Stay Indoors - But Is That Enough?

 

Any casual reader of this blog might know that I was interested in indoor air quality including airborne viruses – long before it became fashionable. That had various origins including an undergrad focus on ecology, being raised by two heavy smokers, having to manage a coal fired stoker as a kid, working in a HEPA filtered clean room as a research assistant, and routinely getting viral respiratory infections in a hospital staff setting where we were all advised that hand washing was supposed to stop the mini-epidemics. And having asthma through all of that.

The indoor air quality issue has become complicated as our outdoor environment deteriorates. As an undergrad 50 years ago, we studied air pollution scenarios that affected large cities.  That included the concept of how smog was created by photochemical reactions but a lot of the specifics were not known.  More recently the entire Midwest and Northeastern US has been blanketed by wildfire smoke from Canada. Wildfire smoke is chemically complex.  In a lot of areas there are air quality alerts on one day due to wildfire smoke and ozone the next day. Those alerts are graduated to advise people with health conditions like asthma, emphysema, and heart disease on the lower end to limit outdoor activities or stay inside.  At high levels everyone gets the same advice.

The advice to stay inside assumes that your indoor air quality is better than the outdoor air quality that you are being warned about.  But is that a valid assumption?  How do you get measurements on everything and know the critical differences?  A good place to start is the outdoor air quality. The EPA has developed a nationwide network of sensors that detects particulates and ozone in the air and calculates the air quality index.  The AirNow app is available for your smart phone.  It gives you the outdoor reading, particulates, and ozone, as well as the break points from Good (0-50) to Hazardous (301-500). It will give you conservative advice about what to do about health and activity for those break points.

The CDC has a publication on indoor air quality in airports (1) where smoking was allowed. It provides some more intuitive markers of indoor quality. They found that the PM 2.5 (<2.5 micron particles per cubic meter) were 300+ in the smoking areas and 50+ in the areas adjacent to the smoking areas.  300+ levels are considered “very unhealthy”.  Anyone who has ever been in a smoke-filled room can probably sense that the atmosphere is not very good for your health either immediately of after leaving.  In Minnesota when the AQI was greater than 300 due to wildfire smoke – you could smell the wood fired smoke.

With an accurate assessment of the outdoor air – what about your indoor air quality?  I was fortunate enough to have purchased an air cleaner for my office with a PM 2.5 measure built into the machine. It usually reads in the 1-5 range but when the wildfire smoke arrived it was suddenly reading 40+ indoors. I had to figure out why that number was so high.  I had just replaced my furnace and it has a MERV13 filter that should provide some filtering efficiency.  The question mark was how my air exchanger fit into the mix.

My house is about 15 years old and like most modern houses it is considered airtight.  The concern by builders and contractors with modern homes is that they are so airtight that it leads to indoor air pollution from a number of sources including any combustion processes in the home and volatile compounds in the air from various sources like cleaning products.  As a result, air exchangers are installed to vent the indoor air and bring in fresh outdoor air.  These air exchangers are designed to reduce heat exchange and most do not have HEPA ( High Efficiency Particulate Air [filter])  filters.  They have a relatively primitive filtration system to remove mainly insects and very large particles. They can easily bring in outdoor smoke so it is a good idea to have it shut off on days where there is very high particulate matter.

The problem with my new system is that I was not sure that the air exchanger was off.  When my new furnace was installed the air exchanger was integrated into a touch panel with 30 different options and several ventilation settings.  I talked with 5 technicians (3 from the HVAC contractor, 1 from the air exchanger manufacturer, 1 from the smart thermostat manufacturer).  They all agreed shut off the air exchanger was a good idea but they gave me widely varying advice.  I decided to experiment myself over a period of 12 hours and generated the following graph (click to enlarge).

The first section shows the AQI outdoors versus indoors running the MERV 13 filter through the furnace.  There is no difference over that time period.  The next period I shut off the furnace filter and used a free-standing Space Gaard air cleaner with a MERV 8 (MERV = Minimum Efficiency Reporting Values) filter. Notice that during this time period the wind picked up outdoors, blew off some smoke and the PM 2.5 dropped from 160 to about 90.  At that time I talked with a 6^th technician and he gave me clear advice on how to shut off the air exchanger.  The last section is with the air exchanger off and all air circulating through the furnace filter MERV 13.  At that point the indoor AQ drops consistently despite a blip upwards in the outdoor PM 2.5 and continued to drop to 10.  To me that illustrates the importance of making sure the air exchanger if off when the outdoor AQ is poor and actively managing it to turn it one when the outdoor AQ is acceptable.

A related indoor AQ related to viral transmission is the carbon dioxide CO₂ levels.  Lower levels correlate with less people rebreathing air in the room and that decreases the risk of infection from airborne viruses. Outdoor CO₂ is roughly 400-420 ppm. My indoor measure is currently 570 without the air exchanger on.

There are currently PM 2.5 and CO₂ monitors available in most home stores and large online retailers.  What we really need is a more comprehensive single device that measures and records all of the parameters. I would suggest PM 2.5, PM 10, CO₂, Ozone, and Volatile Organic Compounds (VOC).  The closest I could come to that device was a gadget that required that I purchase a separate weather station and even then the bandwidth to multiple devices was limited.

Home HVAC system design could also use some innovation. Just based on my experience durability is a problem. Should an HVAC system last longer than 14 years?  Probably.  But the design itself does not seem very efficient.  I am not a certified HVAC tech by any means but it appears to me that the air exchanger introduces outdoor air into the system after the air filter so that any particulate matter in the outdoor air does not get at least one pass through the highest efficiency filter.

Outdoor air quality is a little discussed casualty of climate change. As the environment deteriorates, I expect that there will be increasing amounts of wildfire smoke and it will be chemically more complex. I currently wear an N95 mask outdoors during the alerts, but I can envision a time in the not-too-distant future where respirators that can also remove ozone and organic chemicals will also be necessary. Geography is no longer helpful in separating clean air from polluted air. Monitoring your personal indoor air quality and figuring out how to manage it will become the most critical part of home management. I have posted a few things that you can do right now and I am always interested in other ideas about how to address this problem.  Please post any of those ideas in the comments section.

 

George Dawson, MD, DFAPA

 

 

References:

1:  Centers for Disease Control and Prevention (CDC). Indoor air quality at nine large-hub airports with and without designated smoking areas--United States, October-November 2012. MMWR Morb Mortal Wkly Rep. 2012 Nov 23;61(46):948-51. PMID: 23169316.

2:  CDC Health Alert Advisory.   Wildfire Smoke Exposure Poses Threat to At-Risk Populations.  Link

Update 07/06/2023: 

One week after turning off my air exchanger - the PM 2.5 in my house is down to 6 or essentially normal.  I talked with my air conditioning tech who also services the air exchanger and he agreed with the approach.

Image Credit:

Canadian Wildfire Smoke in Minneapolis

Chad Davis from Minneapolis, United States, CC BY 2.0 <https://creativecommons.org/licenses/by/2.0>, via Wikimedia Commons

file URL:  https://upload.wikimedia.org/wikipedia/commons/c/c0/Canadian_Wildfire_Smoke_in_Minneapolis_%2852907984452%29.jpg

page URL:

https://commons.wikimedia.org/wiki/File:Canadian_Wildfire_Smoke_in_Minneapolis_(52907984452).jpg

Hippocrates the Projective Test

 

There is no doubt that the ancient physician Hippocrates was an advanced thinker in terms of medicine and its conceptualization. He is widely credited with advancing nosology and diagnostics as well as professionalism. In the field of medicine, he was studied right up until the turn of the 19^th century by physicians who attended medical schools in Europe.  Like all prominent figures from the past there is a question of whether invoking Hippocrates these days represents idealization or rhetoric more than his accurate historical position. 

I am referring specifically to a blog by Nassir Ghaemi, MD entitled Hippocratic Psychopharmacology.  After correcting the aphorism “First do no harm” to “As to diseases, try to help, or at least not harm.” he elaborates on a few ideas from Hippocrates and the implications for modern medicine. He interprets the preamble of Hippocrates statement to mean that diseases must be identified and if you cannot or will not take the disease concept seriously you cannot help anyone as a doctor. He emphasizes that there should be a focus on not doing any harm and that overall treatment should be conservative. He acknowledges a bias that too many medications are being used in modern times.

Hippocrates additional idea is that diseases are a natural process and they heal naturally and physicians should not get in the way of that process. He discusses self-limited, treatable, and incurable diseases suggesting only the treatable illnesses are a focus for physicians.

Hippocrates was apparently not enough so Holmes Rules and Osler’s rule are added. The explanation of Holmes Rules is inconsistent because initially it described prescribing based on benefits first and harms second, but in the elaboration the assumption is supposed to be that the medication is harmful. If that is your assumption harms would seem to be prioritized.  Here is an excerpt from the post from 1861:

“……I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind, – and all the worse for the fishes.”

In other words, if you wanted to prescribe something – there is nothing useful to prescribe and given the time frame - that is correct.  1861 was before the discovery of germ theory.  Of the estimated 750,000 Civil War (1861-1865) deaths at the time about 2/3 died of diseases that are treatable in modern times. The only effective medical treatments at the time were citrus fruits and vegetables to prevent scurvy, smallpox vaccines, and quinine for malaria. Four types of wound infections were described including tetanus, erysipelas, hospital gangrene, and pyemia or sepsis with mortality rates of 46-90%.  Since there were no antibiotics infected wounds were treated with repeated debridement or amputation with the hope that remaining healthy tissue would generate an inflammatory and healing response. 

In his writings, Hippocrates describes many forms of orthopedic treatment and general medical treatment for infections including gangrene and erysipelas. Those afflictions were not likely to heal without significant medical and surgical interventions. I suppose in keeping with the stated philosophy they could be reclassified as “untreatable.” The question might become were untreatable diseases less treatable in Hippocrates time than during the Civil War? Either way it is likely that Hippocrates watched at least as many of his patients die as Civil War surgeons did and those were very high mortality rates.

Ghaemi uses the example of antidepressants in bipolar disorder as breaking Holmes Rule “egregiously.” Unfortunately, the presentation of bipolar disorder may not be that clear cut.  As a tertiary care psychiatrist, it was common to see people experience manic episodes after years of treatment for unipolar depression with antidepressants or even as an antidepressant is tapered and discontinued. You must have seen a manic episode along the way in order make the diagnosis and stop the antidepressant.  It also helps if the patient is under the care of a psychiatrist and it is likely the vast number of antidepressants in these presentations were prescribed by other specialists or nonphysicians. I have never heard of a psychiatrist needing more evidence to stop antidepressants in bipolar disorder.  It was done routinely by my colleagues in acute care.

Osler is quoted in the discussion of Osler’s Rule:

“A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practicing a sort of popgun pharmacy, hitting now the malady and again the patient, he himself not knowing which.”

And what exactly was known in Osler’s time about pathophysiology and pharmacotherapy?  Probably not much more than was known at the time of the Civil War.  Paton’s reference (5) contains several additional quotes to illustrate what he describes as Osler’s nihilism including that there were no useful treatments for scarlet fever, pneumonia, and typhoid fever.  Diarrhea and dysentery were common in soldiers leading to both compromised health status and death.  A summary quote from Osler’s time suggests there were only a few useful treatments including iron for anemia, quinine for malaria, mercury and potassium iodide for syphilis and that there were no other drugs supported by experimental evidence.  It turns out that that the evidence for potassium iodide in syphilis was restricted to reducing inflammation in some late-stage lesions since it was not an anti-spirochetal agent (4).

If Osler was aware of a potentially effective drug – he may have pushed it beyond what his colleagues were using as evidenced in this quote:

'At times of crisis Sir W. Osler and others have pressed up the nitrites to huge doses, in persons upon which these drugs had been well tested. Sir William said he had never seen harm come of large doses if cautiously approached. I think he used to speak of 20-30 grains of sodium nitrite per diem. I have administered half as much in a day.' (pp 88-9).” (3)

20-30 grains of sodium nitrite is roughly equivalent to 1,329 to 1,980 mg.  In a 70 kg patient that would be 19-28.3 mg/kg.  The worrisome complication from nitrites is methemoglobinemia. In severe cases it can result in coma, cardiac arrythmias, and death. PubChem suggests that intravenous doses of 2.7 – 8 mg/kg can be problematic. A leading toxicology text suggests that when sodium nitrite is given intravenously to treat cyanide poisoning the dose is 300 mg given at a rate of 75-150 mg/minute intravenously with a repeat dose at half the amount if necessary, monitoring for symptoms of nitrite toxicity. While it is difficult extrapolating oral toxicity from IV administration there are reports of life threatening and fatal oral ingestions resulting from taking 12.5-18 g of sodium nitrite. The EPA recommends limiting exposure to 1.0 mg/kg/day. All of this toxicology information suggests the the doses that Osler was using were pushing the limit, but it also points to another deficiency in suggesting that his parsimony (or nihilism) is a touchstone for modern physicians.  That deficiency is that his outcomes were unknown. The case reports that I have found were generally limited to a case or two. I could not find any outcomes for high dose versus low dose nitrites for angina or congestive heart failure. Modern nitrate preparations such as isosorbide mono and di-nitrates are limited by tolerance to the vasodilating effect. I may be wrong but I speculate the Osler knew very little about the pharmacology of nitrites and the mechanisms of tolerance and toxicity.

A common theme for these conservative historical pharmacologists is that it is easy to be conservative when there are no known effective treatments.  When your category of treatable diseases is small – it is easy to rationalize watching the self-limited and untreatable illnesses run their course.  There was a very long period of slow progress in therapeutics between the time of Hippocrates (460-375 BCE) and Osler (1849-1914). Penicillin was not available to treat syphilis until 1943. Even though there was some basic science research in pharmacology in the mid 19^th century, Paton’s review shows that potentially effective medications, in pill form and in significant numbers did not occur until about 1920.

Apart from limited therapeutic options, the doctrine of informed consent was either nonexistent or much less clear in earlier times.  Gutheil and Applebaum (6) trace the early evolution and consolidation as occurring in the 1950s and 1960s in the US.  The earliest clear application was for surgery and invasive treatments extending to medical treatments.  In psychiatry, that also extended to medication treatment and neuromodulation but at the time of this book whether it was necessary for psychotherapy or not was not clear.  To me one of the clearest reasons for informed consent is the level of uncertainty in medicine. We know probabilities at the population level but are rarely able to predict side effects and adverse reactions at the individual level.  I have written about my approach to this problem on this blog and it is basically a shared decision-making model where the patient is informed of the uncertainty of both efficacy and adverse events as clearly as possible. That information was not available to to earlier physicians. Detailed regulatory information in package inserts is a relatively recent phenomena starting in 1968 in the US with several modifications since then.  

Ghaemi winds down his critique emphasizing diagnoses over symptoms.  He uses the bipolar disorder example again and hedges suggesting that is it acceptable to treat symptoms sometimes but there are no guidelines only the rather extreme criticism that by treating diseases and developing a Hippocratic psychopharmacology we can avoid the “eclectic mish-mash which is contemporary psychiatry.”

It is apparent to me that Hippocrates and Osler have very little to offer present day psychopharmacologists. They both a had very large body of patients who could not be treated. Both had limited evidence-based pharmacopeias and both prescribed toxic compounds with no clear guidelines or suggestion of efficacy. On diseases, syndromes, and symptoms – the issues are much clearer these days but much is still written about how these concepts are confusing. That is especially true in psychiatry where decades of debate has not resulted in any more clarity.  It is not as easy to separate out insomnia, anxiety, and mood disturbance with bipolar disorder as Ghaemi makes it seem, but treating them all at once in a single point of time is probably not the best approach. In clinical practice at least some people have insomnia, anxiety disorders, and depression prior to the onset of any diagnosis of bipolar disorder. Assuming adequate time to make those historical diagnoses, there are no clear guidelines about what should be treated first and no clinical guidelines on when medications should be started and stopped.  It all comes down to the judgement and experience of the physician and patient consent and preference. Evidence based medicine advocates always argue for that approach but it it highly unlikely that there will be clinical trials for every scenario and the trials that do occur are often limited by inclusion and exclusion criteria.   Hippocrates and Osler have no better guidance.

As therapeutics has evolved, polypharmacy has become a part of the clinical environment of all specialists.  It is common to see patients taking multiple medications in order to treat their cumulative diseases, even before a psychiatric medication is prescribed. Despite all of the rhetoric – I am convinced that experts can manage polypharmacy environments if they need to and do it with both therapeutic efficacy and minimal to no side effects.  

For the record, I agree with Ghaemi’s overall message that you need good indications for medical treatments and that the fewer medications used the better. Those decisions need to incorporate, current evidence, informed consent, and frequent detailed follow up visits to reduce the risks of inadequate treatment and adverse events. That is hard work - not helped by guidance from the ancients or modern-day philosophers.

 

George Dawson, MD, DFAPA

 

References:

1:  Ghaemi N. Hippocratic Psychopharmacology.  Jun 16, 2023. https://psychiatryletter.com/hippocratic-psychopharmacology/

2:  Burns SB.  Civil War Disease and Wound Infection https://www.pbslearningmedia.org/resource/ms17.socct.cw.disinf/civil-war-disease-and-wound-infection/  Accessed on 06.20.2023

3:  Paton W. The evolution of therapeutics: Osler's therapeutic nihilism and the changing pharmacopoeia. The Osler oration, 1978. J R Coll Physicians Lond. 1979 Apr;13(2):74-83. PMID: 374726; PMCID: PMC5373168.

4:  Keen P. Potassium iodide in the treatment of syphilis. Br J Vener Dis. 1953 Sep;29(3):168-74. doi: 10.1136/sti.29.3.168. PMID: 13094013; PMCID: PMC1053890.

5:  Howland MA.  Nitrite (amyl and sodium) and sodium thiosulfate.  In:. Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR Hoffman RS (eds). Goldfrank’s Toxicologic Emergencies. McGraw-Hill Education; 2019. P. 1698-1701.

6:  Gutheil TG, Appelbaum PS.  Clinical Handbook of Psychiatry and the Law, 3^rd ed. Lippincott, Williams and Wilkins; 2000; Philadelphia, PA: 154-157.

7:  Writings of Hippocrates. Translated by Francis Adams. Excercere Cerebrum Publications; 2018.

 

 

Graphics Credits:

 

William Osler aged 32: Notman photographic archives, Public domain, via Wikimedia Commons.  https://upload.wikimedia.org/wikipedia/commons/e/e9/William_Osler_1881.jpg

Hippocrates: ESM, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons. https://upload.wikimedia.org/wikipedia/commons/8/82/Facultat_de_Medicina_de_la_Universitat_de_Barcelona_-_Hip%C3%B2crates_de_Kos.jpg

The Freak Show

 

When I was a kid my aunt and uncle took my siblings and me to a multicounty fair about 70 miles from our home town. I was probably about 11 years old at the time and withdrawn and introverted – just trying to make sense of the world. When you live in small towns, fairs are always a big deal. It is a rare approximation of big city life. The only place where you could see that many people in one place. There were the usual carnival rides, carnival food, carnival smells, and carnival people. An odd mix of farm life with the exotic. Felliniesque is a description that comes to mind not so much for the surreal atmosphere but the jarring presentations of unusual appearances and behaviors.  And keep in mind this was all about 40 years before the Internet.  In my town at the time we had 3 very grainy black and white TV networks and on any given day only 2 out of three were working. They all broadcast standard network TV and signed off the air at midnight.

The most Felliniesque location at the fair was the Midway – a long thoroughfare bordered by tents and trailers on each side.  Vendors were selling cotton candy, caramel popcorn, snow cones, and hotdogs and the odor of that food was always in the hot, humid air. It was a noisy place due to the carnival barkers shouting to get people to come to their attraction. My only experience with carnival barkers before that was my well-travelled Grandfather’s imitation of one and he was right on.  There were games of skill that involved tossing rings or baseballs at targets, or shooting air rifles.  In those days it was typically 35 cents to try and if you won – the prize was some sort of stuffed toy animal. The games clearly favored the house.  There was usually an obvious gimmick that made it very difficult to win. It was common to see a young couple at one of these games, with the guy spending a lot of money in order to get one of these prizes for his girlfriend. The idea that these strangers were in town to unfairly take your money added to the excitement of wanting to beat them at their own game. Some of the carnival workers knew how to add commentary to keep people coming back without getting them too excited or angry.  I watched all of that at a distance and did not take a chance on the games.

The most disquieting aspect of the carnival was the Freak Show. At the time – I am sure the term had fallen out of favor replaced by “human oddities” or similar terms, but everybody still called it The Freak Show.  In just a few years it would be appropriated by the hippie generation and reinvented as a positive social term as in “let your freak flag fly.”  Those attractions had colorful and primitive graphics adding to the bizarre cartoon like appearance.  “Man-eating Amazon rats” displayed 7 or 8 rats chewing on a horrified man. Similar signs proclaimed significant alterations in appearance or deformities. Superlatives were everywhere as the “World’s tallest, fattest, strongest, shortest….”  In order to get people to pay the price of admission to the trailer there was typically stage with an introduction where you could get a glimpse of the attraction. I remember watching a middle-aged man extrude his eyeballs out at the crowd to a mixed reaction of amazement and disgust.  He was the most animated and expressive.  All the other human oddity performers seem bored and they were expressionless. I listened to the local people coming out of the attractions talking about how they were disappointed that the part human, part canine man was just a paper mâché creation in a glass case or that the bearded lady was just a short obese man wearing a dress.

I found the entire Freak Show atmosphere very unsettling. It just seemed wrong to me. I was always taught to mind my own business and treat everybody the same no matter what their appearance. In a Freak Show – those norms go out the window.  The social norm suddenly becomes excitement, excessive commentary, and mixed derision some due to people feeling like their expectations for the unusual were not met and some feeling like they were ripped off. It was an embarrassing display of a lack of empathy and I was embarrassed to be there.  In today’s parlance some might say I was traumatized by the event but I won’t go that far. I went home and thought about it for a long time.  What that lifestyle would be like. What it is like to consent to participate. I would see occasional TV shows with similar themes about these potential conflicts.  Workers were who coerced into these positions based on their appearance  and overworked, but I never saw any real-life stories where that was true. Eventually the memory faded.

As a freshman in a liberal arts college, English literature and composition was a year long required course. Kafka’s A Hunger Artist was one of many required readings. In this short story Kafka describes a man who is basically a side show attraction based on his skill in fasting. He sits in a cage on straw and fasts initially to the accolades of an observing public who admired him at a distance.  He is managed by an impresario who limits the fast to 40 days based on entertainment rather than health concerns – public interest fades at that point. Eventually public interest fades altogether and he signs on with a circus where he is eventually ignored during his fasting.  Even though he always knew he could fast much longer than 40 days and was past that point - both he and the circus staff stopped counting.  He was eventually discovered near death when the apparently empty cage was inspected. He speaks briefly about wanting to be understood and how his fasting was easy because he never found a food that he liked. A definitive interpretation of Kafka’s essay is not available and there are multiple interpretations.  Food seems like a metaphor for the attention of others and that we need more than literal food for sustenance. It speaks to the general case of people who are marginalized in society and may need to take desperate measures for social contact. In the end the Hunger Artist rejects food/social contact.  He dies and is buried with the rotten straw in his cage.

Was a Freak Show a similar attempt to establish social contact? A more typical interpretation is the practical one – it is just a way to make money or more commonly a way for these people to make money. If there were societal safety nets, would these shows need to exist?  It seems that there is a top-down way to deal with the problem and that is just banning these venues or making them so culturally unacceptable that they would not exist.  A societal safety net would be the bottom-up approach - adequate income, housing, medical care, and empathic support.  The reality today is that I don’t see either of those approaches happening.

I have not been to a fair in at least 10 years.  The last one I attended was the second largest state fair in the country.  There were no Freak Shows or human oddities, but they still exist, usually on television where much more biographical content is provided.  The sensationalism associated with them has been taken over by the Internet where any observer can basically see whatever they want ranging from 3 minutes clips of soft (or hard) core pornography to watching Komodo dragons swallow livestock whole headfirst to watching someone split firewood.  

Various authors have suggested the dopaminergic effects of watching sensational videos and the importance of taking a break from all that dopamine. Like most neuroscience in the popular press that is undoubtedly an oversimplification.  Flashing back to my childhood experience – there is a right and a wrong way to do things.  Even as a kid I did not need to be shamed into avoiding freak shows, but one of my colleagues assures me that some people need to be and that shame is not necessarily a bad thing.  

Widespread acceptance of high frequency and indiscriminate sensationalism does not seem like a good development for society. Instead of attending a rare annual event - people can engage in this activity all day long and every day.  It has occurred with the expansion of exploitation from just the marginalized to everyone and resulted in a much coarser general audience for public discourse. There is some discussion about the lack of critical thinking skills - but that critical thought starts upstream from the cognitive processes with emotion and some clearcut ethical rules and knowing that your excitement may be clear violation of those rules.

We need to figure out ways to move beyond the Freak Show existence.  We already know some of those rules. We need to do it before AI makes things a lot worse. 

 

George Dawson, MD, DFAPA  

 

 

 

Image Credit:

Jack Delano, Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Freak_show_1941.jpg "Freak show 1941" https://upload.wikimedia.org/wikipedia/commons/thumb/1/19/Freak_show_1941.jpg/512px-Freak_show_1941.jpg

Killer Mike's Gun Recommendations for Families

I watched TMZ Live yesterday. They interviewed the rapper Killer Mike. Harvey Levin was his usual overcomplimentary self. He asked the rapper about his recommendation that every family should have "multiple guns, all sorts of guns" and this is what he said:

"5 - 5. I have always just said 5. You should have a revolver, a semi-automatic pistol, you should have a shotgun, you should have one bolt action rifle, and you should have a semi-automatic rifle."

When questioned about the semi-automatic rifle:

"I said semi-automatic, military is fully automatic. It's not military - it just looks cool. It can look like a race car but it doesn't go 200 miles an hour. My thing is simply this - the founders of the Constitution saw a need to fight tyranny at some point and they believed that that could happen again so they wrote that provision so to get to the ultimate answer you got to dig up those old white guys and ask them. I'm simply applying - I'm going by the rules that were given to me in the Constitution - nothing more-nothing less."

When asked about the risk of an increasingly armed and divided population, Killer Mike points out that the fastest growing group of gun owners is black women and he does not want to get in the way of black people enjoying their freedom.

In terms of stopping gun violence he was in agreement with curfew and an exception for working adolescents. He believes that no new gun laws are needed and echoes the line that there are enough laws to take care of the problem already on the books and that criminals are not going to follow the laws anyway. That ignores the fact that almost all mass shooters have no criminal record and in many cases have recently purchased firearms that they use in the mass shooting crime.  Instead he recommends "Stop the Bleed" classes and joining gun associations or gun clubs. His rational is that if you have a tool that can cause harm you should be educated about what to do for that harm.  Unfortunately if you get hit anywhere in the body - the education you will need is how to be a trauma surgeon and even then you had better be at a Level 1 trauma center. 

Consistent with the previous writing on this blog Killer Mike is clearly behind gun extremism and normalizing it as a constitutionally derived right. Obvious gun extremist rhetoric includes the claim that just because an assault rifle is not fully automatic it is somehow less worrisome. Anyone who has fired an AR-15 knows that you can fire as many high velocity rounds just as fast as you can pull the trigger and if that gun is discharged in a residential community that bullet is going a long way and in some cases through multiple buildings.  In fact, all of the weapons he recommends for the family will penetrate multiple walls and are a potential risk for the entire neighborhood.  The normalization of assault rifles by the NRA and Republican party was a move away from the use of guns for hunting to the use of guns for killing people and there is no way around it.  From the testing link this was a quote about the assault rifle result.  It speaks to the mechanism of assault rifles as a combination of high velocity and bullet deformation and tumbling:

"Though the 5.56 bullets showed the most deformation, they were also terribly penetrative (19 panels, or nine walls) and, beyond the first two or three panels, created relatively large holes as they tumbled along their paths."

Just as a reminder this is the full text of the Second Amendment:

"A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed"

Nothing about tyranny. Gun extremists ignore the preamble. The "well regulated militia" these days is each state's National Guard.  This country went through a period of gun regulation that was widely accepted and reasonable until one political party realized they did not have many ideas to run on and decided to make guns a part of that culture war. I don't know Killer Mike's political affiliations.  There may be a subcultural effect since this same show regularly reports gun violence and deaths within the rapper community.  

The problem with all forms of extremism is that it is an appeal to emotion and it typically ignores the facts. Killer Mike sees the problem as encroaching on the rights of black people but that doesn't address the problem that firearm homicides have increased in the black community by 39% from 2019-2020 (1). We know that the political rhetoric that more guns for defensive purposes does not put a dent in those numbers and that these are almost always impulsive homicides based on gun availability.

The answer to how to reduce gun violence is not increasing guns and I don't care what your rationale is - but that is the residue of this interview that started with that question.

George Dawson, MD, DFAPA

References:

1:  Kegler SR, Simon TR, Zwald ML, et al. Vital Signs: Changes in Firearm Homicide and Suicide Rates — United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2022;71:656–663. DOI: http://dx.doi.org/10.15585/mmwr.mm7119e1

New Onset Headaches In An Old Man - What Should Be Done?

 

 

In November of 2022, I started to experience headaches that were new and unusual. They would start out as a dull ache behind the left eye to varying degrees and generally persist until I took 1,000 mg of acetaminophen. Acetaminophen (APAP) works like a miracle for me for most kinds of pain and it would reliably knock the headache out in 1-2 hours. Back in my early 20s I experienced more severe headaches that were quite debilitating and most likely cluster headaches. For a couple of years, I would get them every spring and would have to take aspirin (ASA) or APAP and take a nap until they went away.  I make that diagnosis in retrospect after learning quite a bit about headaches and learning how to treat them. The new headache was nothing like those cluster headaches.  I could still read, exercise and function well. I also noticed that sleep alone had no effect on the new headache. I would still wake up with it if I did not take APAP.  Only recently I had an episode where the new retroorbital headache worsened with coughing and that seemed to be an isolated event. The headache could occur at any time of the day, was not related to stress, or any activity.

I was seeing optometrists at the time – initially for an annual eye exam and then for severe dry eyes. I asked both optometrists if any of the eye diagnoses (Meibomian gland dysfunction, ocular rosacea, blepharitis, punctate keratitis, dry eyes, and astigmatism of the left eye) could be causing the headaches and was told it was a possibility but that I should follow up with primary care and neurology. By January of 2023, I tried to get an appointment to see a neurologist – but could not get in until September 2023.  I saw my primary care MD twice during this period and his diagnosis was tension type headaches because I had no other neurological symptoms. The plan was to keep taking APAP.

Digressing a moment to diagnosing and treating headaches as a psychiatrist. As an acute care psychiatrist, I was in the position of diagnosing and treating many people with severe chronic headaches. They were typically admitted because of associated severe depression, suicidal thoughts or behavior, or a complete inability to function at home. Many of those patients started out with migraine headaches that were eventually complicated by medication overuse headaches. Frequent use of medications like APAP, triptans, and non-steroidal anti-inflammatory medications (NSAIDs) resulted in a headache that would not longer resolve. That diagnosis led to a different treatment plan that was moderately successful until a better plan for headache prophylaxis could be established. I had excellent back up by neurology and often consulted with a friend of mine who is a local neurologist and pain specialist.

Diagnosing headaches is not too far removed from making a psychiatric diagnosis in that the phenomenology of the headache it critically important.  What is the pain like, how is it described, does it radiate, are there any associated events or sensory phenomenon?  History is a critical part of the headache evaluation. The physical exam can contribute in the case of autonomic findings, making an underlying diagnosis that is a cause of the headache, or in some cases  a finding that suggests an underlying pathophysiological mechanism.  An example would be tenderness in the facet joints of the cervical spine (C-spine) for cervicogenic headaches.  Associated testing can be diagnostic but in most cases it is supportive.  That is degenerative disk disease and arthropathy of the facet joints of the C-spine supports the diagnosis but other elements need to be there like the characteristic pain distributions associated with this headache. A complete list of the common forms of headaches can be found at the National Headache Foundation and much more detailed discussion in headache specialty texts. The list is not exhaustive since headaches can occur across many settings and can be the general result of chemical alterations (alcohol, alcohol withdrawal, medication side effects, etc) and inflammation (influenza, coronavirus, etc).  As far as I know neurologists have not embraced the transdiagnostic term that we see cropping up in the psychiatric literature, but headaches are both a disease and a transdiagnostic symptom.

An illustration of the complexity of these headaches uses my specific example.  The table below illustrates the onset and frequency of these headaches from October 2022 to June 17, 2023).  Headaches are recorded only if they were treated with APAP.

 

	Generalized Bilateral	Left Retroorbital
OCT	7	1
NOV	8	4
DEC	1	6
JAN	2	4
FEB	5	5
MAR	4	3
APR	3	14
MAY	3	10
JUN (to June 17)	0	5

 

I will attempt to correlate various comorbidities to see if there are any possible explanations:

C-spine disease – I was diagnosed with C-spine disease by clinical exam and MRI about 20 years ago. The MRI showed stenosis but EMG studies were normal and physical therapy resolved the neurological symptoms I had at the time – primarily numbness in the C7-C8 distribution of both arms.  I have been doing the PT exercises for the past 20 years.  From the chart I do get episodic bilateral occipital headaches that radiate up from the neck and I attribute these to C-spine disease.  I typically treat them with physical therapy maneuvers and occasionally APAP.  Cervicogenic headaches have three reported pain distributions - occipital, occipital temporal maxillary, and supraorbital (most common).  Other sources say that the pain can be experienced anywhere on the face (1).  Retroorbital headaches from this cause seem unlikely.

BPPV- my only other MRI of the brain was done when I developed benign paroxysmal positional vertigo about 25 years ago.  Although that brain scan was normal, a polyp was noted in the frontal sinus but no further evaluation or treatment was recommended. I typically have episodes that seem to be improving over time.  Not debilitating.  

Astigmatism- severe in the left eye – causes visual distortion and seems to contribute to vertigo.

Dry eyes – multiple diagnoses as noted

Paroxysmal atrial fibrillation – have had about 20 episodes lifetime.  Much better control recently with a brief episode every 1-2 years. On an antiarrhythmic for 16 years. The main non-cardiac risk is embolic stroke.  I have had highly variable experiences with the physicians I have consulted about this disorder over the years.  There appears to be no consensus on the time frame necessary for cardioversion to prevent strokes.  I have been cardioverted initially in time frames of up to 15 hours both with medications and electrical cardioversion. In one case, I was anticoagulated and in other cases not. I have had patients who were in permanent atrial fibrillation and were not anticoagulated. Primary care seems to have a fairly casual approach to atrial fibrillation possibly because early studies showed there was no difference in outcomes based on rate control or rhythm control (normal sinus rhythm). Since then, studies have shown that people with rhythm control may have a higher quality of life. I decided to start anticoagulation 18 months ago because the pandemic had seriously compromised physician access and I did not want to end up in atrial fibrillation with no access to cardioversion. For the purpose of this post the question is: “Is it possible that a silent stroke occurred and caused this headache?”  At least one reference suggests that silent strokes are common in the elderly but not a cause of headaches, but deep white matter lesions on MRI may be. (2)

ATM and other risk genotypes- In a previous post I explained the ATM genotype and how it significantly increases the risk for pancreatic cancer.  I also have genotypes associated with increased risk for epithelial cells cancers.

Migraine Aura without Headache- I have experienced this in the past but not recently as a single episode of visual phenomenon.  The ophthalmologist I consulted with knew what had happened immediately and no specific treatment was recommended.

 Obstructive sleep apnea (OSA) – Diagnosed 18 years ago and I have been 100% compliant with CPAP/APAP ever since. I get a daily report on hypopneic episodes/hours and they are always well withing the target range.  OSA can be a cause of headaches, typically in the morning (3) but improve with treatment and are unlikely in this case.

Not all these factors were considered by the physicians I consulted about these headaches. The protocol was basically a cursory (or detailed) neurological review of systems and neurological exam.  In all cases I was told that it was a “non-focal” neurological exam.  My primary care physician saw that as a reason for no imaging and continuing the current treatment with APAP for a diagnosis of “tension headaches”.  The neurologist initially said he thought I had a migraine but on further consultation the diagnosis was “inflammatory headache” and I was given a standard tapering dose of methylprednisolone.  I filled the prescription but decided not to take it until after the imaging study.  None of the physicians suggested that it could be pain due to C-spine disease and I have found that unless you are talking with a rheumatologist, a lot of physicians do not spend a lot of time discussing or treating arthritis. The neurologist also ordered an MRI scan of the brain and two of the images are at the top of this post.  It was read as a normal MRI scan of the brain. The headaches persist.

This exercise in the differential diagnosis and treatment of headaches is instructive for several reasons:

1:  It highlights the complexity of medical conditions and everything that needs to be considered.  I could argue that 20 or even 30-minute visits with a generalist or even a neurologist might not result in an adequate assessment just based on the information that needs to be considered.  I described 50 years of medical history as succinctly as possible but it also requires somebody to put that together as rapidly as possible and look for the relevant patterns of disease. There are headache specialists out there who do this – but they are rarer than child psychiatrists and that is rare.

2:  The complexity is compounded by the fact that there can be more than one type of headache present and that each requires a separate diagnosis and treatment. In my case I came in with my own ideas that I had one type of cervicogenic headache and a new headache of undetermined etiology.  There are studies available that attempt to differentiate migraine headaches from cervicogenic headaches by selective injections of various cervical vertebrae.  In some cases that clarifies the source of the headache and in others the patient has both types. Similarities to the psychiatric diagnostic process are noted.  There are some who suggest that there should only be one treatable diagnosis.  If you can have more than one headache I don’t see why you could not have more than one psychiatric diagnosis.  

3:  Testing is a wild card – but should it be?  In this case my primary care physician opted to not order brain imaging but the neurologist did.  The kind of testing done in psychiatry and in much of neurology is non-diagnostic.  In other words, if a lesion is detected there is still a question of whether it is causative. The best example is degenerative disk disease and arthritis of the spine. It is easy to detect degenerative changes but the question is how they relate to the clinical problem. At the same time, the prevalence of serious secondary causes of headaches in the elderly such as tumors, vascular, inflammatory and other space occupying lesions like hematomas is significantly higher than in younger population – making any primary headache diagnosis in an older person - a diagnosis of exclusion.  I have certainly imaged patients in my practice based on various combinations of neuropsychiatric, cognitive, and neurological symptoms for this reason. It is no different in neurology.  In addition to the central nervous system secondary causes of headaches, orbital lesions need to be considered and that list is also extensive.

4:  Are headaches a disease?  With all of the repetitive rhetoric from the anti-science and anti-psychiatry crowd – my mind wandered to this question.  I had also recently encountered the term “Szaszian binaries” in a philosophical paper that was mildly critical of the disease arguments from antipsychiatrists that to this day are based on Szasz’s 60-year-old definition – that diseases must be based on morphology or a known pathophysiological mechanism – like infection from an organism.  It turns out that headaches are indisputably called diseases even though the mechanisms are as speculative and no morphological lesions are seen on brain imaging.  Like psychiatrists – the only positive findings will be the identification of secondary causes and that is no small accomplishment.  As I searched this topic, I found an article written by Ron Pies, MD on this very topic (5).  Szasz never wrote a Myth of Migraine Headache or commented on why headaches were not diseases.  

Where does all of this leave me today?  First relieved that there is no life threatening or debilitating brain pathology and that my brain looks pretty good for an old man.  I previously documented a serious traumatic brain injury in my 20s and my C-spine problems are likely the result of playing high school football and compression injuries transmitted through my helmet and head and into my neck. I was also involved in a collision playing third base that resulted in my neck being locked up for several hours that did not help. Second, it adds to my long-term health plan.  Despite that list of health problems, I have exercise and physical therapy plans to deal with most of it. Maintenance measures will take care of the rest.  I have a follow-up with neurology in October and if the retroorbital headaches start to increase in frequency I might try the methylprednisolone, but I don’t have high expectations. I had an asthma flare after a trip to Alaska about 8 years ago and had to take prednisone at a substantial dose and that did not seem to do much for the cervicogenic headaches.  My primary treatment modalities will remain exercise, physical therapy, and APAP.

It may seem like that is a significant list of problems, but after working in the field for 40 years they seem expected to me.  As long as they are manageable and I am tracking them and making necessary adjustments life is good. I also have a high index of suspicion for future problems and hope to identify any that come up, but I am also not fooling myself that I can control everything or that new problems will always be manageable. 

 

George Dawson, MD, DFAPA

Supplementary on Neck Pain:

I did a previous post of the importance of the spine in psychiatric practice largely because of bidirectional considerations.  I was seeing a large number of people who had sleep problems that were either caused by neck pain or had insomnia that seemed to cause neck pain. My interest in the mechanical and neurological spine dates back to excellent neurosurgical rotations in medical school and the associated radiology rounds with the late Sanford J. Larson, MD, PhD.  Even though neurosurgery was a tough rotation for students, residents, and attendings - every Saturday morning Dr. Larson would meet all of us in the Radiology reading room at Froedtert Hospital and would spend the morning reviewing all of the films from the last week.  I say films because all of the images were on large films placed on a device that could rotate them all in order.  The standard film in those days was 35 x 43 cm (14“ x 17“) so each row on that machine held about 8 films.  I was able to continue that practice when I worked at an acute care hospital but outside of that setting - it was always difficult to access films and later digital images. 

Another outcome of that early experience was continuing to read papers on common spinal problems and way to address them.  The epidemiology of neck pain has progressed significantly over time (6.7). In 2015 it was noted to be the 4th leading cause of disability.  Most acute neck pain resolves in a couple of weeks but in 50% of those cases it recurs over the next year. Annual prevalence is estimated to be 15-50% with an average of about 37.2%.  There have also been some studies of the impact of structured exercises on neck pain that typically show improvement.  I have not seen any estimate on the percentage of people with neck pain who have associated headaches but expect that would depend on risk factors and degree of mechanical and neurological impairment. This also seems to be a medical education issue. In my experience very few physicians know how to do a back and neck examination and interpret the findings. 

 

References:

1:  Al Khalili Y, Ly N, Murphy PB. Cervicogenic Headache. 2022 Oct 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29939639.

2:  Fujishima M, Yao H, Terashi A, Tagawa K, Matsumoto M, Hara H, Akiguchi I, Suzuki K, Nishimaru K, Udaka F, Gyoten T, Takeuchi J, Hamada R, Yoshida Y, Ibayashi S. Deep white matter lesions on MRI, and not silent brain infarcts are related to headache and dizziness of non-specific cause in non-stroke Japanese subjects. Intern Med. 2000 Sep;39(9):727-31. doi: 10.2169/internalmedicine.39.727. PMID: 10969904.

3: Verbraecken J. More than sleepiness: prevalence and relevance of nonclassical symptoms of obstructive sleep apnea. Curr Opin Pulm Med. 2022 Nov 1;28(6):552-558. doi: 10.1097/MCP.0000000000000915. Epub 2022 Sep 14. PMID: 36101923; PMCID: PMC9553267.

4:  Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A narrative review. Cephalalgia. 2015 Sep;35(10):894-911.

5:  Pies RW.  Why Thomas Szasz did not write about the myth of migraine. Psychiatric Times.  July 29, 2021.  https://www.psychiatrictimes.com/view/thomas-szasz-myth-migraine

6:  Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015 Feb;90(2):284-99. doi: 10.1016/j.mayocp.2014.09.008. PMID: 25659245.

7:  Kazeminasab S, Nejadghaderi SA, Amiri P, Pourfathi H, Araj-Khodaei M, Sullman MJM, Kolahi AA, Safiri S. Neck pain: global epidemiology, trends and risk factors. BMC Musculoskelet Disord. 2022 Jan 3;23(1):26. doi: 10.1186/s12891-021-04957-4. PMID: 34980079; PMCID: PMC8725362.