More On Conscious States......

In my previous post, I concluded that the conscious states of human beings were far too complicated to allow an algorithmic decision on whether or not they are candidate for the euthanasia and assisted suicide.  The argument may not be all that clear to anyone who does not have psychiatric experience so I thought I would add more examples,  These are all fairly standard clinical scenarios but not specific case reports.

Scenario 1:  A 65 year old man with a long history of alcoholism presents for assessment of possible bipolar disorder.  He is euphoric, grandiose, and appears to be mildly intoxicated.  The psychiatrist performs a clinical interview that includes a standardized cognitive screen.  On the cognitive screen the patient performs perfectly for a person with his level of academic and occupational achievement, including on all tests of short term and working memory.  He returns two weeks later for follow up and does not recall ever meeting the psychiatrist or doing the cognitive exam.

Scenario 2:  A 42 year old woman with a history of bipolar disorder presents for follow-up from a recent hospitalization.  Her psychiatrist also works in the hospital and provided her care when she was in the inpatient unit.  During the follow-up visit the patient asks her psychiatrist if she recognized the fact that she was "not myself" either in the hospital or at the time of discharge.  When asked to be more specific she said that she was very angry and had attempted to drown herself while in the hospital but did not disclose that to the psychiatrist or nursing staff.  She criticized the psychiatrist for not recognizing that and suggested that she should never have been discharged.

Scenario 3:  A 50 year old woman is being seen for depression.  She has had recurrent episodes of depression following an episode of postpartum depression at age 28.  She has been on maintenance antidepressant therapy since age 28 and requested this appointment because it seemed like the maintenance therapy was no longer as effective.  In the appointment she appears to be mildly depressed.  She has some depressogenic thinking that does not seem much different from many other similar episodes in the past that generally required minor adjustments of medication and supportive psychotherapy with cognitive-behavioral interventions.  Those changes were made and suicide risk was assessed in a standard way by her psychiatrist.  She has no past history of suicide attempts.  Deterrents to suicidal behavior were discussed and she reminds the psychiatrist that she is very religious and her religion has a strong proscription against suicide.  A follow-up appointment is set.  Three days later, the patient's husband calls the psychiatrist to let her know that the patient attempted suicide and is recovering in a local hospital.

Scenario 4: A 22 year old man is being seen for heroin addiction and depression.  He is hospitalized following an accidental heroin overdose and contemplating transfer to residential treatment for substance use disorders.  During the interview he discusses his depression as the result of guilt and regret from some of the activities he has engaged in to have a steady supply of heroin.  He talks about those activities in detail including stealing from his friends and family, dealing drugs, and and in one case witnessing an episode where drug dealers severely beat up one of his acquaintances to the point that person nearly died.  He concludes that all of these activities are "not me - I wasn't raised this way.  I have values and I don't break the law.  Now I break the law every day and it is just a matter of time before I end up in prison.  I can't do this anymore."  The psychiatric consultant asks him about the decision to go to the rehab hospital so that arrangements can be made and the patient says: "I don't think that I am ready to stop using heroin yet"        

This is a short list of what I see as changes in conscious state that are not well captured or described in the current psychiatric nomenclature.  Part of that comes from the fact that psychiatry is a subspecialty of medicine and all medical classifications are by their nature imprecise, linear and somewhat static.  The ideal medical diagnosis implies a certain general course and prognosis.  That selection process will find static linear processes more ideal in terms of meeting those criteria than dynamic processes that can change minute to minute or hour to hour.  Human consciousness changes on that shorter time frame, is nonlinear and therefore unpredictable.  There certainly can be more drastic and persistent changes in consciousness that are more easily recognizable-like delirium or dementia.  Even the scenarios outlined above suggest significant disruptions in consciousness to the point that result in amnesia, unpredictable suicidal behavior and suicide attempts, and drug addiction.  Some would consider the alcohol induced amnesia or blackout  to be the more severe disruption, but that is purely a subjective judgment.  It is possible for people to have hundreds if not thousands of blackouts and appear to be functional during that time.  That is certainly a major problem and a high risk problem but no more risky than a suicide attempt that results in hospitalization or the decision to continue heroin right after an overdose as tolerance is waning.

Recognition that these conscious states exist makes a psychiatrist a far better clinician.  He or she is much less likely to get angry or upset about unpredictable events like suicide attempts and relapses to drug or alcohol use.  An appreciation of the fluidity of human consciousness, precludes any angry or blaming of the patient for something that happens outside of a limited standard evaluation.  There is a strong tendency of physicians who are unaware of this phenomenon to either get angry and think that the patient lied to them in the original assessment, adopt the fatalistic attitude that these events are all unpredictable and nothing can be done about them, or adapt a paternalistic attitude and sympathize that the person has a mysterious disease that they should not be blamed for.  None of these attitudes captures the true conscious state of the individual.

Are there any interventions that can be done to reduce the risk from these rapid changes in conscious state?  That is currently an empirical question.  A lot depends on the ability to detect persons with the problem.  There are certainly plenty of people who told a physician that they were not suicidal and who went on in a short period of time to attempt or complete suicide.  In some cases the survivors are available for interview.  In hospital settings interviewing survivors of self-inflicted gunshot wounds it is very common for the patient to recall pointing the gun at themselves but not recall pulling the trigger.  Survivors who have jumped off the Gold Gate Bridge almost all regret jumping when they were a few feet away from the rail.  At the minimum this suggests that the conscious state of the actively suicidal person is transient and impulsive as in unpredictably driven to act on the suicidal plan.  Young opioid addicts are very common these days and generally personify the Hijacked Brain Hypothesis or a brain that is biased to continue an addiction and the associated behaviors that are in stark contrast to their previous moral development and educational and vocational trajectory.    

Any clinician who is aware of these changes in conscious state can educate the patient about what is happening.  During an assessment of suicidal risk after a discussion of all of the risk and mitigating factors, I think that it is reasonable to have a discussion with the patient about their current conscious state and risk based on that conscious state as well as the fact that conscious states change in some cases to a high risk state.  Any psychiatrist who has interviewed survivors of suicide is often struck with what that person describes as a clearly different state of mind from the one being experienced in the interview.  In some cases that altered state is drug induced.  The DSM-5 catches a glimpse of these phenomena with two tables on Neurocognitive domains on Page 593 and Diagnoses associated with substance class on Page 482.  Both categories recognize that  changes can be transient and limited to intoxication or withdrawal states, but there are also some persisting states depending on the intoxicant.  The table on neurocognitive domains lists some subtle manifestations of known brain disorders.  The DSM-5 does not look at the more subtle changes as noted in the above 5 scenarios or even in everyday life.   Another limitation of medical diagnoses is that they work the best in extreme states where there are obvious problems.  Everyday life and the kinds of changes we all observe in our spouse or parents in any given environment are the most subtle yet.

I hope that these examples have made it clear that psychiatric practice is much more than categorial diagnosis and risk factor analysis.  If there is any hope for a 21st century psychiatry - this is where I would put my marker - not on the same diagnostic system and mental exam that we have been using for the last 50 years and certainly not on a checklist and mass medication approach being promoted as collaborative care.

A focus on consciousness is the best way to help our patients and the best way to learn how the brain is really working.




George Dawson, MD, DFAPA



Supplementary: 

The graphic at the top is part of one slide from one of my lectures on the neurobiology of addiction.  My emphasis to the students is human consciousness and why it is unique.  I try to get them to think outside of the DSM-5 box when considering how the patient changes on a practical basis day-to-day and how that relates to neurobiology.  

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.

Snow Shoveling Theory and Plasticity

I drove back from my home town to the Twin Cities area yesterday  In this age of connectedness, there are times when you get a false sense of information.  My wife called her friend who was driving north to Duluth on Hwy 35.  She got the message that there was about 6 inches of snow on the freeway and numerous vehicles in the ditch.  I don't mind driving in the snow.  I used to drive north in the winter in some notoriously unreliable vehicles.   Rear wheel drive and no limited slip differential.   Poor weight distribution was an added bonus.  Some of the worst engineered cars in the world.  Most people my age all still use the brand name Positraction, rather than the generic limited slip differential.  More evidence that pharmaceutical companies don't differ much from other businesses in terms of branding of inserting themselves into the public consciousness.  Like most people, when you get to the point where more safety is affordable you buy it.  I am driving a modern four wheel drive sport utility vehicle (4WD SUV).  I was confidant that 6 inches of snow would only be a problem if there was congestion from large trucks and snow removal vehicles.  I was also confidant that would only happen close to the Twin Cities.  Competency in snow removal seems to vary directly with latitude with northern latitudes being the best.   I thought about that as I drove down Hwy 2 across northern Wisconsin.  The road was clean down to the pavement about 4 hours after white out conditions.

As we turned the corner in Duluth, the grey skies lifted and it turned out to be a bright sunny day but 10 degrees colder than the day before (about 22 ℉).  There was no bad road all the way back to the Twin Cities.  That only happened when we pulled into our neighborhood and there was 6 inches of snow in the driveway.  All of my neighbors driveways were clear and in many cases the pavement was dry and clear.  The physical chemistry of snow is always interesting.  In this case the bottom few millimeters of the snow was liquefied, but the upper 5 inches plus was medium density snow, the kind that is good for cross country skiing.  Clear it off and the liquid evaporates in the direct sunlight, even when it is well below the freezing temperature.  In some cases sublimation occurs and the snow vaporizes directly from the solid state.  But I was focused on additional theories.

People living in northern climes think a lot about moving snow.  We have had some epic snowfalls.  Some of my fantasies coming into this season included getting an enclosed tractor with climate control and the ability to move a massive amount of snow.  The image I have is a condensation of a couple of images.  The first is a cola commercial from many years ago - a set of combines cutting wheat.  All of the operators in their climate controlled cabs drinking Coke (or Pepsi?).  The second is a show about building ice castles in Norway and a small vehicle that was described an an airport runway snowblower that could move a tremendous amount of snow through a chute directly over the operators cab.  Those are my grandiose commercial induced fantasies.  Even a small tractor with a cab set up to move snow is ridiculously expensive and it needs a lot of ongoing maintenance.  I have never been able to locate the manufacturer of the Norwegian snow blower.

The reality is that I have a 15 year old Toro 2 stage snow thrower and about 200 square feet of sidewalk and 1,000 square feet of driveway to clear.  The snow thrower cuts a 24 inch path.  In many ways the strategy is mathematical and practical.  What is the most efficient way to clear away the snow?  Is it just going back and forth and turning the chute on the snow blower on every turn or is it something else?  Since moving into this house I have decided it is a right angled arc starting up the left hand side of the driveway and then turning back (and turning the chute on the snowblower) and heading back in the same direction.  This moves all of the blown snow to the eastern side of the lot, away from the sidewalk and areas where ice might accumulate.  It also results in fewer change in the chute direction that just going back and forth or the length of the driveway.

Mathematics aside - what are the practical aspects?  The first of course is the weather.  Is more snow expected?  Do you really want to concentrate the effort if there is going to be another foot?  In some cases of wet and heavy snow it is imperative.  That layer cannot be allowed to freeze and it is the most difficult to handle with a snow blower.  In this case I was left with about 1/2 inch of translucent slush that I had to scrape up with shovel before it all froze in the colder temperatures.  The second is the surface that you are clearing.  There are some web sites that recommend snowblower sizes based on whether your driveway is finished (asphalt or concrete) or not (gravel).  In my case I have two different surfaces - a concrete driveway and a textured concrete sidewalk.   I can't use the steel shovel on the textured concrete.  I use a plastic shovel very similar to the metal shovel that my father used to shovel coal into a steam engine on the 1950s.  One of my earliest recollection was being placed in the cab of a steam locomotive.  My father was a locomotive fireman at the time and the engine was hand fired.  His job was to keep coal burning to keep the steam pressure up.  He explained to me at the time how the scoop shaped shovel was designed to slide large amounts of coal off of it and into the furnace without wasting any energy.  To clear the sidewalk - I clear one edge and then cut across that using the same motion my father used to shovel coal.  Snow is a lot lighter than coal but it takes me about 50 passes to clear it using this motion.

With every pass, I am careful to extend the stroke out onto the grass by about 2-3 inches.  When my father first taught me to shovel snow, he said this was critical in the event that there was any melting of the snow.  Without that 2-3 inch margin the water pooled on the sidewalk and created ice.  With the margin the water soaked into the grass and no ice was formed.  I have tried to pass that knowledge along to other sidewalk shovelers, but it falls on deaf ears.  Either they don't believe me or they have their own theories of shoveling.

In addition to the theory of clearing snow and carrying it out, I get another thought from about 50 years ago.  I have always been an insomniac and one night back then I was waiting for my father to come home from work.  By then he was a railroad engineer and drove freight and iron ore trains.  It was about midnight.  It was snowing and drifting to a depth of about 3 or 4 feet on the street outside of our home.  He told  me that day before he left that they might need to plow snow off the tracks.  The worst case scenario would be hitting deep snow and blowing it into the diesel engine air intakes on the top of the locomotive.  That would kill the engines and result in a long restarting process that would slow him down.  I kept staring out the window.  The wind was so intense that I could not hear any trains even though we were only about 3 blocks from tracks.  I could finally see him leaning into the wind and snow.  He always wore union style clothes and none of it was really made for winter weather.  He wore a chromer cap with ear flaps that offered limited protection.  He was carrying a leather satchel that he called a "grip" that contained all of his important paperwork.  He was wading through hip deep snow, using the exaggerated hurdler motion that you had to use to travel in deep snow without snowshoes.  I was very happy to see him and even happier when he burst into the kitchen and it smelled like the fresh air version of diesel fuel, Lucky Strikes and leather.

I have a greater appreciation of these events than I used to.  Early on it was easy to grasp the psychodynamic significance, especially when it came to countertransferences toward mechanics and anyone else who might smell of diesel fuel and cigarettes in my office.  There were the associated issues of blue collar rage, exploitation of union workers, and a stronger affiliation with workers rather than management.  These days I can think of it in terms of the brain systems that are represented and the underlying mechanisms that allow for this experience.  I still feel happy when I have that image of my father pushing through deep snow toward home.  It probably accounts to some degree for my affiliation with snow and winter weather.  Every month or so I give a lecture and talk about the time frame, neuroscience and structures that are probably responsible for that experience.

Most of all I remind the students about how these structures allow for unique human experience.  I like to say that if there are 7 billion humans on Earth, there are 7 billion unique conscious states.  I suppose planning and fantasizing about clearing the snow is not that unique in the upper midwest.

But I doubt that any two of us learned to do that in the exact same way.


George Dawson, MD, DFAPA    

          

A Few Words About Sex

Sex remains a poorly studied and controversial topic.  It is a powerful interpersonal and cultural force.   Many ideas that originated with Freud are considered outmoded and yet when I have attended seminars that I thought might lead to ways to advance my knowledge in this area, they seemed like a dead end.  In fact, at the last seminar I attended I asked the speaker about experts in sexual consciousness he referred me to a psychoanalyst who I had corresponded with but who had since died.  The only real innovation in the area has been sexual compulsivity or sexual addiction.  Several authors write about this as though it is an actual disorder.  There have been the compulsory brain imaging studies showing activation of the reward center.  I have reservations about defining an addiction when so little is known about the baseline sexual consciousness of men and women.  It is against that backdrop that I watched two films by von Trier - both of them with the title Nymphomaniac.

After some deliberation let me say that I am not recommending that anyone watch these films.  At the very minimum they are highly controversial and they contain images that will be regarded as highly offensive or disturbing to many if not most people.  The point of this post is to illustrate how the basic storyline of these films brought me back to an issue that I have been pointing out for years, that psychiatry is no longer focused on this area of human experience even though we diagnose and treat these problems all of the time.  In many ways reading Kandel's book The Age of Insight highlights how there were more enlightened conversations about these issues in early 20th century Vienna, than I have seen anywhere during my professional career.   The public discourse is abysmal.

I was familiar with von Trier's work from an earlier film Antichrist, a film that I suppose in a very basic way was a psychotic repudiation of genital sex.  Like most things it popped up on my Netflix screen as I was getting ready to cycle.  Let me preface this post by saying that this is not a review of these films.  From what I can tell the film has been exhaustively reviewed.  The Netflix rating was a meager 2.9 stars.  Even informal reviews usually adhere to a thumbs up/thumbs down convention.  This is one of those films that is not conventional in that sense.  There are few people that would be very enthusiastic about this film based solely on content.   It is difficult to watch.  It is depressing, desolate, and in some cases violent.  It is a film that you would not necessarily recommend or even say that you had watched because it would invite inferences about your character or taste.  It may be an ideal backdrop for the trajectory of the main character and her sexual experiences in the  film.

The storyline is basic enough.  A middle aged man finds a woman who was apparently beaten up and left in an alleyway.  It is night time and lightly snowing at the time.  The alleyway is surrounded by brick walls and there is an impression that it is an impoverished part of the city.  The man offers to call for medical help but she declines.  She accepts his offer to go back to his apartment.  When she is more comfortable, she relates her history of compulsive sexual behavior in a series of eight vignettes with titles that seem interwoven with observations and stories from the man who appears to be helping her.  These stories are the main content of both films.

The stories all have the common elements of compulsive sexual behavior.  We start to learn that the chief protagonist Joe (Charlotte Gainsborough), made a conscious decision about this lifestyle at an early age.  We get to known her parents, her interactions with them and witness her father's death.  We see her embark on a vigorous program of engaging as many sexual partners per day as possible.  I think the number over much of the film that could have covered 15-20 years of her life was 8-10 men per day.  We witness some of the logistics when some of these men meet in her apartment and a scene where one of the men leaves his wife and his wife shows up at Joe's apartment with her children and is very agitated.  She angrily details the cost of  extramarital sex for the family.  Practically all of these scenes are difficult to watch.  We observe Joe over time as she becomes exhausted and eventually physically ill and debilitated, presumably from the excessive sexual behavior.  Whether or not she contracts sexually transmitted diseases is never made explicit, but we see rashes that do not heal and she describes bleeding from the genital area.  We also see her physically injured as a result of sadomasochistic behavior.  We watch her struggle emotionally.  The basic idea at the outset was not to develop any emotional attachments and to have as much sexual intercourse as possible.  Sex strictly for the sake of sex.  There are critical times during her life when that does not happen and attachments, jealousy, and envy happens and we see how she deals with these developments.  Near the end she is psychologically devastated, trapped and alone because of the sexual compulsion.  At the end, we have come full circle and realize how one of these emotional involvements has resulted in her being beaten and left in the alley.   There is additional drama at the end that I will not disclose.  If you can watch the entire sequence of these films, you deserve to discover that for yourself.

Films like Nymphomaniac are thought provoking and if you like your thoughts provoked that could lead you to give it a thumbs ups.  I have already listed my criteria for cinema as good entertainment and good acting and the film meets some of those standards.  As I thought about the content, my first thought had to do with the fact that this film was written by a man, so it is really a man's estimate of the sexual consciousness of a woman.  Strictly speaking, it is impossible for any one of us to understand the conscious state of another human being.  The thought experiment from consciousness researchers is typically, my experience of the color red is not your experience of the color red.  It is interesting to contemplate whether there might be a larger gap in understanding the sexual experience of the opposite sex.  People may argue that observations of dating and sexual behavior, anatomy and fairly crude mental and physiological data allow us to make reasonable estimates, but I would say this is more likely conjecture than the reconstruction of an actual conscious experience.  Since there is so little scientific evidence about this, the area is highly politicized.  Experts frequently talk about stereotypes of sexual behavior and the theories about why they occur.  Any attempts at discussion may break down to personal anecdotes supporting these political approaches that nobody wants to hear.   There are probably any number of reviews available online that will examine Joe's behavior from these perspectives.  Many of these arguments can come down to existential and moral dilemmas and what side of these arguments an observer happens to take.  And there is always the artistic argument that reality is relevant insofar as it may be part of the beholder's experience (see Kandel).

We get to know the man who seems to have saved Joe.  His name is Seligman (Stellan Skarsgård).  He is a self-described asexual man who gives the impression that he is an ascetic with far too much time on his hands.  His associations to some of Joe's stories often has a level of analysis that you could only get in a college classroom by a professor who is an acknowledged expert in his field. That level of sterile intellectual analysis seems consistent with his self described asceticism.   He seems to be different from the numbers of other men that Joe has encountered.  A key question is whether or not Seligman can interact with Joe in a non-sexual manner, although the obvious question is whether that can occur if a man is calmly listening to the sexual history of a self professed nymphomaniac for a number of hours.  That issue does not get resolved until the final moments of the film and I am sure that many film goers will find it controversial and suggestive of motivations on the part of the director and writer.

As as psychiatrist and a physician I naturally think about the implications of this movie.  Have I seen people with this problem?  Do I think this problem exists?  Have I been able to help people with all of the variations in between?  Are there implications for the training of psychiatrists and physicians?  As a first year medical student, I was exposed to a course that was described as cutting edge at the time.  It was devised and taught by a psychiatrist who had been brought  to my medical school expressly to teach this course.   It consisted of a surprisingly dry curriculum about the importance of taking a sexual history, videos of sexual behavior with group discussions, and lectures on how to address some very basic sexual problems.  It always struck me as the "birds and the bees" talk that your parents gave you at the end of elementary school but with better audiovisuals.  It seemed shockingly unsophisticated relative to some of the theories of the day.  The timing was also wrong.  Taking 30 minutes to do a detailed sexual history is not going to work when you start rotating through acute care medical and surgical settings.  Knowing enough medicine and psychiatry and practicing in an ambulatory care setting seem like better prerequisites.  A course like that is inadequate preparation for what occurs in those clinic settings.  The mechanics are irrelevant.  The focus is all intrapsychic and interpersonal, helping the person process that information and adapt.  A focus on the mechanics of sex,  either in the sexual history or sexual education in school really seems to miss the mark.  All of the discussion of mechanics even with the recent details of how the ventral striatum is activated during sexual behavior seems to marginalize the meaning of sexual behavior and how it influences the entire conscious state of a person.  Whether Joe's story is accurate or not, the common experience of sexual behavior organizing one's conscious state probably makes this story believable for most people.

The issue of whether of not nymphomaniacs exist is certainly another issue for psychiatry.  The diagnostic manual lists no similar term and no reference to the equivalent condition in the film - sexual addiction.  In some circles, sexual addiction is seen as a behavioral equivalent of substance use disorders.   The existing sexual dysfunctions available for diagnosis include problems with hypoactive sexual desire, arousal and orgasms.  Hypersexual disorder is not an option and Grant and Black explain:

"During DSM-5 deliberations, there was some controversy about the possibility of including hypersexual disorder, which is characterized by sexual behavior that is excessive or poorly controlled (commonly referred to as either "sex addiction" or "compulsive sexual behavior") and paraphilic coercive disorder, which consists of a sexual preference for coerced sexual activity (i.e. rape).  After considerable discussion and input from fellow APA members, the decision was made not to include these disorders in DSM-5." (p. 274)

A current Medline review shows that the research in this area is thin considering that there are experts out there who are treating sexual addiction or sexual compulsivity and there are several instruments that are designed to gather that data.   I also can't help but think that there are more cases that are under the epidemiological radar.  By that I mean the cases that present to psychoanalysts.  Some of the most fascinating areas that I studied as a resident were the different approaches to psychoanalysis, particularly the differences between Kohut and Kernberg.  Kohut's paper called "The Two Analyses of Mr Z." was particularly interesting because the presenting symptom was compulsive sexual behavior.  The symptom did not respond to traditional psychoanalysis but required Kohut to modify the technique and he used this as an example of his new self-psychology approach in psychoanalysis.  So a question for the analysts out there, I know that many analysts treat focal sexual symptomatology out there and eschew the DSM categorical approach to sexual behavior.  Are there psychoanalytical papers written about hypersexuality in general and is it a problem frequently seen in psychoanalytic practice?  The Psychodynamic Diagnostic Manual has the following commentary on the subject of the categorical (DSM) classification of sexual disorders:

"Sexual inclinations and experiences are sufficiently diverse among human beings that we urge caution in diagnosis.  In this area we are particularly uncomfortable with the categorical depiction of "disorders" in the DSM.  Especially in the area of paraphilias, it becomes easy to pathologize behavior that may simply be idiosyncratic.  In contrast to categorizing specific acts as inherently pathological irrespective of context and meaning, we recommend a thoughtful assessment of subjective factors, meanings, and contexts of variant sexualities...." (p. 126)

The diagnosis of Hypersexual Disorder was listed in the online proposed DSM-5 as a paraphilic disorder but it did not make the final cut.   There was a note posted that it would be included in "Section III" conditions for further study, but in the final version it was not listed there either.  It would appear that there is little guidance from either the DSM or PDM camp on this disorder.

I had originally planned to include a new graphic here summarizing the imaging results from studies of human behavior, but I am having some difficulty getting the original papers and images.  For anyone interested in that list of references you can find them here.  A recent paper in Science, raises some serious questions about what reward center activation really means (see Donoso, et al).  In this paper the authors demonstrate that reward center activation can occur with a purely cognitive task and seems to function in a way to continue to make correct choices.  That raises some questions about conventional approaches to reward center activation and what it means in the study of human sexual behavior but also addictions of all types.  How much reward center activation is purely due to making a "correct" choice and what does that mean in the case of an addiction or in the cases of normal function like eating, drinking, or sexual behavior?

In terms of clinical practice, I have treated hundreds of people with hypersexuality, socially inappropriate sexual behavior, and victims of sexual assault.  They were almost all due to mood disorders (mostly mania), neurocognitive disorders, chronic intoxication states associated with addictions, medication side effects (primarily medications used to treat Parkinson's Disease), or the effects of various forms of sexual violence.  I have fielded a lot of questions on the whole notion of sexual addiction, especially in chemical dependency treatment settings where compulsive behaviors are viewed as behavioral addictions.  I have never really encountered anyone describing a problem similar to what is portrayed in Nymphomaniac.   There is always a strong selection bias in clinical practice and for a long time, I assessed and treated people with severe mental illnesses and addictions.   The hypersexuality in these cases usually had causes that any psychiatrist could diagnose and hopefully treat.   My read of the psychoanalytic and family therapy literature suggests that there are cases that are independent of the etiologies that I have seen and many of them have intrapsychic/interpersonal and social etiologies.  Apart from individual case presentations by psychoanalysts and psychotherapists it is very difficult to see this as a widespread problem.  That seems to happen in other areas like Intermittent Explosive Disorder.  I have not seen a single case in 28 years and yet there it sits in the DSM-5.

This is probably another area in psychiatry that will require a lot of data and more research to resolve.  People often take offense to the idea of more research as a standard answer, but it should be clear that when it comes to sex, the approaches are largely anecdotal and it seems like an area that most people avoid thinking about in any scientific manner.



George Dawson, MD, DFAPA


Black DW, Grant JE.  DSM-5 Guidebook - The Essential Companion To The Diagnostic and Statistical Manual of Mental Disorders.  American Psychiatric Publishing, Washington, DC.  2014.  p.274.

Kafka MP.  Hypersexual Disorder: A Proposed Diagnosis for DSM-5.  Arch Sex Behav (2010) 39: 377–400.

"There are significant gaps in the current scientific knowledge base regarding the clinical course, developmental risk factors, family history, neurobiology, and neuropsychology of Hypersexual Disorder.  Empirically based knowledge of Hypersexual Disorder in females is lacking in particular."

Kandel ER.  The Age of Insight - The Quest to Understand the Unconscious in Art, Mind, and Brain.  Random House, New York, 2012. p. 394.

Kohut H. The two analyses of Mr. Z.  Int J Psychoanal. 1979;60(1):3-27. PubMed PMID: 457340.

PDM Task Force.  Psychodynamic Diagnostic Manual.  Alliance of Psychoanalytical Organizations.  Silver Spring, MD.  2006. p. 126

Donoso M, Collins AG, Koechlin E. Human cognition. Foundations of human reasoning in the prefrontal cortex. Science. 2014 Jun 27;344(6191):1481-6. doi: 10.1126/science.1252254. Epub 2014 May 29. PubMed PMID: 24876345.



Supplementary1:  This post may be modified as more data becomes available.  I just had to move on.

Supplementary 2:  Since there are apparently no conferences I had this idea for a conference based on this post to put sex back into psychiatry.  The conference would consist of the following elements:

1.  Update on the current epidemiology of sexual behavior.
2.  Review of the physiology and neuroendocrinology of sexual behavior.
3.  The neurobiology of the human sexual response.
4.  Brain imaging of the human sexual response.
5.  The sexual consciousness of men and women.
6.  An approach to useful clinical classifications across the DSM-PDM spectrum.
7.  Clinical approaches to identifying sexual problems and normal sexual function.
8.  Approaches to treatment across the DSM-PDM spectrum: disorders to focal problems.

Let me know if you can think of other topics, I am trying to get people interested in putting this conference together right now.