The Laparoscopic Cholecystectomy

I had a laparoscopic cholecystectomy done on January 28.  The indication was possible biliary colic and atypical symptoms of gallstone disease and a gallstone and polyp in the gallbladder noted on abdominal ultrasound.  That scan was done to determine a possible cause of 2 years of bloating and tachycardia.  There was no right upper quadrant pain or colic following fatty foods.  The confounder there is that I hardly eat any fatty foods.  All of my dairy products are fat free.  I have not eaten beef in over 30 years and the only time I eat bacon is as a condiment.  I know the cultural swing in medicine is that fat and cholesterol are now supposed to be "good" for you but I don't buy that and the proof is my fasting lipid profile. I also recently learned that two of my cousins had cholecystectomies at a young age for gallbladder disease so there may be a genetic factor.  The diagnosis did take me by surprise and might illustrate the value of retrospective analysis.

When I presented to my internist with symptoms of abdominal bloating and postprandial tachycardia in the absence of any blood test abnormalities it suggested to him that it was more of a dumping syndrome except there were not associated symptoms or diseases. He set up the ultrasound and called me with the results.  Surgical referral was next. The surgeon suggested that while I did not have "classic" symptoms of gallbladder disease that he had seen varied presentations over the years including the symptoms set that I came in with.  He  suggested cholecystectomy as on option but didn't oversell it: "You may find that those symptoms are not changed after the surgery." He did tell me about a patient who did not want the surgery and managed her illness by diet alone for 20 years until the laparoscopic approach was widely applied.  I thought about it for a few minutes and decided to go with it.

Several factors went into my decision.  First, when I was a freshman in college I had severe appendicitis and had a gangrenous appendix excised and a Penrose drain hanging out of my side for a week that drained the residual tarry remnants of my appendix.  It was the only time in my life I thought I might be better off dead.  Friends visiting me at the time thought I was joking.  So my first thought was that I dodged a bullet at age 18 and I did not want to take that chance again. And then there was my medical school experience. One of my first patients on surgery was an 85 year old man with an ED diagnosis of acute cholecystitis.  He died postoperatively and at autopsy no cause of death was determined.  Could I really afford to try to manage this with diet for the rest of my life and take that kind of chance?  The other patient was a 45 year old woman who presented with an acute abdomen.  In those days imaging not widely applied and the clinical examination was the key determinant. My surgical attending at the time found out that I was considering psychiatry and went out of the way to berate me.  He challenged me to tell him the diagnosis on the patient. He was certain it was acute appendicitis.  I went with the odds and said she had acute cholecystitis.  The surgical team dissected out a normal appendix and he said: "Looks like the medical student was right" and proceeded to make another incision and remove the gallbladder.  I put more weight on the imaging, but from my discussion with the surgeon there is still a fair degree of uncertainty. If I am an old man some day with abdominal pain it might be useful to tell the physician: "I don't have an appendix or a gallbladder".

The surgery itself seemed like a breeze.  I had a brief pre-op discussion the surgeon and the anesthesiologist.  My basic concerns were that I do not get any antibiotic or anesthetic agent that interacts with my existing medication - especially the one that affects cardiac conduction.  They assured me that would not be a problem.  I also told the anesthesiologist that I had never been intubated before or had either inhaled anesthetics or neuromuscular blockade.  I had several minor surgeries where the agents used were fentanyl and midazolam and that seemed to work fine.  I also let him know that I have significant arthritis in the neck and he checked it for range of motion.  They gave me the intravenous pre-anesthetic, wheeled me into the OR and I was out before I could remember anything.  Totally unconscious without a single dream.

In the recovery area I was stoned for about 2 hours. I remember the anesthesiologist coming in and asking me if I had shoulder pain.  Sure enough I had significant right should pain. Two milligrams of Dilaudid (hydromorphone) not only cleared that up but it never returned.  I had both fentanyl and hydromorphone on board and the nurse kept telling me to "take deep breaths" because my oxygen saturations were dropping.  Eventually I woke up completely, got out of bed and started walking around.  I reflected back on my gangrenous appendix experience.  The day after that surgery, it took two nurses to stand me up next to the bed and then my doctor pushed my chest in order to straighten me up. Every step resulted in severe abdominal pain.  That was not the case with this surgery. I had 4 puncture wounds in my abdominal wall but I did not have peritonitis. I was not only moving with ease, but I could also flex my abdominal muscles to get out of bed.  The discharge pain medication was oxycodone 5 my every 4 hours as needed.  I get headaches and mild nausea from it and stopped it and switched to acetaminophen.

Post op day #1 - I felt progressively worse getting home.  It was a general flu-like syndrome with mild nausea.  Whenever I think about flu-like illness I think cytokines. There has been a lot of work on that specifically to cholecystectomies, but none of it seems very specific.  I was also having difficulty voiding despite having to void as a requirement before being discharged form the hospital.  I did not figure out until the next morning that it was probably all part of the physiological changes that occur with abdominal surgery.  That was the most interesting chapter in my undergrad surgery text.  I also wondered about the oxycodone and the intraoperative cephalospoin (cefazolin) given for antibacterial prophylaxis.  I prefer cephalosporins if I need antibiotics and had a similar reaction to cephalexin. With that flu like syndrome I started to get mild tachycardia and blood pressure elevation that I attributed to anxiety about the flu-like symptoms and continued problems with voiding.  All of my temps were normal.  A final significant symptom was episodes of hiccups, a result of the pneumoperitineum  induced to perform abdominal surgery.

Post op day #2 - The voiding problem cleared entirely.  Negligible pain.  I was contacted in follow up by the hospital. They seemed impressed with the lack of pain, especially shoulder pain and advised me to get active and eat foods that might be beneficial for constipation.  The flu-like syndrome seems to be nearly resolved with the exception of some mild facial flushing. At this point it seems like I am on the way to recovery but will post if anything of further interest develops.

I post this experience here to highlight how individual conscious states impact medical decision making - even surgical procedures.  I encountered a number of physicians in this process but the core physicians were my primary care internist, the physician who did the pre-op assessment, and the surgeon.  My primary care internist has known me for about 30 years. He was highly recommend to me by a psychiatrist who worked in the same clinic.  He performed the most thorough examination and gave me a good differential diagnosis at the beginning before ordering the ultrasound.  He knows me well enough to know that I am neurotic but when I have a problem it is usually significant.  I know that I can expect a very thoughtful analysis of the problems and that he will always call me in follow up. The physician doing the pre-op physical has done two other pre-op physicals on me in the past year. He is also thorough and notes my concerns on the pre-op history and physical - but the problem is that nobody seems to read them after that.  The surgeon in this case did a cursory exam but provided me with key information about what to expect up to and including no resolution of symptoms.  He didn't have to tell me about the bad outcomes - I was almost a bad outcome myself.

Everything I read about evidence-based medicine and the corporate standardization of medicine minimizes all of the subjective elements that I have listed above.  I could have seen different physicians at any step in the above sequence and the outcome may have been different.  I could have been a guy who did not have a near death experience with acute appendicitis.  I could have had an internist who told me to try simethicone for gas and not ordered the ultrasound. There is also a level of uncertainty that a lot of people seem unaware of. It is certainly possible that I would die from something else and the gallbladder finding was totally incidental.  UpToDate suggests that is the course for most incidental gallstones 15-25% become symptomatic in 10-15 years of follow up (1).  But was I already symptomatic? Whether it works for the presenting symptoms is still undecided.

There is always room for personal experience and subjectivity in medicine - on the side of the patient as well as the side of the physician.  People often refer to this as the art of medicine. The only parallel with art is the apparent creativity that occurs when unique conscious states are all focused on trying to solve the same problem. Informed consent is often seen as a medico-legal procedure but it also acknowledges the subjective experience of both people in the room. There are probably multiple paths to address a problem - but the usual debates I see suggest that there is only one right one.


George Dawson, MD, DFAPA


Reference:

1.  Salam F Zakko, MD Section Editor:Sanjiv Chopra, MD Deputy Editor: Shilpa Grover, MD.  Overview of gallstone disease in adults.  UpToDate.  Accessed on January 29, 2019.

Graphics Credit:

The above graphic was downloaded from Shutterstock per their standard agreement.




 

What Is Missing From The Divisiveness Debate?

Migratory routes of Homo heidelbergensis from East African origins (numbers are approximate years in past) - see attribution for reference.  Homo heidelbergensis is thought to be the common ancestor for Neanderthals, Denisovans, and modern humans - Homo sapiens.

The recent high profile incidents involving the shooting deaths of young black men and police officers and the associated news coverage and involvement by high profile celebrities and politicians has sparked a social activism, debate, and dialogue.  Like any complex issue, there are people who have opinions that mirror their political party lines, people who have their own opinions and they are not interested in changing them and people who are more open to a dialogue.  Practically all of the dialogue seems focused on high risk incidents that happen in a matter of seconds that involve deadly force.  I have seen some neuroscientific ponderings about how unconscious or implicit biases can affect those split second decisions.  I thought that was possible until I went to the web site and took the tests involving implicit bias.  There was not a single case where I could not predict the outcome ahead of time based on what I already know about myself.  To me it appeared that unconscious bias was not operating in the decision.  Since I am a white psychiatrist and not a police officer, I am not going to suggest specific solutions for police officers or the black community.  I do see a number of scientific dimensions that nobody or very few people are talking about so it is time to add my two cents:

1.  We are all from Africa -

Practically all of the debate centers on race.  There are statistical studies that show black drivers are stopped at higher rates than white drivers.  There are more white people killed by the police but as a proportion of the population black people are overrepresented.  The numbers are real and require serious analysis, but the larger picture is ignored.  That larger picture is that race is a social and cultural convention and not a scientific one.  On a scientific basis, everyone in the world - all human beings originated in East Africa about 200,000 years ago.  At some point, different races were described but at the time this genetic evidence was unknown.  The genetic evidence for racial and ethnic differences is still an area of active investigation.  Those studies illustrate the difference in skin color for example may come down to mutations in two genes (1, 2).  At the proteomic level, a recent study (3) looked at an analysis of interindividual variation in the total number of proteins that could be identified in cerebrospinal fluid (CSF) and urine and found considerable variation between individuals.  There was a 26% difference across 968 urinary proteins and a 18% difference for 512 CSF proteins.  Those numbers are very large compared with the difference between 1 or 2 skin proteins.

Although the total number of proteins identified in the human proteins is 10,500, estimate of the true size has varied from 10,000 to several billion (4) making the number of proteins responsible for skin color differences even less significant.  More skin specific information is available from the Human Protein Atlas.  Their analysis shows that there are 95 skin enriched genes and 412 genes with enhanced expression in the skin.  Only three of these genes MLANA, DCT, and TYR involve melanin synthesis or skin pigmentation.  Person to person variation on an arbitrary racial classification based on skin color is obscured by the expected genetic variation among members of the same race.

Further evidence is available to anyone by sending their DNA for analysis by the National Geographic Genographic Project.  You will receive a map of how your ancestors migrated from East Africa and information about marker that you share with other ethnic groups across the world.  The analysis will also include information about DNA that you share with ancient humans specifically Neanderthals and Denisovans.  The current project also estimates regional ancestry based on markers that appeared over time if migration from Africa occurred.  All of these science considerations should point to the fact that what we have generally considered to be racial boundaries may have political and cultural meaning to people - but there is no scientific meaning.  Every human being on the planet is descended from a small group of ancestors in East Africa.  Time to put the cultural and political stereotypes about race behind us.        

2.  Every person in the world has a unique conscious state -

One of the concepts that I am careful to mention whenever I am discussing aspects of psychiatric diagnosis is human consciousness.  From a neurobiological perspective the human brain has evolved to be a very efficient information processor.   Plasticity leads to experience dependent changes in the brain.  Experience can have a biasing effect of the general form that "my experience is everyone's experience" or "my experience is more valuable than anyone else's experience" or in the extreme case "my experience is the only one that counts."  Fortunately the human brain also has top-down controls like empathy, the ability to recognize that other unique conscious states exist, and the ability to correct its own erroneous biases.  Just the fact that every person on earth has a unique conscious state has significant ethical and moral implications for how one person interacts with another.  Those individual ethical imperatives are seriously watered down by political and legal limits that often target the lowest common denominator.    

3.  Anger has a predictable biasing effect -

Let me start off by saying that this paragraph is not meant to discount anyone's anger.  Anger is a universal human emotion, but the analysis of anger usually stops at the point of whether it is justified or not.  The analysis seldom looks at how anger biases subsequent decisions or how it might affect the initial encounter between the police and suspects.  Any student of social media can observe the very predictable polarizing arguments that occur following these incidents.  Partisans will frequently post arguments and counterarguments followed by statistics and counter statistics.  In many cases the arguments are rhetorical at at some level fallacious.  The dynamic driving these arguments is never mentioned and that dynamic is anger.  Anger has been studied by cognitive scientists and it functions to squarely focus blame on a specific person whether that is accurate or not.  This is as important for the police officer on the scene as it is for the secondary clashes between protesters, the public and the police.  When police officers confront a suspect and start swearing angrily at him/her to comply with their demands - that may be part of their training, it may be something that happens spontaneously, but in either case any real anger on the part of the officer implies that the subject has done something wrong and that the officer's decision-making capacity may be affected by his/her emotional state.  Emotions are critical in human decisions, but not all emotions result in a focus on another person as a source of wrongdoing.  

4.  Human reaction time is a limiting factor - 

The human nervous system takes time to process information.  There is surprisingly little public data available on how much time there is to make a decision to shoot an armed suspect.  The only study I could find (6) involved a simulation where an untrained armed suspect was either holding a handgun to his own head because he was allegedly suicidal or holding a handgun at his side when confronted by a police officer.  In the case where the suspect decides to fire a shot at the officer instead - it took an average of 380 msec.  Highly trained officers shot in 390 msec.  That translated to inexperienced suspects shooting first or tying the officers in 60% of the scenarios.  An interesting article in the literature also suggests that shooting errors in high threat situations persist even after weeks of practicing these scenarios (7).  For comparison, this web site allows for a determination of reaction time in a scenario that is completely free from distractions and noise - like anxiety and trying to determine if what the suspect is holding is really a firearm or not.  It is obvious that these decisions to fire by both officers and armed suspects are not like they are portrayed in television programs and films.  In real life there are no prolonged standoffs with officers and suspects pointing firearms at one another while they talk.    


5.  Human beings have a long history of solving difficult problems through violence and aggression -

One of the major lessons of human history is that lives matter only up to a point and if nobody agrees at that point - people will die.  In human history there are very few exceptions to that concept.  The best analysis of the situation that I have seen comes from anthropology (8) and the detailed study of modern and ancient warfare.  Several authors have written about the attractiveness of war to some of the participants - most prominent Chris Hodges (9).  The powerful combination of war and winning a conflict by force and being reinforced by the secondary aspects of camaraderie, teamwork, meaningfulness, and the political illusions of what an armed conflict can accomplish are all powerful incentives to avoid peace and conflict resolution.  The last time there was as serious peace movement in the USA it was largely a reaction to a prolonged and unnecessary war in Vietnam.  Since then there have been three unnecessary wars and no corresponding peace movements.

The war metaphor doesn't stop at the level of nations fighting nations.  At the next level it is always local governments and police departments fighting drug dealers, gangs, terrorists and various criminals.  I don't think that the reinforcers that occur at a global level stop just because the conflict is at a local level.  Americans in general want to see the bad guys stopped in any way possible.  With that attitude there are invariably serious mistakes.    


6.  Widespread availability of firearms ups the ante -

I have written about firearm related issues in many places on this blog.  My primary focus have been to suggest that violence, especially firearm related deaths including suicide, homicide, and mass shootings can probably be stopped by public health measures.  Very few people agree on those points and there are various political reasons why they do not.  Stopping firearm related violence does not necessarily require addressing firearms availability, but make no mistake about it - firearms access rather than mental illness is the number one cause of these deaths.  The problem with high risk scenarios involving either firearms or the threat of firearms with the police is even more obvious.  Statistics are available for the number of people killed by the police in a number of countries and the numbers are skewed in the expected manner toward the US.  It is clear that widespread availability of firearms is dangerous for both the police and the people who are being policed.  A lot of that comes down to being able to assess the threat and react in less than a half second.  That is the time a police officer has in a high threat scenario.

The six dimensions I briefly described are critical but unmentioned in the current debate.  The current debate is framed in terms of race, immutable interracial relationships, and a lack of scientific consideration at several levels.  At the cultural level, the notion of race having some specific meaning needs to be put to rest forever.  There is no scientific basis for classifying people based on skin color or other so-called racial characteristics.  Racial diversity is nothing compared with genetic diversity and that needs to be the new standard.  The second scientific consideration is based on the unique conscious state of humans.  This important concept should form the basis for everyone being treated with respect and consideration.  That is not to say that will preclude criminal conduct or violent acts against bystanders, but it should be a standard for everyone else.  The expression of anger especially sustained anger has a particular biasing effect that is never mentioned.  We hear that anger is appropriate or justified, and therefore it should be expected.  Appropriate, justified and expected anger still affects human decision making in a predictable way.  The angry - no matter who they are need to realize that they may not be seeing things clearly due to the predictable and biasing effects of that emotion.  The technical aspects of human reaction time and the fact that decision making in high threat situations does not improve - even with training is a sobering fact that all police officers need to deal with.  Given the quoted statistics, in high threat situations when a subject is armed - the outcome of that confrontation will essentially be a coin toss.  The only logical approach to the situation is to design a new situation where it does not come down to reaction time and every officer knowing they have a 50:50 chance of being able to shoot first.  There is an innate human tendency for conflict resolution by aggression and choosing sides on how that plays out is not the best way to resolve the problem.  All that I have seen in social media and the press highlights a string of arguments designed to support one side or the other.

Considering the science behind this problem will lead to permanent, long term solutions.          



George Dawson, MD, DFAPA


References:

1: Murase D, Hachiya A, Fullenkamp R, Beck A, Moriwaki S, Hase T, Takema Y, Manga P. Variation in Hsp70-1A Expression Contributes to Skin Color Diversity. J Invest Dermatol. 2016 Apr 16. pii: S0022-202X(16)31047-8. doi: 10.1016/j.jid.2016.03.038. [Epub ahead of print] PubMed PMID: 27094592.

2: Yoshida-Amano Y, Hachiya A, Ohuchi A, Kobinger GP, Kitahara T, Takema Y,Fukuda M. Essential role of RAB27A in determining constitutive human skin color. PLoS One. 2012;7(7):e41160. doi: 10.1371/journal.pone.0041160. Epub 2012 Jul 23. PubMed PMID: 22844437; PubMed Central PMCID: PMC3402535.

3: Guo Z, Zhang Y, Zou L, et al. A Proteomic Analysis of Individual and Gender Variations in Normal Human Urine and Cerebrospinal Fluid Using iTRAQ Quantification. Pendyala G, ed. PLoS ONE. 2015;10(7):e0133270. doi:10.1371/journal.pone.0133270.

4:  Elena A. Ponomarenko, Ekaterina V. Poverennaya, Ekaterina V. Ilgisonis, et al., “The Size of the Human Proteome: The Width and Depth,” International Journal of Analytical Chemistry, vol. 2016, Article ID 7436849, 6 pages, 2016. doi:10.1155/2016/7436849.

5:  Skin specific proteome.  The Human Protein Atlas.  Accessed on 7/16/2016.

6:  Blair JP, Pollock J, Montague D, Nichols T, Curnutt J, Burns D.  Reasonableness and reaction time.  Police Quarterly Dec 2011; 14: 323-343 (especially pages 15-20).

7:  Nieuwenhuys A, Savelsbergh GJ, Oudejans RR. Persistence of threat-induced errors in police officers' shooting decisions. Appl Ergon. 2015 May;48:263-72. doi: 10.1016/j.apergo.2014.12.006. Epub 2015 Jan 16. PubMed PMID: 25683553.

8:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

9:  Chris Hodges.  War Is A Force That Gives Us Meaning. Public Affairs, New York, New York, 2002.

Attributions:

Attribution:  Graphic at the top is by Altaileopard SVG by Magasjukur2 [CC BY-SA 2.5 (http://creativecommons.org/licenses/by-sa/2.5)], via Wikimedia Commons at: https://upload.wikimedia.org/wikipedia/commons/4/41/Spreading_homo_sapiens.svg

Being Suicidal - The Conscious State

The assessment of potential for suicide is a large part of a psychiatrist's work.  Within the past decade these footnotes have popped up even in algorithms that are designed to guide decisions about psychopharmacology.  They have always been present in treatment guidelines for most major psychiatric disorders.  They are a major cause of anxiety for practitioners, because we all know that our predictive capacity is low, but more importantly we know that unlike Internists and Surgeons we have limited access to the resources necessary to address the problem.

Considering for a moment a typical outpatient crisis, for a person known in the practice with depression who is now clinically changed in an office assessment with suicidal thoughts, the options are very limited.  In the case of an assessment of extreme risk, inpatient treatment may be offered.  If the patient has any inpatient experience at all, he or she knows that inpatient units are generally miserable places where very little active care happens and where they are enclosed with a number of very ill patients.  They may also know that there are an arbitrary number of hoops that must be jumped through in order to be discharged and that as a result they may be in that environment much longer than they need to be.  They may also have had a typical experience of the inpatient psychiatrist not talking with their outpatient psychiatrist and making a number of abrupt medication changes that are neither necessary or indicated based on their brief familiarity with the case.  For those reasons and also because most people are averse to sitting in hospitals - people will balk at the suggestion of inpatient care.

The suggestion of inpatient care also assumes there is the availability of that option in the community.  Most hospitals in any given state do not offer inpatient psychiatric care.  That level of care has been discriminated against at a political and financial level for 30 years and as a result hospital services and inpatient psychiatric beds have contracted in an expected manner.  Patients are often transferred hundreds of miles within states to reach these beds.  A related issue is the availability of electroconvulsive therapy (ECT) for severe depressions.  In the case of high risk depression it may be the only effective option.  Many states have no availability of this option for patients who need it.

The suggestion of emergency department (ED) care is an even bigger dead end.  The vast majority of ED care is provided by mental health professionals who are not psychiatrists and who are making triage decisions that ED physicians can sign off on.  The wait is hours and if a high risk determination is made it might be days in the ED before any disposition can be made.  Patients are often discharged on the basis of whether their suicidal ideation is chronic or not and whether they are saying that they have a suicidal thought and an intent to harm themselves right at the time of the assessment.

All of the above factors generally place the burden of care back on the original treating psychiatrist, even when the risk is higher that he or she would want.  Most psychiatrists recognize that if they are treating very ill patients, there needs to be an element of acceptable risk in order to provide treatment and the hope of recovery.  Psychiatrists realize that resources are severely rationed, that their patient needs acute treatment, that the patient will only accept certain treatment, and that there is a societal expectation of medical paternalism if the patient in not able to remain safe.   The psychiatrist and the patient are frequently operating in this zone of acceptable risk that is perceived very differently by others.  Family members are the clearest case in point.  Like society in general, many family members have their biases when it comes to psychiatry.  Many have been instrumental in discouraging their family member from getting treatment.  In some cases they have interfered with treatment and suggested that the family member discontinue treatment or throw away any medications that they have been taking.  At the same time, family members generally favor a zero risk treatment environment.  They would prefer that the patient's suicidal thinking resolve completely so that there is no risk that they will attempt suicide.  They see suicidal thoughts as controllable and the product of a series of correctable decisions.  They don't understand why the thoughts just can't be turned off by the patient, their psychiatrist, or in some cases - the medication the patient is taking.  In extreme cases, they may threaten litigation if the patient suicides or makes a suicide attempt implying a volitional and controllable basis for suicidal thinking.

An understanding of human consciousness provides a way to analyze this situation and the misperceptions about suicidal thinking and behavior.  The predominant model of risk assessment for both suicidal ideation and aggressive potential is risk factor analysis.  It generally proceeds from an elaboration of the specific thoughts to past history of attempts, availability of lethal means, diagnostic risk factors, past history and analysis of attempts, and specific demographic risk factors associated with suicide attempts.  Many texts like the Harvard Medical School Guide To Suicide Assessment and Intervention have detailed approaches to the problem and further conceptualizations like proximate and distal risk factors.  In an earlier post, I discovered a checklist of risk factors that looked at the issue of Increased Reasons or Decreased Barriers to suicide called the Convergent Functional Information for Suicide Scale (CFI-S).   Many institutions these days prefer the Columbia Suicide Severity Rating Scale (C-SSRS).  All of these methods are essentially based on risk factor analysis.  Some are more elaborate than others.  There all estimate risk to one degree or another and in some cases factors that mitigate risk.  I won't debate the merits of these methods here.  All that I want to say about them is that after the risk has been estimated, the psychiatrist may still be working with a high risk patient who is unpredictable in both an inpatient and an outpatient setting.  Interventions can be initiated to reduce the risk, but there is no assurance that they will be effective fast enough to prevent a suicide attempt.  In many clinics where a standardized approach like this is used with an electronic health record and a cutoff score is used to determine risk, a psychiatrist may find the patient visits being flagged for months or longer based on these numbers.

Is there another model that might supplement or improve upon the risk factor analysis models?  For about 15 years now, I have been looking at a model that considers the basic question of what happens when a human conscious state shifts from one that would never contemplate suicide to one that does or in the extreme state proceeds rapidly to suicide.  The usual psychiatric model considers the development of an illness state like depression, bipolar disorder, borderline personality disorder, or alcoholism as a precursor state.  The cognitive changes, like depressogenic thinking seen in the precursor states are seen as the basis for suicidal thinking.  The intervention is generally directed at reversing the precursor state, acutely structuring the environment as necessary for safety, and direct verbal interventions to address the suicidal thinking.

It is possible to explore with people the transition of their conscious state from a person without suicidal thinking to a person who develops suicidal thinking and consider a broad array of associated factors.  Just being able to recognize that this transition has occurred is an important part of any evaluation and intervention.  Some people are so severely depressed that it seems like the suicidal thinking has been there forever.  They can barely recognize a time when they felt better or were not suicidal.  In many cases they are preoccupied with existential factors such as meaningfulness of their life, personal freedom, and of course life and death - factors that they were only peripherally focused on during their daily life.  In some cases they are important psychodynamic factors such as the death of a family member or friend from suicide.  I speculate that many psychiatrists have heard of or been involved in situations like this.  These events are also described in some of the psychoanalytic literature but not necessarily the risk factor analysis literature.  John Bowlby described some examples in his book Loss:

"From many examples from Cain and Fast we select two: one eighteen year old girl who drowned herself alone at night in much the same fashion as had her mother many years earlier;  the other a thirty-two-year old man who drove his car over the same cliff that his father had driven over twenty-one years earlier.  Some of these individuals, it seems, had lived for many years with a deep belief, amounting to a conviction, that they will one day die by suicide.  Some quietly resign themselves to their fate.  Others seek help." (p. 389)

Of course the complexity of this situation is much greater than Bowlby can capture in his brief explanation.  Just at the psychodynamic level there is the issue of identification with the parent and their suicidal actions.  Do they believe that they have a deeper understanding of the parent's action and consider them to be logical?  Have they incorporated this into their worldview and consider it to be their fate?  At the neurobiological end of the spectrum, is it a case of straight genetic vulnerability to suicide or were there epigenetic factors related to a severe disruption of the home environment that the suicide of a parent can cause?  Do they remember an event or series of events during childhood when the affected parent seemed to transmit a tendency to anxiety or depression directly to them?  All of these are relevant considerations when examining what is going one at the conscious level in an individual who has become suicidal.

Elementary risk factor analysis also benefits from the broader perspective of considering other conscious factors.  It allows for an exploration of additional degrees of freedom.  For example, the issue of firearms possession and the elaboration of risk often depends on possession and risky behavior with that gun.  But what constitutes risky behavior and what needs to be asked?  Have you had the gun in your hand when you were thinking about suicide?  Was the gun loaded?  Did you actually point the loaded gun at yourself? What were you thinking about at that time?  The questions and responses cannot be anticipated in a linear risk factor analysis or algorithm.

A nonlinear consciousness approach can also incorporate an informed consent approach to provide active feedback to the patient on the current risk and the limitations of treatment.   This often opens a window into the dynamics of how the patient conceptualizes risk and their ability to work with the psychiatrist in minimizing it.  A more linear assessment often takes on the structure of the psychiatrist trying to guess whether or not the patient is going to kill themselves and leaves the patient as a relatively passive participant.  A consciousness based approach recognizes that the patient has entered at least partially into a conscious state that is foreign to them, less predictable, and represents some degree of risk to them.  They need to hear very clearly that they and the psychiatrist need to work together to restore their baseline conscious state and reduce risk in the meantime.  The process encourages them to not leave the interview leaving something that is potentially important - unsaid.  


George Dawson, MD, DFAPA      


References:

1:  John Bowlby.  Attachment and Loss - Volume III: Loss - Sadness and Depression.  Basic Books. New York.  Copyright by the Tavistock Institute of Human Relations.  1980, p 389.

2:  Douglas G. Jacobs (ed).  The Harvard Medical School Guide to Suicide Assessment and Intervention.  Jossey-Bass Publishers; San Francisco.  Copyright by the President and Fellows of Harvard College. 1999.

AMA versus CDC Patient Education On Opioids

CDC Poster On Opioids For Chronic Pain

The easiest place to start the critique of the initiative to stop opioid overuse in this country is the patient information products for both the CDC and the AMA.  The CDC poster on this subject is shown above and is public domain.  There is more detailed patient information from the CDC at Guideline Information for Patients.  The AMA page on the same subject is at this link.  AMA web site materials are copyrighted and I did not think it was worth the effort to attempt to get that permission.   It is available free online.  How do these guidelines compare with one another and are they likely to be useful to patients?

On inspection they both seem to warn patients that there are potential health problems including addiction and death from taking opioids.  The CDC graphic advises  the patient to actively collaborate with their physician around any potential opioid prescription.  It suggests that the physician in this case will present a number of non-opioid options and a receptive patient will decide how to use them.  Apart from the 1 in 4 statistic it is almost a fairy tale approach to the problem of addiction.  Keep in mind that direct-to-consumer advertising these days frequently end with a staccato-like recitation of side effects "including death" and pharmaceutical companies are not deterred from adding that qualifier.  That suggests to me that these dire warnings are really not a deterrent to people looking for what appears to be a "cure" - at least in some cases.  The more detailed approach from the CDC guideline seems more reasonable, but both do not take into account unconscious factors on the part of both the patient and physician.  The AMA version is seriously watered down, but both lack realistic information about addiction works.

The real issue with opioids is not that 1 in 4 people end up addicted to them.  That 1 in 4 number is after all an intent-to-treat number.  There are probably at least that many people who don't tolerate opioids at all, even on an acute basis.  Taking those people out, bumps up the number of potentially addicted to 1 in 3.  The real problem here is how the addiction occurs and the implications for primary and secondary prevention.  I can tell anyone who cares to listen that the secondary prevention aspect of opioid addiction is a long and arduous process, with no guarantee of a cure at the end of it.  Imagine that you have just started a family and started out in the workplace when the addiction occurs.  Contrary to all of the hype about medication assisted treatment with buprenorphine or naltrexone, this kind of treatment does not work well for everyone.  Addiction to an opioid may require that you participate in some form of education based treatment for up to three months or take long absences from your work and family to live in sober structured environments.  The structured environments are costly and the quality of these settings cannot be assured.  What the AMA and CDC references do not show is that if you have an addiction - you might be in a very expensive treatment program and still not be interested in stopping the opiate.  You may not feel ready to quit after one or more of these treatments.  The real danger of an addiction is that it alters your conscious state to continue the addiction, even in an environment where you are supposed to be learning how to get sober and maintain sobriety.

The AMA and CDC resources are short on this aspect of opioid addiction.  These pages should tell people a couple of other things aimed at preventing addiction rather than recognizing addiction and trying to treat it after it happens.  Here are the bullet points:

1.  Practically all people at-risk know it after they have taken the first few doses of medication.  The opioid makes them feel euphoric or ecstatic.  Contrary to the popular image of heroin addicts falling asleep, the at-risk population is energized and may feel like they have become more productive than they have ever been.  That response establishes a dangerous link between productivity and opioid use.  The at-risk population also has an enhanced perception of themselves.  They may suddenly perceive themselves as having become the person they always wanted to be.  That can include the perception of a number of positive personal qualities including confidence, intelligence, and creativity.  All of these reinforcing qualities disappear once tolerance to the drug occurs.

2.  People at-risk may notice that long standing anxiety, insomnia or depression is suddenly gone.  As an example, there are many people with social anxiety in childhood and early adult life.  Social anxiety is a condition where the person is overly concerned about being judged when they are out in public.  The associated concerns may be that they will be embarrassed or humiliated.  There is often an associated performance anxiety in certain situations.  This part of the at-risk population may notice that all of those concerns are completely gone when they start taking opioids.  All of these reinforcing qualities disappear once tolerance to the drug occurs and anxiety, depression, and insomnia recur (often amplified) during withdrawal and detoxification.

3.   The concept that opioids are medications that can reinforce their own use whether or not they actually work for pain is a difficult one to grasp.  In other words, the at-risk population may want to keep taking opioids even in cases where they do absolutely nothing to alleviate pain.  In this case it is not a question of tolerance to the analgesic effects of opioids.  The opioids did not work in the first place.  Opioids are only moderately effective for chronic pain in the first place and those effects are on par with antidepressants and anticonvulsants like gabapentin.

4.  Opioids can change your baseline personality and cause you to do things that you ordinarily would never have done.   Once an addiction has been established decision-making is in the service of maintaining the addiction.  That can include any number of legal and moral decisions that that involve the people who are closest to the person with the addiction.  The repercussions of these acts are not fully appreciated until the person is detoxified and is sober from the opioid.

5.  Opioids are legendary in the American culture.  The American culture strongly reinforces the place of intoxicants in the lives of even average Americans.  Intoxicants are in the literature, the media, and even day-to-day conversations.  People tend to hoard their unused opioids, exchange them with their friends and family, and talk about the effect of these drugs with their neighbors.  To illustrate, an acquaintance of mine recently had arthroscopic surgery of the knee.  He was in a large post-op recovery area with 8 other people.  Nursing staff were approaching people and asking them what they wanted for pain relief.  The choices were hydromorphone (Dilaudid) - a potent opioid, oxycodone-acetaminophen (Percocet) - a less potent opioid, and ibuprofen - a non-opioid.  The vote in the recovery room was 8-0 in favor of hydromorphone.  That vote parallels the disproportionate increase in emergency department visits for complications from hydromorphone relative to all other opioids.   Of course there are many variables at play, but I am suggesting at least one of them is the reputation that hydromorphone has in American culture as a potent euphoria producing opioid.

6.  Part of the American legend is that opioids are the magic bullet for pain.  The corollary is that if the doctor would just give me enough of this drug - my pain would be gone.  The important distinction here is chronic pain.  Across large populations there is no medication that will get rid of chronic pain.  For many people, no treatment at all, treatment with a non-opioid medication, or treatment with a different modality like cognitive-behavioral therapy works much better.

There are all important points for people to know before they start taking opioids.  I think that a clinical trial is indicated to see if people with this information do better than those without it.  If I was designing that trial, I would have an intervention that advised people to stop taking the medication and call the physician immediately if they experienced any change in their conscious state like the ones I described in points 1, 2 or 3 above.

Stopping opioid addiction well before it is established is the preferred intervention.  There is certainly effective treatment once an addiction has been established but it can be long, expensive, difficult, and the outcome is never guaranteed.  Anyone who starts to take an opioid needs that level of transparency.



George Dawson, MD, DLFAPA         

Attribution:  The infographic at the top of this post is from the CDC web site and is reused per their general information about being in the public domain.  The poster is available at:
 http://www.cdc.gov/drugoverdose/pdf/guidelines_patients_poster-a.pdf

Euthanasia And Other Ethical Arguments Applied To Psychiatric Patients

An article entitled Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011-2014 caught my eye in this month's JAMA Psychiatry (1).  It wasn't that long ago that I recall being in the midst of a rather intense argument in a staff meeting about euthanasia in the broadest of terms.  Like many heated political arguments (I consider a lot of what goes on under the heading of ethics to be little more than politics) this one degenerated to personal terms.  The pro-euthanasia proponent ended the argument with: "Well if I am dying of terminal cancer and I want to end it, there is no one who is going to tell me that I can't do it.  Not you or anyone else."  In the dead silence that followed nobody brought up the obvious point that is the state of affairs currently.  Euthanasia proponents have always made that argument when in fact what they really want is to recruit physicians to provide them with euthanasia.  That is hardly the same thing as actively stopping them.  I would make the secondary argument that nobody really needs to be actively recruited these days.  I can't remember the last legal battle about whether a physician providing hospice care ordered too many opioids and benzodiazepines for a suffering terminally ill patient.  If I had to guess, the last time I saw that question raised in a court in the Midwest was about 20 years ago.

The concept of euthanasia in patients with psychiatric disorders is an even more complicated process.  Psychiatric disorders per se are not terminal illnesses, there is no protracted phase of increasing suffering and futile live saving measures with a fairly predictable death.  Death primarily due to psychiatric disorders occurs as a result of suicide, risk taking, comorbid medical illnesses, and severe disruptions in self care and homeostasis due to acute disorders like catatonia.  These are all relatively acute processes.  That does not mean that there are no people with chronic mood disorders, personality disorders, and psychoses.  Is the suffering in these situations acute and severe enough that euthanasia should be considered and if so, do any standards apply?

The authors of the Dutch study set out to study the characteristics of psychiatric patients receiving euthanasia or assisted suicide (EAS) in Belgium and the Netherlands.  The case studies of 66 cases were reviewed in the database of the Dutch regional euthanasia review committees.  There were 46 women and 20 men.  A little over half (52%) had made previous suicide attempts.  80% had been hospitalized in psychiatric units.  Most of the patients were aged 50-70 but 1/3 were older than 70.  Most (36) had depression and 8 of those patients had psychotic features.  The patients were described as chronically symptomatic and 26 patients had electroconvulsive therapy (ECT).  Two had deep brain stimulation - one for obsessive compulsive disorder and one for depression.  There was significant medical comorbidity.  The authors comment that there was very little social history to the point that they could not reconstruct the persons current living situation from what was abstracted.  Some of the reports contained fairly subjective data - as an example: "The patient was an utterly lonely man whose life had been a failure."  There was extensive treatment but also treatment refusal in 56%.

Twenty-one patients had been refused EAS at some point and in 3 of these cases the original physician changed their mind and performed EAS.  In the other 18 patients, the physician performing the EAS was new to the patient.  In 14 of those cases that physician was affiliated with a mobile euthanasia practice called the End-of-Life Clinic.  In 27 cases a psychiatrist did EAS and the rest were general practitioners.  Physicians disagreed in about 24% of the cases and EAS proceeded despite the disagreement.  In 8 cases the psychiatric consultant did not think that due care criteria specifying "no reasonable alternative" had been met.  The Euthanasia Review Committee (ERC) found that due care criteria were met in all psychiatric cases referred except for one.  In another case the ERC was described as being critical but in the end agreed with the euthanasia decision. It was a case of a man who broke his leg in a suicide attempt and then refused all treatment and requested EAS.

The authors come to several conclusions.  The first involves the issue that in this study the ratio of women to men was 2.3 to 1 and that is the opposite of what is expected with suicide.  They suggest that the availability of EAS may make the desire to die "more effective" for women.  Although the overall psychiatric sample was younger than the non-psychiatric EAS cases, they argue that the fact that a significant portion have significant comorbidities and this may indicate that Dutch physicians tend to self regulate EAS to a specific patient profile.  They point out that more judgment is required in psychiatric cases than in the cases involving terminal physical illness - 83% of which involved a malignancy.  They note that decision-making capacity can be affected by neuropsychiatric illness and that medical futility is difficult to determine especially when care is refused.  There were no official EAS psychiatric consultants involved in 41% of the cases.  In 11% of cases there was no psychiatric involvement at all.  Their overarching observation was that EAS for psychiatric illnesses involved making decisions about complex disorders and considerable judgment needed to be exercised.  They suggested that the decision about EAS required "considerable physician judgment" and that regional committees overseeing euthanasia deferred to the opinion of the treating physician when consultants disagreed.  

I have never seen it discussed but conflict of interest issues are prominent in any decisions about the autonomy of people who are designated psychiatric patients.  At the first level, there is the wording of the policy or statute.  There are criteria that are thought to be very objective that are used to decide if a person should be subject to civil commitment, guardianship, conservatorship, or any of the laws involving competency to proceed to trial, cooperate with one's defense attorney, or a mental illness or defect defense.  In all cases, the wording of each state's statute would seem to determine an obvious standard.  Those standards are routinely compromised in practice by any number of political considerations.  In the case of not guilty by reason of mental illness, the compromise occurs any time there are high profile cases that involve heinous crimes.  No matter how severe the mental illness, there will be a raft of experts on either side and the verdict will almost always be guilty.  At the other end of the spectrum is civil commitment.  Observing any commitment court over time will generally show the oscillation between libertarian approaches to more strict standards where need for psychiatric treatment is the more apparent standard.  The libertarian approach often uses a standard of "imminent dangerousness" as an excuse to dismiss the patient irrespective of what the statute may say.  It also seems to coincide with the available resources of the responsible county.   That is why in Minnesota the land of 10,000 lakes and 87 counties we say: "On any given day there are 87 interpretations of the civil commitment law."  Despite that range of interpretations, it would be highly unlikely that a patient who broke his leg in a suicide attempt (a case presented in this paper) would not be a candidate for court ordered treatment rather than euthanasia.  On the other hand, I do not know anything about civil commitment and forced treatment in the Netherlands.

There is no reason I can think of that a euthanasia standard can be interpreted any more logically. This Dutch study points to that.  It also points to another issue that is never really discussed when it comes to psychiatric diagnosis or the ethics and laws that apply to them.  The conscious state of the individual is never recognized.  Brain function is parsed very crudely into separate domains of symptoms, cognitions, and decisions.  The examiner or legal representative usually has some protocol by which they declare the person competent or not and the legal or ethical consequences proceed from that.  There may be a discussion of personality that is also based on this parsing process.  Very occasionally there is a discussion of the person's baseline, but that is about it.  That is a serious problem for any student of human consciousness.  Let me explain why.  I think that it is a universal human experience to experience a transient (days to months) change in your conscious state that might result in you not wanting to live.  The insult could be a physical or mental illness.  It would seem to me that at a minimum there can be multiple conscious states operating here that look like a request for assisted suicide or euthanasia.  The limits would be bounded by a completely rational decision based on medical futility and suffering on one side and an irrational decision based on the altered conscious state on the other.  The only way for any examiner to make that kind of determination is to know the patient very well over time to recognize at the very least that they are not themselves.  Doing an examination for the express purpose of determining if a person meets criteria for euthanasia in a short period of time is by contrast a very crude process.        

There is too much variability in the patient's conscious state and how that impacts treatment and ultimately recovery to consider psychiatric disorders as a basis for a decision about euthanasia and assisted suicide.


George Dawson, MD, DFAPA


References:

1:  Kim SH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry.2016;73(4):362-368. doi:10.1001/jamapsychiatry.2015.2887.

2:  Appelbaum PS. Physician-Assisted Death for Patients With Mental Disorders—Reasons for Concern. JAMA Psychiatry. 2016;73(4):325-326. doi:10.1001/jamapsychiatry.2015.2890.


Supplementary 1:  I intentionally wrote the above post without reading the accompanying commentary by Paul S. Appelbaum, MD.  Dr. Appelbaum is an expert in forensic psychiatry and has written extensively on ethical issues in psychiatry.  Dr. Appelbaum's essay provides some additional facts, but his areas of  concern do not touch on my focus on the conscious state of the individual.

Psychiatry With And Without A Conscious State

One of the great attractions of psychiatry for me - is the skill set that you have to develop to understand a person's real problems.  By real problems - I mean the problem or problems that brought them in to see you in the first place.  I am not talking about the problem listed on a referral sheet, or spoken in a telephone call, or even described to you by another physician or family member.  Advocacy groups and some psychiatrists tend to be self congratulatory on the amount of information about psychiatric disorders that is out there.  There is an excessive amount of confidence in lists of symptoms being the same thing as a diagnosis.  Any psychiatrist will tell you that the number of people who walk into the office and proclaim they have depression, bipolar disorder, or attention deficit-hyperactivity disorder is at an all time high.  They typically come to that conclusion by some combination of listening to TV ads or friends and family members.  In some cases they are directed to Internet sites where they can take a brief quiz to determine the diagnosis.  In almost all cases they are wrong.  Interviewing people to come up with both diagnoses and diagnostic formulations - is a considerable skill set that cannot be replicated by handing that person a symptom checklist or interviewing them like a talking checklist.

The problem in cases of self-diagnosis is that most people have a limited awareness of what diagnosable mental illness is.  They get their ideas from a static checklist or advice from a person who has not seen hundreds of people with the condition.  That process is often a checklist by proxy as in "I read this checklist in a magazine and you seem to have the symptoms.  You must have bipolar disorder."  In many ways that is like reading a manual about how to repair a complicated problem with your car.  Some untrained people may be able to pull that off, but the vast majority will fail.  The failure will occur at the level of pattern matching with the severe problems as well as the appropriate assessment of biases along the way.  That is not to say that experts are free of bias, but they are less susceptible to the common biases that occur along the way largely due to an accumulation of patterns that they have encountered over the course of their careers.

To develop the best possible understanding of psychiatric diagnosis and how it works might require consideration of some overlapping models of the conscious state in humans.  Consciousness is a complicated process concept, but it basically refers to the collection of mental processes that result in a stable personality and behavior over time.  An example of elements of consciousness is included in the representation below.  It contains descriptions that are found in the writings of David Chalmers and other authors on consciousness.  Chalmers breaks consciousness down into the easy problems or readily observable properties of consciousness and the hard problem.  The hard problem involves figuring out how the neurobiological substrate can generate conscious states and how those states are all unique.  There are a lot of theories about how that might happen, but none of them have been proven.

 The psychiatric assessment is trying to determine the parameters listed in the box at the right.  Some of the properties of consciousness are listed in the box at the left.  There is not a clear correlation between these elements, but what needs to be elicited in the interview will be determined to a large extent by the conscious state of the individual.  As an example, if I am interested in asking about sleep, I routinely take a sleep history that goes back to childhood.  I ask about insomnia, nightmares, night terrors, sleepwalking, and all of those states over the decades that gets me to the current age of my patient.  As an adult I ask about whether or not they have had polysomnography, whether they snore or have restless legs at night.  I ask them about the medical and non-medical treatment they have received for insomnia and if there were any complications.  I have to observe whether or not the person can reasonably respond to those questions or not and a lot of that depends on their conscious state.

In order to make a psychiatric diagnosis of a basic mood disorder, the primary criteria is that there has been a phasic mood disturbance for a certain duration.  In the case of depression the primary DSM-5 criteria is:  "Depressed mood most of the day, nearly every day, as indicated by subjective report or observation made by others" or  "Markedly diminished interest or pleasure in all, or almost all activities, most of the day, nearly every day."  That basic distinction taxes the conscious state of many people who are already diagnosed with mania or depression.  Wait a minute - "most of the day, nearly every day" - don't I have good days and bad days."  The number of people who make that observation when they are asked the specific question is significant.  When I hear that response, I remember the pre-DSM Feighner criteria for intermittent depression.  In those days it was acceptable to have good days and bad days.  Today in a complicated process occurring in the person's conscious state they need to decide if this phasic mood disturbance really applies or if there are other reasons for endorsing a positive response.  If they are handed a standard checklist for depression like the PHQ-9, the conscious thought process is much different than a psychiatrist asking them about an all encompassing mood disorder rather than "good days or bad days."

The process might even have to take a step farther back when the patient states:  "Wait a minute doc, I am not sure that I know what anxiety or depression really is.  Aren't they the same thing?  Doesn't one turn into the other? Can you explain it to me?"  This is a much different interview than a person coming in and declaring a problem.  This person is aware that some kind of problem exists.  They may have learned that from feedback from a spouse or an employer.  They don't know what to call it.  They might be aware of physical distress, but be unable to make the connection to emotional perturbations.  Is their concept of a disorder the same as the person who comes in declaring themselves to have the problem.  Probably not, but it is apparent to me from interviewing tens of  thousands of people over the past thirty years that everyone has a slightly different idea of the problem.  It is obvious that it is also a much different situation when the patient is handed a checklist of symptoms of depression and makes what is essentially a series of forced decisions about if they have depression and how severe it is.   Consciousness researchers have used the thought experiment about the color red for years.  That is, my experience of the color red, is probably different from your experience of the color red.  In other words, my conscious state processes the color red in a different and unique way compared with your conscious state.  Why would that not be true with regard to the various types of depression and anxiety?

 That brings me to another conceptualization that is often used to look at diagnoses like the dementias, schizophrenia, and attention deficit-hyperactivity disorder.  The abilities to plan, act, and perform these acts successfully is often referred to as executive function.  Although these functions tend to be arbitrary and arrived at by consensus, they have always been important in psychiatric diagnoses.   Major mood disorders, schizophrenia, and neurocognitive disorders may all have varying degrees of impairment in executive function.  Testing specific functions and trying to correlate them with behavior at the clinical level is frequently disappointing except in cases of significant brain damage.  By inspection, it is apparent that there is an overlap between executive functions and consciousness - but not a complete mapping by any means.  DSM-5 has a fairly extensive table on six Neurocognitive Domains (pages 593-595) that describes executive function as one of these domains.  Executive function is defined as planning, decision-making, working memory, inhibition, mental flexibility, and responding to feedback.  Clear examples of what can be observed in each case are given.  Neurocognitive disorders are clear problems in consciousness.

The common psychiatric approach to diagnosis and treatment is what I would call a biomedical approach.  It was elaborated on by George Engel in his famous paper on the biopsychosocial approach to medicine, but it was practiced extensively before that paper was written.  A lot of the social and familial aspects of this interview were undoubtedly influenced more by epidemiology and genetics rather than consciousness factors.  It has been known for some time that you make be more likely to have a heritable illness if it runs in your family or it occurs in members of your occupation.  But what does a psychiatrist also need to know about how anxiety develops.  Can it be transmitted directly from a parent who is a "worry wart" to a child?  Does the child recognize it at the time?  Do children remember when their father was enraged or their parents were fighting and they were wide awake listening to it all night long?  Do people remember what it was like to "walk on eggshells" due to all of this adversity occurring during their childhood?  Do all of these incidents affect elements of their conscious state that keep them stuck in what are defined as psychiatric disorders?  Without a doubt.

 Conscious states are important in both the diagnosis and treatment of psychiatric disorders, but for the purpose of this post I am ending on diagnostic considerations as noted in the first slide of this series.  I will briefly comment on the importance of each dimension.


Interview Context:  Psychiatrists are called on to provide services in a wide variety of environments.  The appropriateness of the environment for both assessment and treatment needs to be assured.  It is common for a third party to want to restrict access to the time of psychiatrists by rationing their time with the patient or total time allowed to see each patients.  Times vary greatly from system to system.  In some cases, a the time allocated for a new evaluation is 30 minutes and in others it can be up to 90 minutes.  I have completed complete interviews at both ends of the spectrum, but the limiting factor can never be some preconceived notion by an administrator.  The patient's conscious state is the limiting factor.  That includes how they respond to the psychiatrist and the introductory process of the interview.  It also depends on a quiet confidential environment and whether there are any observers in the room.  I have had many colleagues tell me that their interaction with patients is definitely affected both other people in the room.  This is a factor that can affect both the conscious state of the psychiatrist and the person being interviewed.

Empathy:  All psychiatric trainees learn a lot about empathy in early interviewing courses.  The necessary prelude to empathy is therapeutic neutrality.  That is a confusing term to nonpsychiatrists, but it essentially means not bringing in any extraneous interpersonal factors or emotions into the interview of a specific patient.  That ability is gained by self-analysis, experience, and in some cases personal psychoanalysis.  From the patient perspective, emotional reactions often surface as part of longstanding patterns of behavior.  They are often proximate to the problem at hand and very relevant in the initial interview situation.    

Empathy is taught as essentially a cognitive appreciation of the patient's emotional state.  The single best definition of empathy is from Sims in his book on descriptive psychopathology.   “In descriptive psychopathology the concept of empathy is a clinical instrument that needs to be used with skill to measure the other person’s internal subjective state using the observer’s own capacity for emotional and cognitive experience as a yardstick. Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own.”  Sims captures the dynamic basis of the interview in this definition.  An empathic interview should result in a patient feeling very understood by the end.

Intellectual Capacity:  The intellectual capacity of the patient may vary considerably based on the psychiatric disorder they are experiencing.  By intellectual capacity, I am not referring to IQ scores.  I am referring to the ability of both the patient and the psychiatrist to recall and process information and consider a maximum number of explanations for what the patient is going through.

Emotional Capacity:  In the dyadic interview, the emotional capacity of both the psychiatrist and patient are important.  Can the patient describe the extent of any emotional disruption and the time course of that process.  Are they psychologically minded or can they appreciate social or psychological etiologies for these symptoms or do they view the problems as being treated only with a medication.  Psychiatrists are to a large degree self-selected on the basis of their interest in emotional problems. Many psychiatrists have had first hand experience in families where members have had a mental illness or addiction.  They had experience with all of the difficulties of getting that family member adequate treatment.  They recognize that these problems are very real and are generally highly motivated to provide treatment and advocacy.  As previously noted in the discussion of empathy, the ability to experience the emotional states of patients and describe them is necessary.  Sampling one's emotional state during the interview can also provide insights about the interview process, diagnosis, and overall meaning of the information being discussed.  As the average age of psychiatrists has increased, they have also seen thousands of patients with different kinds of emotional problems and successfully treated them.    

Information Content:  I find it surprising that the information content of diagnostic interviews is never estimated and the importance is never really taught.  There may be a correlation with the length of the interview, but not necessarily.  I can interview a person who gives brief high information content responses and do a reasonably good assessment in 30 to 45 minutes.  I can talk with a person who digresses and gives a lot of irrelevant details and still not have what I need at the end of 90 minutes or an hour.  The person who can assist me in doing the brief interview is not as common in my experience and I would say they represent 5% or 10% of the people I have seen.  There are also the Augenblick diagnoses or ones that can be made in the blink of an eye.  If I see a person with catatonia, delirium, or a stroke - I may not have to have them say anything to me.  Those rapid diagnoses will precipitate a thought process about what else needs to be ruled out and what tests need to be done immediately to confirm the diagnosis.  The information content in an interview is bidirectional and probably encompases severe channels including speech and paralinguistic communication.  The paralinguistic channel also contains information about the affiliative behavior of the participants.

Therapeutic Alliance:  An optimal diagnostic and treatment relationship flows from therapeutic alliance between psychiatrist and patient.  In other words - both are working together on a problem or set of problems that is bothering the patient.  It proceeds lie all patients interactions in medicine on an informed consent model.  Acute care psychiatry often involves the assessment and treatment of patients who are being detained on an involuntary basis because of safety concerns and in that situation the psychiatrist can be perceived as an agent of the state.  In that case and in many cases of long term treatment, it is often a good idea to review this principle with people in treatment to reorient them to the process.  Even a person who is being briefly seen for medication can have a problem in treatment if they perceive a psychiatrist a being poised over a prescription pad, ready to address their briefly stated problems with a new prescription.

Structure:  The psychiatrist has a responsibility to structure the interview so that the time is ultimately used to get results for the patient.  That means a singular focus on the patient, how the patient is proceeding in the interview, and how they are presenting the information.  That can mean giving additional information about the interview to the patient, providing necessary definitions, and doing whatever can be done to enhance the information content of the interview.  The introduction to the patient is critical because to this day there is still confusion over the definition of psychiatry.  I generally tell everyone my name, my years of experience, and present them with my business card.  After that I clear up any questions about psychiatry.  Some people ask about where I trained and I provide them with that information.  Some ask for clarification about the interview as we proceed.  A common question is: "Do you want the long version or the shirt version?"  Some early questions are also red flags and may be an indication of strong biases by the person being interviewed that may even preclude the interview itself.  Some of those decisions may also depend on the interview setting.  An example might be religion as a selection factor.  If a person tells me that they can only talk to a Christian using their specific definition and they want to ask me questions to determine my status, it might be easy to suggest that they see someone else in an outpatient setting, but a lot more difficult if you are the only available psychiatrist on an inpatient unit.

Technical Skill:  Like most professions, there is some variation in the interview and interpersonal skills of psychiatrists.  A psychiatric interview requires technical skills that psychiatrists have been focused on since early in their training.  Those skills are the focus of courses, seminars, books, papers and direct observation by training supervisors.  Since the oral board examinations have stopped, psychiatric residents now do the equivalent of oral board examinations on interview techniques during their training.  During an interview, a psychiatrist is listening for patterns and inconsistencies.  A psychiatric interview is not an interrogation.  In an interrogation, the interviewer generally has a bias and asks very leading questions to confirm that bias.  That style is evident in any number of police and crime television shows and films that are easily accessed these days.  In a psychiatric interview, the psychiatrist is developing hypotheses about diagnoses and formulations and inconsistencies with those hypotheses.  The interview itself can be very nonlinear and the psychiatric directs the interview from one major cluster of information to another.  A parallel process during the interview is recognizing the person's mental state and its potential origins.  Empathy as noted above is a critical aspect of that process.

Psychiatry is currently being practiced with an implicit rather than explicit focus on consciousness.  Making consciousness more explicit adds a lot to assessment and treatment.  The idea that every new patient being seen is truly a unique individual based on their conscious state is a primary organizing factor.  Their experience of mental distress is unique and can only be categorized with the broadest categories.  That emphasis creates a high bar for anyone who wants to be a good psychiatrist.  That psychiatrist by definition will critique each interview while they are documenting it and consider what was missed.  That psychiatrist will also critique any practice setting that requires them to interview patients according to electronic health record forms, diagnose people based on rating scales, or respond to patients in a stereotypical manner.  The recent emphasis on collaborative care is also a dead end in terms of consciousness.  The idea that a psychiatrist looking at rating scales and "managing populations" without ever talking to any of those patients is absurd from the standpoint of conscious states and diagnostic precision.

Human consciousness doesn't work that way and psychiatrists can't either.




George Dawson, MD, DLFAPA

Cycling Tips From A Psychiatrist

I have been a serious cyclist for longer than I have been a psychiatrist.  At midnight on Labor Day in 1972, two friends and I took off on a trip that we hoped to accomplish the same day.  I was riding a CCM 10-speed bike built around Reynolds chromoly tubing.  We were traveling to a town 164 miles away.  My first friend dropped out at 57 miles.  The second made it all the way but for the last third of the trip he was falling asleep on his bike.  That trip and several others taught me valuable lessons about cycling.  The picture at the top of this post is me stepping off the bike after my initial test cruise yesterday.  When I was slightly younger, I would have been out biking as soon as the snow melted.  Less than 5 years ago I was out biking down the Gateway Trail on a mountain bike and I hit a patch of ice and went down hard.

As I was dusting myself off, I recalled a story from a gastroenterology colleague of mine who is about 10 years older than me.  He would always ride in the Minnesota Ironman,  a spring ride that is designed to be a century (100 mile) ride but also can be broken up to shorter rides.  It is scheduled this year for April 26th, with options to ride 14, 27, 29, 60, and 100 miles.  The problem in Minnesota at this time of the year is the weather.  My GI colleague told me he was sitting there waiting for the ride to start.  It started to rain and sleet.  By starting time, he was soaked, cold and his shoes were full of ice cold water.  He got off the bike, walked over to the van that would be at the finish line with T-shirts, picked up his T-shirt, and went home.  I guess the lesson there is that at some point, you realize that you can enjoy cycling and not be miserable doing it.  It is a lot easier to ignore misery when you are younger.

When you are younger, your physiology is also a lot better.  I was doing pretty well until about 7 years ago when I had an episode of atrial fibrillation.  By pretty well, I mean essentially unlimited exercise potential.  I could go as hard as I wanted for as long as I wanted up until that point and even after that point for a while.  But eventually I realized that even exercise induced tachycardia predisposes a person to atrial fibrillation.  I had to tone my very high heart rates down into a more conservative range in order to prevent episodes of atrial fibrillation and the conditions that predispose to atrial fibrillation.  Now when I am out in the country, I am always watching a heart rate monitor instead of my speed.  That is somewhat depressing and it has an impact on self image when you have to go from unlimited exercise capacity to somewhere on the deterioration spectrum.  My goals have varied over the past 30 years from biking 200-250 miles per week to doing more speedwork for racing.  My fastest race time occurred when I would do 2 - 50 mile rides on the weekend and 4-18 miles rides during the week.  For half of the 18 milers I would try to ride as fast as I could.  These days my goals are a lot more conservative and these are my modest goals for 2015.

That may be a little optimistic but for comparison I watched Fabian Cancellara lead the peleton at what appeared to be a leisurely pace into a small French town a few years ago.  They were doing 30 mph on the flat and his heart rate was 130 bpm.

I thought that I would share a few observations here about some other things I have learned over the years about cycling that might be useful.

1.  Use good gear and keep it in good working order:

The kind of bike you ride is highly subjective.  When I first started cycling, high end bikes could only be assembled from components.  I used to ride Vitus frames that were aluminum tubes that were glued together.  The mechanical components were made by Campagnolo, Shimano, and SunTour in various prices ranges.  My all time favorite components were SunTour Superbe Pro.  They seemed so light and effortless.  I just liked the way the gears changed.  It seemed like there was just a lot less rolling resistance.  But SunTour just went out of business one day.  I currently ride a Trek bike with a carbon fiber frame after riding aluminum frames for over 20 years.  Bikes today are so much better in just about every way than they used to.  If you bike a lot, it pays to ride the best bike that you can afford and go to a shop where people can explain it to you and fit you to the bike.  Don't ride a bike that gives you consistent pain in any part of your body.  You should always feel stretched out and ready to go.  Don't hesitate to buy a bike that you think looks cool.  Don't hesitate to buy as many bikes as you want.  These are both strong motivators for riding.

2.  Be safe and stay alive: 

Biking is in many ways like getting into an open Land Rover and driving out into the Serengeti among the predators and large animals.  Anything can happen and you have minimal protection.  Just pulling out of my driveway I always double check the air pressure (it should always be at the max) and I make sure my front wheel is not ready to fall off by pounding on it with my fist.  I am riding high pressure tires with tire liners to prevent a blowout.  I don't have time to fix flats out on the road.

And then I become hypervigilant......

I was screaming down a hill in Duluth one day and all it took was a split second for a large black Labrador to run out of a bush and right under my front tire.  Hitting that dog was like hitting a tree stump at that speed and I went right over the handle bars and onto the shoulder.  I personally know too many cyclists who were killed or became quadriplegic in accidents like this.  It is the main reason I continue to do a lot of upper body strength training to provide some elasticity in the event of a crash.

In another close call,  I was heading south on Cty Hwy 15 from Square Lake Trail just north fo Stillwater, Minnesota.  Washington County has the highest per capita income of any county in Minnesota and that is reflected in the state of their roads and what happens to the roads at the county line (they get worse).  It is the ultimate biking territory because most of the roads have 5 - 10 feet of pavement  to the right side of the white line.  That is a lot of biking space compared to most county highways.  Coming north in the other lane was a truck pulling a boat on a trailer.  I heard some scraping and saw some sparks.  Suddenly the boat and trailer reared up, disengaged from the back of the truck and was headed right at me.  It cut in front of me by about 5 feet.  I think I was saved by the ultra-wide shoulders in Washington County.

I always stay to the right hand side of the while line by as wide a margin as I can.  All it takes is this little experiment to prove to yourself that this is the best place to ride.  Count the number of cars out a hundred that you see crossing that line in proximity to you when you are riding.  The number I get is about 6% and that is when they see that you happen to be riding next to them.  Hopefully the new car designs with lane deviation alerts will train people to stay in the driving lane.  But it is going to be a long time before everybody has them and let's face it some of those drivers may be intoxicated even in the light of day.

3.  Stay as competitive as you want to be:

I was never a big time racer.  I rode only in an annual unsanctioned 40 mile event.  It was kind of a free-for-all and it was pretty dangerous.  It was a pack style race but in the end, some of the riders were using aero handlebars (ouch) and there was always a massive crash at about the ten mile mark.  Some of the riders were Cat 2 and rode in it for practice.

 I can recall reading Greg Lemond's book about the attitude to have as you get older - basically that you have more responsibilities and more time commitments away from cycling.  That is also true.  Ever since I left Madison, Wisconsin in 1986 - I have been a solo biker.  The only exception was a play date that my wife arranged.   He was a tri-athlete and the husband of one of her health club friends.  The plan was to do a 60 miler from Mahtomedi to the Chemolite plant in Hastings back up to Square Lake Park via Stillwater and back to Mahtomedi.  This guy took off like he was time trialling and I did not catch him until the 20 mile mark.  By then he had hit a wall and his speed started to fall of precipitously.  The last third of the way he was down into the 10 mph range and eventually fell off his bike and fractured his wrist.  The last few miles into Stillwater I was riding next to him trying convince him to stop so that I could call his wife and get him picked up.

That incident captures some of the problems of biking with other people.  What are the mutual expectations?  If it is some kind of competition is it at least a benign competition?  The skill level has to be in the same ballpark as well as the overall expectations of the ride.

What about people that you encounter along the way?  During my time of unlimited exercise, my rule was not to be passed (within reason).  I  would also try to catch anyone on the horizon, but to do it in the most unassuming manner possible.  As aging has taken its toll I have to pick my battles.  Two years ago I was out biking towards an average sized hill when I noticed a pack of about 8 guys quite a bit younger than me closing fast.  I naturally assumed that their social brain worked like mine and they were trying to trounce the old man going up the hill.  By this time I was trying to stick to my heart rate rule of not exceeding 130 bpm and I looked down and I was already at 120 bpm.  I increased my speed to match their figuring that some of them were maxed out trying to close the distance.  At the bottom of the hill I shifted to a bigger gear and hit it as hard as I could.  The group caught me halfway up the hill and then seriously faded.  I was the first guy up and over the top.  I won't tell you what my heart rate was at the time.  I was somewhat elated, especially when the last rider in that group looked over at me and said sarcastically: "Nice work Lance".

Some people view competitiveness as either a character flaw or the most desired personality characteristic.  I see it as neither.  To me it is the embodiment of training and study in the field as well as the third dimension of how long you can put off the ultimate deterioration of your body.  When I win these little competitions that I devise for myself, it is not about the anonymous opponents who I will never know.  It is a battle against my own death anxiety and mortality and a good way to stay physically fit in the process.

4.  Drivers are either not paying attention or they are trying to kill you:  

If you bike long enough or even pay attention to the newspapers, cyclists are always getting killed.  Seven hundred and thirty two cyclists are killed every year and 49,000 injured, but it is possible that the police only record about 10% of the injuries.  In my town it is about 1-2 people per year.  That suggests to me that the fatality estimate is also too low.  I personally know both experienced and inexperienced cyclists who were killed and seriously injured.  In one of the most noted cases a driver mowed down three cyclists while trying to adjust her CD player.  The only defense against the inattentive and/or drunk driver is to be as far to the right of the lane marker as possible and try to avoid sharing the actual traffic lane whenever possible.  There are some additional helpful approaches.

Avoid riding in traffic until you know what you are doing.  The basic skill requirement is to be able to bike in a straight line and not veer all over the road.  That seems easy but it is not.  Any type of distraction including talking with your fellow riders and looking over your left shoulder can cause you to drift into the traffic lane.  Don't ride in traffic if you are drifting all over the road for any reason.  Don't ride in traffic until you can glance over your left shoulder and not drift into the traffic lane.  If you know you can't do that - stop the bike completely, put your feet on the ground and look behind you.

Bike with people you know and trust.  If you are biking distances at speed you have to know that the person in front of you is not going to pull up all of a sudden without warning and cause a crash or lead you to veer into the traffic lane.  Ride single file most of the time,  except where you have enough shoulder surface to comfortably ride side by side.  You should have enough confidence in your fellow riders that you know they will not make any contact with you.

In some cases, the nature of the ride is just plain dangerous.  I can recall riding out of Aspen to Independence Pass.  The shoulder on that road gets down to 6 inches wide as it winds up to the pass.  The day that I did it, there was constant Airstream trailer traffic.  The vehicles pulling those trailers were all outfitted with very long side view mirrors to see around the trailers and they were dangerously close.  To make matters worse,  I was aware of a cyclist who was hit from behind by one of these mirrors.  That image of a mirror imprint on my back made the ride up a lot less enjoyable than it should have been.  Sometimes your cycling goals take you into dangerous territory in spite of everything you know about safety.

Aggressive drivers are an entirely different problem.  They come in several classes that I would described as the appropriately angry driver,  the enraged driver and the personality disordered driver.  There is a significant overlap between the personality disordered driver and the enraged driver and that depends on the assumption that a person can have defects in emotional reasoning in the absence of major character pathology.  As far as I know that study has not been done.  Prevention is always the best initial approach and by that I mean not doing anything to piss drivers off.  It does not take much.  After all they are in a two ton vehicle obligated to adhere to the rules of the road or risk legal penalties and suddenly the cyclist in the oncoming lane buzzes right through a stop sign.  That action is enough to cause the mild-mannered banker who you personally know to start pounding his steering wheel with both hands while screaming epithets out the window (Don't ask me how I know that).  Simply put you will anger fewer drivers by adhering to the same rules that they have to.  That will not prevent all angry encounters because there remains some ignorance about traffic laws.  For several weeks I encountered an angry young woman cycling toward me in the wrong direction on my side of the road.  She was riding against the traffic.  She was aggressively swearing at me and telling me I was going the wrong way until I politely told her to read the drivers manual.

But obeying all of the traffic laws will not keep you out of the cross hairs of our various personality disordered citizens.  I was biking up Myrtle Street in Stillwater, MN one day.  It is quite a haul and most road bikes don't come with small enough chainrings to make it up that hill very comfortably.  I was 2/3 of the way up when suddenly a young man in a large 4WD pick up truck (not that there is anything wrong with that) pulled up next to me and started to harass me all of the way to the top.  His basic heckle with the expletives removed was: "Yeah you're not so tough now are you?"  Wait a minute, I am the 55 year old guy riding up this hill on a bike and you are the thirty something guy sitting in a 400 horsepower truck going up the same hill and I'm not so tough?  Harassment like that can be disorienting, I flipped into my mindfulness mode and thought about all of the times I have biked this hill - while keeping an eye on how close the truck was to me.

In a previous incident, I was at the bottom of this hill when an elderly driver decided to turn right into me as we came up to the third or fourth cross street.  Luckily she was going at a low rate of speed and I was at the right place where I could slam my hand down on the roof of her car and spin myself and the bike out of the way.  She was oblivious to the whole situation and kept driving.

One of the worst things that you can do with the enraged or personality disordered driver is to escalate the encounter.  It took me a while to figure this out.  The best example I can think of involves being harassed by a motorcycle club on day toward the end of my ride.  I doubt that they were 1%ers, but they were all young very muscly guys wearing sleeveless motorcycle jackets and seeming quite intoxicated.  As I rode by one of them had climbed the cyclone fence that surrounded this establishment and started to shout "Wheelie! Wheelie! Wheelie!......" as I pulled up to a stop sign.  Several of his peers caught wind of this and started to do the same thing.  It was a scene out of a biker film from the 1970s.  Clearly they were expecting a response from me.  In the old days, I might have said something and it would have been off to the races.  Today the exchange went something like this:

Me:  "I can't do a wheelie."
Intoxicated Biker: "Why not?" (angry tone)
Me:  "Because I am too old!"
Intoxicated Bikers: Explode into laughter.  As I ride away they are reassuring me that I am not too old to do wheelies.

So the bottom line is that some of these ugly confrontations can be defused with humor.

5.  Fantasize your brains out:

Psychiatrists don't talk about fantasies any more.  I think that an active fantasy life can be very adaptive.  I have fantasies that I can pull up in any terrain.  In the hills or mountains I can imagine myself riding between the Schleck brothers in the Alps.  On level ground or into the wind, I can see Miguel Indurain time trialling in front of me and I am just trying to maintain the correct spacing between us until I can pull out and pass him.  The weeks of the Tour de France are generally the times of peak fantasy for me.  There is always the case of a solo rider who breaks away from the best cyclists in the world and stays away.  I can't think of anything as exciting in all of sports.  I am waiting to watch that clip and incorporate it into my fantasy world.  I can hear Phil Liggett calling out my name.....

6.  The cognitive versus the emotional aspects of life:

I have decades worth of meticulously detailed training information - all handwritten.  Distances and times, routes, intervals, heart rates, etc.   In the 21st century, none of that stuff is necessary.  You can automatically record all of that data and download it to your computer after the ride.  You can study whatever parameters that you want.  But don't get too lost in the details.  I live for the time during the year when I am cruising along in a fairly steep gear and can put my foot down and go.  Bam!  I am sure that any coronal section of my brain on fMRI at that point would show my nucleus accumbens lighting up, but the subjective experience is most pleasurable.  It can occur only with the right distribution of power and weight and I notice that it is advanced on in the season.  If it ever disappears, I know that I will miss it.    

7.  Wear the most radical clothing you feel comfortable with:

Most non-cyclists don't understand the utilitarian nature of cycling clothing.  I was speedskating one night and came off the ice with some biking gear on.  One of the hockey dads decided to give me a rough time and commented how I must think that I was pretty cool because I had special speedskating clothing on.  Keeping in mind that he had several kids with about a thousand dollars worth of hockey gear on,  I said:  "Well no, this is my cycling clothing."  On top of thermal underwear of course.

I have been in pursuit of the perfect biking shorts and saddle for the past 30 years.  When I find a pair that seems to meet the criteria, it doesn't take long for the manufacturer to change the design or the chamois.  It is a basic fact that you cannot expect to bike every day if your perineum is trashed or you develop saddle sores.  The best way to do that is to think that you are going to ride more than 10 miles in a pair of cotton Bermuda shorts over boxers.  I am currently trying out some very high tech shorts.  They were so high tech that I had to send an e-mail to the company.  I was concerned about what kind of chamois lubricant to use, because of all of the high tech materials used in the short.  Their reply was totally unexpected.  Don't use anything.  Wear these trunks dry.  So for the first time in 30 years I don't have some kind of lubricant between my ischial tuberosities and my bike saddle.

Live and learn.

8.  Inclement weather:

I don't bike in the rain or snow anymore.  I will also not be biking up to Independence Pass again unless they ban Airstream trailers.  I have an ergometer in my basement and I try to match the outdoor conditions.  I know that at many levels that is an illusion.  I do however always bike in extremely hot weather and in the wind.  It takes a certain mindset to overcome those conditions.  You have to be able to feel that you are going with the wind and benefitting from the temperature at some level.

This is a long post and that's all I can think of for now.  So the next time you see some old dude out on the road biking - he may be a narcissist wrapped in Lycra, but it is more likely he has a lot on his mind and he is trying to live the best way that he can.


George Dawson, MD, DFAPA




Supplementary 1:     

Disclaimer:  I am not a cycling coach or expert.  The point of this post was to look at some of the unspoken psychological aspects of biking from the standpoint of individual consciousness.  Don't take any of this as advice on how to cycle or live your life.  Follow the advice of your personal physician on all matters related to exercise especially if you have decided to start a new program or alter your intensity.


Supplementary 2:

I am a guy so this is written from a male perspective.  I know that women are as dedicated and serious about biking as I am, but I can't speak to their conscious state.  If you are a female cyclist feel free to comment about your conscious state in the comment section below.  Or better yet, send me an essay and I will post it as an invited commentary by a distinguished guest.  I am very interested in your motivations, cycling fantasies, and daydreams about cycling and any insights that you have developed as a result.  Not everyone can keep riding and I am very interested in the ways that people do.