UpToDate and the Rx Transitions in Mental Health

 

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

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

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

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

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

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

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

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

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

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

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

 

George Dawson, MD, DFAPA      

 

Supplementary:

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

References:

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

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

Why Equal Opportunity for Women Is Not “Woke”

 

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

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

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

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

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

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

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

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

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

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

6. People are attracted to men who dominate others

7. Muscles are indicators of masculinity

10. Men are superior to women

11. Gender and sex are the same thing

15. Men cheating on their partner is natural

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

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

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

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

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

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

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

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

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

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

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

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

 

George Dawson, MD, DFAPA

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

This blurb from Hegseth:

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

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

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

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

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

Supplementary 2:

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

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

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

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

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

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

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

Retired Lt. Gen. Ben Hodges: Link

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

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

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

Retired Lt. General Ben Hodges:  Face the Nation  Link

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

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

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

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

References:

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

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

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

 

Graphics Credit:

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

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

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

 

 

How People Think About Escalator Malfunctions

 

What would you do if you were in your favorite shopping mall and the escalator was not working?  Would you consider it an act of sabotage and demand an investigation?  Most people would just walk up the frozen staircase and not give it a second thought. You don’t have to take my word for it.  Just go out in the wild, find a frozen escalator and see what happens. The escalator in the mall I go to is usually not working.  There is no outrage or complaints to the manager. People just walk up and down it using the stair function.  That is what most people know about escalators from personal experience.  This post will examine how you could think about that problem.  But first – a few facts about escalators.

There are about 35,000 escalators in the US. Escalator density varies widely from state-to-state from much higher number in large metropolitan areas to only 2 escalators in the state of Wyoming.  Performance metrics are available for systems where they are used extensively like transit systems. Systems are rated on availability and how long they operate before failing.  The engineering metric is Mean Time Before Failure (MTBF).  An example from one metro transit system of 588 escalators measured availability at about 92% and MTBF of 153 hours (6.4 days). The average time to repair those escalators was 14 hours.  Of all the maintenance work done only 32% was scheduled.  The remainder was due to service calls, safety repairs, and customer incidents.  Interestingly service calls included escalators that turned off unexpectedly. All this data indicates that escalators are high maintenance devices compared with other commonly used devices like your automobile.

There are an estimated 10,000-17,000 escalator related injures per year.  75% of those injuries are from falls and slips (1).  Risk factors include advanced age and alcohol use. Many of those injuries are severe enough to require admission to a trauma center and in rare cases can result in death.

If you encounter a frozen escalator or one working erratically you could tell yourself: “Well I know from my personal experience that escalators will not be working from time to time. This is a little annoying but I can walk up the escalator or find an elevator like everyone else. I assume the next time I am here it will be repaired.”  If you know more about escalators you might think: “I know escalators have a high failure rate and about one in ten may not be available on any given day – this is to be expected.  I will just work around it”  After all the escalator was put there for the convenience of customers and the public.

These lines of thought are the collective reality that we experience. In considering a probability model of thought our collective experience creates a high probability that when we encounter a broken escalator, we will consider it a routine occurrence and quickly move to a work around.  A thought experiment illustrates this fact.  If I poll 100 people on how they handle a broken escalator – most of them will give the expected responses.  The outliers may be people who know about escalator maintenance or how these situations need to be handled.

But there are outliers.  Outliers could have phobias about escalators.  Escalators have well known safety hazards of falling and slipping. They have an awkward motion for many people and a person with vertigo or other balance problems may find it difficult to use them.  These people may have had a mishap on an escalator and sustained an injury.  There is a term for escalator phobia that I will not use here because I don’t think it adds much. People who are phobic of escalators may tend to avoid them.  That is easier to do in shopping malls than transit systems.  Not having worked in escalator dense areas I have never encountered a person with that phobia but have seen many people with phobias about crossing bridges and railroad tracks. 

Are there other ways to think about a broken escalator than just inconvenience.  As I was writing this, I thought of Jason Bourne one of my favorite fictional movie characters.  In the famous escape from Waterloo Station the scene begins and ends with escalators.  Fortunately for Bourne they were working in both cases.  But if they were not working, we can speculate he would probably be seeing the problem though his usual combination of situational awareness that would include alternate routes and what could be used to his strategic advantage.  The bottleneck created is an example of potential strategic use.

There are outliers beyond the outliers.  Folks with unique interpretations of everyday situations at a frequency of one person in a thousand to ten thousand.  They may have never seen an escalator or how it works.  But if they were born and raised in a modern society that is not very likely.  One recent interpretation was that the escalator was not working because it was sabotaged.  Where does sabotage fit in to a probabilistic model of everyday thought?  Sabotage is an unlikely explanation of everyday events.  People who I have professionally encountered over the years have told me about how the electricity in their home, their health, their food, their pets, their automobile, their work, their spouse, their legal status, and their finances were sabotaged by several methods.  Some of the methods were incredible like beams from satellites or delivery vans parked outside on the street using some kind of electronic device.  Others seemed more possible like “they came in the middle of the night and replaced my wife while we were sleeping.  She looks sounds, and acts the same but I know she is not real.”

Note the operative term they in the above scenarios.  They are a possible or imagined enemy causing the real or imagined problems. They can easily be a scapegoat.  Rod Serling was an expert in looking at how this dynamic plays out in society.  Slightly after the McCarthy era – he wrote an episode of the Twilight Zone called The Monsters are Due on Maple Street.  The entire plot focuses on what happens when there is a power outage on a residential street and people start looking for a scapegoat.  The final narrative is a comment on human nature and how we can be counted upon as a group to get the probabilities wrong.

What happens if the sabotage explanation persists and cannot be explained by groupthink, spycraft or reality?  Fixed false explanations and beliefs about action or delusions come to the attention of psychiatrists as paranoia on an individual level.  There are various disorders and those diagnoses depend on other features but one of the central features is the delusion.  There are also many people living in the community who are hypervigilant and suspicious without false beliefs who function normally.  Paranoia can be a personality feature or a delusion.

The ability to modify delusional beliefs by psychotherapy has been suggested since 1952.  Aaron Beck – one of the founders of cognitive behavior therapy published a case report (1) on the successful treatment of delusional thinking is a patient with schizophrenia.  Since then, techniques have been discussed in many supportive psychotherapy texts (2-5).  The common elements of psychotherapy including the therapeutic relationship, therapeutic alliance, and specific interventions necessary to discuss delusions are all covered in detail.  A detailed phenomenological interview and discussion are necessary focused on the onset of the thought.  This is necessary to explore emotional elements and how they potentially lead to a delusion.  Anxiety is a common initial state with many delusions being an explanation for the anxiety.

In the case of escalators – it is easy to imagine a person anxious and rushing to an appointment or trying to complete their shopping and they discover the escalator they use for that purpose is broken.  They may express frustration: “Why today?”, Why me?”, “Today of all days!”, etc.  But it is unlikely that they would think the escalator is sabotaged to prevent them from completing their task. Having an established set of delusions prior to the incident would increase the probability of thinking about sabotage.     

If I was seeing a patient with escalator paranoia telling me about how the escalators he was using were sabotaged – I would proceed with preparation for the therapy with the basic steps outlined above.  At some point we would need to discuss alternate explanations for the escalator malfunction.  That list may look like this and this list is not exhaustive:

1:  Need for service or maintenance/mechanical failure

2:  Power outage and other random events

3:  Imagined sabotage by a real or imagined enemy

4:  Control by a government agency

5:  A sign from a deity – a curse or a message

6:  Telekinesis – the person observing the malfunction believes he is causing it telepathically.

That discussion would examine whatever theories a person has with the goal of moving toward numbers 1 and 2 on the list.  That conversation as psychotherapy may take several months before there is any significant progress. It could involve gathering much evidence for and against the hypotheses and beliefs.  The contrast with politics and the Twilight Zone episode is interesting because it potentially works in the opposite direction. Direct evidence against the hypothesis is never considered since it is based on a political theory of persecution.  The message is reinforced by loyal followers and affiliated media.  These days that involves significant amplification through social media. The press in general does a very poor job of fact checking and refuting the process that Rod Serling correctly characterized in 1960 (6).  That group dynamic is difficult to stop and we currently watching that unfold.    

 

George Dawson, MD, DFAPA

 

References:

1:  Schminke LH, Jeger V, Evangelopoulos DS, Zimmerman H, Exadaktylos AK. Riding the Escalator: How Dangerous is it Really? West J Emerg Med. 2013 Mar;14(2):141-5. doi: 10.5811/westjem.2012.12.13346. PMID: 23599850; PMCID: PMC3628462.

2:  Beck AT. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry. 1952 Aug;15(3):305-12. doi: 10.1080/00332747.1952.11022883. PMID: 12983446.

3:  Perris C.  Cognitive therapy with schizophrenic patients.  New York. The Guilford Press, 1989: 160-186.

4:  Wright JH, Turkington D, Kingdon DG, Basco MR.  Cognitive-behavioral therapy for severe mental illness – an illustrated guide.  Arlington, VA.  American Psychiatric Publishing, Inc., 2009:  99-123.

5:  Garrett M.  Psychotherapy for psychosis – integrating cognitive behavioral and psychodynamic treatment.  New York.  The Guilford Press, 2019: 194-197.

6:  Novalis PN, Rojcewicz SJ, Peele R.  Clinical manual of supportive psychotherapy.  Washington, DC. American Psychiatric Press, 1993: 138-146.

7:  Serling R.  The monsters are due on Maple Street.  Twilight Zone.  Season 1, Episode 22 originally aired on March 4, 1960. YouTube clip.

 

Graphics Credit:

Sascha Kohlmann, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons