched with sweat.  Just then I notice that it is hot. The announcer asks her if the heat was a factor in the game and she says:

"The hot was so hot that when my hot fingers touched the hot ball - I could barely feel it." 

The ballpark looks real.  There are thousands of cheering fans and the announcer and the pitchers statements are amplified over the PA system.  Everything is in color.

I wake up and feel hot and flushed.