I Have Hit A Wall

 I am currently working on two complex posts that will require a lot of research and graphics work but hopefully will be worth it at the end. I thought I would include a few comments about this here basically to document the progress and to see if anyone has already done the more detailed neuroscience post.  I also plan on taking a break by posting on a topic that I can more easily cover about – subclinical hypothyroidism.  That will hopefully appear in the next few days. There is a long history of endocrinology interfacing with psychiatry and as a research fellow in that field I am very aware of the associated concepts.

The complex posts are the neuroscience of a central autonomic network (CAN) and the borderline personality disorder concept. I am very interested in the CAN because of the issue of cardiac anxiety. In other words – can the heart itself be a source of anxiety and if that is the case should it be addressed differently?  And what are the implications for nosology?  The current DSM approach is agnostic when it comes to potential mechanisms of anxiety, but should it be? Considering the wide variety of medical approaches for anxiety including a few that are cardioselective – it would be useful to know if the anxiety originates in the brain or somewhere else and if that implies a different type of treatment.

The borderline personality disorder concept has always been controversial – but various psychiatrists and researchers also have a history of addressing the controversies and providing solutions for patients.  Most importantly those techniques have demonstrated efficacy for reducing suicidal ideation and self-injurious behaviors. Despite those advances an editorial in a recent British journal called for the abandonment of that diagnostic class and substituting an older diagnosis. Much of the justification for replacing the diagnosis seems to suggest that it is a pejorative label.  Having worked in a multitude of medical settings I can attest to the fact that pejoratives exist everywhere in medicine and it has very little to do with diagnostic criteria. It is largely related to countertransference issues by health care workers who are unaware of that concept and who are psychologically unable to maintain a neutral stance in emotionally taxing situations with patients. Changing a diagnosis is unlikely to change that predicament. I could generate a long list of what I have heard patients referred to – but is counterproductive and does not address the issue. I am not suggesting that every health care worker needs training in countertransference management.  Maintaining a professional stance can occur with appropriate coaching, education, and supervision.  As an example, I was asked to consult during a grand rounds on this topic presented by Emergency Medicine and comment on physician reactions in common situations.    

The basic problem with the CAN concept is not the basic structures involved but the initial signals and connectivity.  As an example, I am looking at my diagram of the subfornical organ and note there are 10 major efferent connections and 6 major afferent connections with some overlap.  The subfornical organ is one very small component of the CAN.  Not sure about my ability to diagram that complexity but I am going to give it a try.

I am also hoping this comment about hitting this wall provides me with some insights on how to approach this work. My only full-time job these days is blogging. After doing several presentations in the past year – I know I am much more enthusiastic about what I am researching and presenting than anybody who attends those presentations. I am also aware of the biases in society against old people and retired people. But I can’t let any of that get to me. I will stop when it is obvious that I have nothing left to contribute or I am stopped by a health problem.   

When you are a blogger – it seems like it is always feast or famine.  I have been very productive and posted what I think are excellent posts that nobody reads.  At other times and seemingly out of the blue there are bursts of reader activity that are hard to decipher with the available tools on blogger.  A friend of mine read through a few of my posts and said: “That is a lot of work.”  I appreciated that comment because it captured the reality of many posts and the implicit “for nothing.”  I still think there is an undercurrent of thinking that all bloggers or influencers get paid for what they post.  I have never been reimbursed for what you see written here and all the permissions that I have acquired over the years specifies the non-profit aspect. 

Finally – if you do read what I post here I appreciate it. Take the time to let me know if you want to see any psychiatry or medicine specific topic and I will do my best to write about it. If you look back over the years of posts – several firsts have been posted here that are not seen anywhere else – both in psychiatry and medicine in general. I see that as validation of some of my approaches.

In the meantime – stay tuned!

 

George Dawson, MD, DFAPA

 

 

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