The Tomorrow River

 

The Tomorrow River is a small Wisconsin stream that crosses US Highway 10 three or four times between Fremont and Waupaca.  It eventually runs into a creek and becomes the Waupaca River.  I crossed all those tributaries twice on a trip last weekend. It gave me the usual opportunity to free associate to my past life. Two memories came immediately to mind – both from about 1977.  I was freshly out of the Peace Corps and trying to establish myself in a job as a research assistant cloning trees at an Institute in the area. That involved a lot of travel down Highway 51 to Highway 10 and I did not have a car.

One day I was travelling on a Greyhound bus heading to my apartment.  That was the first time I caught the Tomorrow River sign, as I looked up from a letter I was writing to my friend Glenn. I had a good experience in the Peace Corps entirely due to the Americans I met in my group.  They were bright, excitable, and energetic. We had gatherings where we listened to music, ate pizza, and played basketball.  We had long discussions into the night about what was important, what art meant, literature, music, math, science, and the meaning our work as high school teachers in the Peace Corps. We read the hipster literature of our time – Kerouac, Pirsig, Kesey, Brautigan, Wolfe, and others.  There were animated discussions and arguments.  All of that probably influenced the letter I was writing and then I saw the sign. The letter took on a surrealistic quality that Glenn appreciated in a letter he sent back to me.  As I visualized that decades old experience – it was a good feeling. I still feel a connection to my Peace Corps friends even though it has been decades and we rarely see one another or communicate.  I know that when I do – we will pick things up the way they have always been.

Between the second or third Tomorrow River sign there is an uphill curve in the road that bends to the left when you are traveling east. It is a long half mile bend. Later that same year just after Thanksgiving – I was getting a ride to my apartment from my friend Walt.  We went to the same high school and college. He was two years younger than me. Walt’s personality was completely the opposite of me. He was spontaneous, outgoing, and engaging. He could joke about anything.  I was the lab assistant in his organic chemistry section and one day his condenser hose broke loose and started spraying water just over the top of a freshly cut pile of sodium metal. I was able to grab the hose and redirect it.  Luckily there was no contact with the sodium, but after that point he started referring to himself and his lab partner as Captain Sodium.  On that day he was dropping me off and heading to his graduate program in endocrinology in Chicago.  The weather was not cooperating.  On that bend – the traffic that was usually travelling at 65-70 mph was at a dead stop in an ice storm and backed up for miles.  We both got out for a better view and realized it was impossible to stand on the road. Even  maintaining your balance, you eventually slid from the highest to the lowest part of the road and were forced to crawl back across the lane of oncoming traffic. We got back in the car and spent a long time joking about his bright reddish orange Dodge sports car and all of the trash talk he got from people in our home town about that car.  When he walked into a local bar he would hear: "Here comes the Fire Chief!"  We eventually completed the trip and I would see him from time to time over the next decades as he completed his PhD, then medical school, then residency in anesthesiology.  He became one of the top anesthesiologists in the country. And then several years ago, I got the news that he had died suddenly after a brief illness.  He was at the top of his game at the time – a department head and national expert in neurosurgical anesthesia.  I felt badly about not seeing him and not congratulating him on all of his success. I always feel badly when people don’t make it to retirement and a lot worse if I know them.  

Even before I went into the Peace Corps, I spent a lot of time navigating these roads with my friend Al.  We did that mostly in a 20-year-old Volkswagen beetle with a defective gasoline heater. When you tried to turn the heater on it might blow the hood open. Al was a mathematical genius and had accumulated almost enough math credits for a major when he was in high school - all self-taught by reading the texts. He decided to go to medical school and that led him to spend an additional 2 years as an undergrad taking the prerequisite courses.  Somewhere along the line driven by my insomnia and his sense of adventure, we ended up driving long distances to other towns at night to see movies or bands that we knew would never come farther north to our college town.  When you drive on roads in Wisconsin, Minnesota, and Michigan unusual things can happen.  When the pitch-black night is underlit by the snow cover – anything can happen. One night at about 2 AM we were on a road running parallel to Hwy 51 north when suddenly – an old model Chevrolet was airborne about 50 feet in front of us.  By airborne I mean it crashed over the top of a 5- or 6-foot snowbank at a high rate of speed and crossed our highway in a perpendicular path.   It landed on the other side of the road clipping the top of that snowbank first.  Turning around it was obvious that this was a planned attempt to launch the car from a parking lot outside of a bar to the other side of the road.  A few seconds later would have resulted in our Volkswagen being T-boned. That night we were able to turn up the radio and keep going.

These are the kinds of associations I have when I am driving these roads.  The paragraphs seem flat compared to the images in my head. I can envision my friends, our youth, images of what happened, the associated emotions, and the thoughts I have stacked on these events over the past 40-50 years. People I knew then often in a casual way.  People who I wanted to know better. People who – if I had interacted with them differently – would have drastically altered the course of my life and the people who did alter the course of my life. People who I wish would call me or send me an email.  People who I regularly think about and dream about.  But then I tell myself – “This is your own weird perspective on life – most people don’t think like this.”  Generally, that is good to know but at the same time – people do reach out from the past. They seem to realize that we are not the same people we used to be – but the common experience means something.  In many cases, it means a lot.  At my 50^th high school reunion, I was sitting outside of the main room when a classmate approached me and asked if she could sit down. I have known her for over 50 years and yet, that conversation was the longest I had ever spoken with her. It was longer than all of the conversations I ever had with her combined.  It was probably the best experience of the reunion.

I should probably clarify that I have no regrets and consider myself to be very fortunate.  All of these thoughts about the past don't cause regret - but there is often that feeling that you get when you go back to your home town for the first time. You see things in a different light.  You realize that you can't go back to the way things used to be. These thoughts have continuity with the present and the future.

At some point in the drive, I do a memory check.  I use the autobiographical memory test format and think of famous movie stars, visualize their image, and try to match names.  So far – so good.

I fantasize - primarily generative fantasies. I first encountered that term in the writings of the late Ethel Persons, MD.  She was an American psychoanalyst I found when I started to research fantasies in the 1990s.  She seemed to be one of the few psychiatrists writing about it. Generative fantasies are primarily problem solving fantasies that are more stimulating than coming up with lists in your head or your software. As I type that I am reminded of another road trip (east of Duluth on Hwy 2) when my wife asked me: "Do you ever have fantasies?' I told her I was fantasizing right at that time and she was very interested in the content. "I was thinking about what it would be like to win the men's 500M in the Olympics." She knew immediately that I was thinking about speedskating. I took up speedskating during residency and got quite good at it in my 40s. I was never an elite speedskater by any means, but I had the movements down, could endure the pain, and skated a lot of laps.  Part of learning the movement had to do with fantasies and thinking about the skaters I was seeing in the Olympics and racing against and remembering any advice I had received. I always have plenty of these thought patterns that seem focused on a hypothetical future.

 As a student of consciousness, I always wonder about how all of these thoughts are generated and (as a psychiatrist) what they might mean. Twenty years ago, I did a presentation on what I called the bus theory of the human brain. In computers, a bus is any system that connects components and allows data transfer between those components.  I decided that there was not enough emphasis on white matter and studied those tracts, their fiber content, and tried to calculate the bandwidth of those fiber tracts. At about the same time, I was wrapping up a course that I taught for many years on dementia diagnosis and cortical localization that was more of a behavioral neurology approach to the problem.  I tried to think of all of the recent papers I had pulled on hippocampal connectivity and recent papers on the neurochemistry of the hippocampus.  I thought about a paper I recently read on entropy and consciousness and whether thermodynamics could be a granular explanation for conscious states.  I am still a skeptic.

My wife wakes up.  We are driving home from her high school class reunion. There is a significant celebrity in her class and he sent a video when he could not make the reunion. The audio-visual equipment did not work, but we could see his projected image. We start to talk about the events of the night and what some of them might mean.  We talk about the A-V problems and the celebrity who clearly has become a projective test for everyone in her class. We talk about how good it will be to get back home and what we will need to do to reestablish the routine.

Thinking is a big part of life for me and life is very good…..

 

George Dawson, MD, DFAPA  

 

Photo credit for this one goes to my wife.  That is a Tomorrow River sign shot alongside Highway 10 last weekend.

References:

1:  Osanai H, Nair IR, Kitamura T. Dissecting cell-type-specific pathways in medial entorhinal cortical-hippocampal network for episodic memory. J Neurochem. 2023 May 30. doi: 10.1111/jnc.15850. Epub ahead of print. PMID: 37248771.

Computational Aspects of the Human Brain

As part of my lectures on the neurobiology of addiction - I digress briefly to discuss the computational aspects of the brain.  A lot of that discussion is focused on on the above graphic showing that overlaps in capacity with a list of the world's ten fastest supercomputers.  At least that is the estimate of the AI Impacts group.  It is basically a computation based on edges and nodes. I include power estimates for a brain from existing hardware to the actual power estimate of the human brain that I would guess every physical chemistry student from my era had to contemplate at one time.  And then I try to stimulate some discussion of supercomputers versus the human brain and it generally falls flat.  My Socratic process goes something like this:

"OK so we know that humans can't really beat computers on straightforward calculations so what advantages do we have?"

"I will give you a hint - why do we all go thorough residency training? Why can't you learn your specialty by reading about it in a book?"

The first lesson is pattern matching.  The human brain is designed not only to match patterns but to be trained to match a lot of them.  Some research article suggest about 88,000, but when  you consider what has to be matched that has be very a very low estimate.  I quote references from 15-20 years ago and a course I used to teach on diagnostics and diagnostic decision making.  Ophthalmologists correctly diagnosing diabetic retinopathy at a much higher rate than nonspecialists.  Dermatologists diagnosing rashes faster and correctly classifying ambiguous rashes with greater precision than nonspecialists. If I am really on a roll I might digress to talk about Infection Disease rounds at the Milwaukee VA sometime during 1982.  I was the medical student on a team of residents and fellows doing a consult for possible subacute bacterial peritonitis.  As the attending listening to the presentation he was also looking at a rash on the patient's shin.  By the time we were done he had also diagnosed a strep infection in addition to the peritonitis.  When you have significant pattern matching capacity, and you have been exposed to relevant patterns you can recognize them quickly and improve the speed and accuracy of the diagnosis.

I move on at that point to illustrate that the computers are catching up.  The simple captcha is less robust in discriminating machines from humans.  Opening an account may take more that checking the "I am not a computer" box. Now you might have to look at 8 pictures and check the one that contains an automobile or a stop sign.  Some of these photos are often difficult for humans to decipher.

At that point I touch on human consciousness - both the unique aspects and computational power it takes to generate.   About a decade ago I started saying that if there are 8 billion people on the planet - there are 8 billion unique conscious states. It makes sense at a number of levels especially when I put up hard numbers on cell types, protein types, the genetic information represented, and the typical stream of consciousness that every person experiences every day.  What is the content and flow of that activity? How does it get biased in psychiatric disorders and addictions?  How much computational power does it take to generate all of this information?

My latest step is what I like to consider The Matrix observation.  If I am standing in front of a room of 15-20 residents - what does it take to generate the physical representation of all of the people and all of the objects in that room? What does it take to make all of those representations unique? There can be a general consensus about what is happening - but just looking around it is clear that there are obvious different experiences.  One person looks very interested and one semi-interested.  One person is more focused on her Smartphone and is indifferent to my presentation.  Some people look sleepy.  Others look irritated.    They also appear to be indifferent to the context.  I know that my job is to try to get this information across and make is semi-interesting.  There is no real expectation on the residents.  It is clear from the questions I ask that they really don't know too much about the brain.  There are parallel streams of information processing that allow us all to evaluate what is occurring on the fly both the information content and emotion.  In some case there are pre-existing heuristics and in other cases associative memories and biases.  All of this represents a tremendous amount of information or computational power depending on how you may want to discuss it.

I have been preoccupied myself with the computational power and estimating it accurately. I used to try to model it in terms of electrical buses and neuronal firing rates - but the numbers I got were far too low.  There really are no good equivalents in the physical world with the possible exception of the Transversed Edges per Second (TEPS) metric used by the AI Impacts group for the above graphic.  You can't really use estimates of typical audio or visual information and concluding that is what is being processed by the brain.  I have never really seen an accurate estimate of all of the sensory information that the brain is handling in real time.

I went to bed last night and waited for sleep reverie or that period of time where you stream of thinking is jumbled and illogical just before you fall asleep.  As a chronic insomniac it is one of the few reliable cues that I am probably getting some sleep.  It happened when I had a sudden image of a baby high up on a brick wall, followed immediately by a person who seemed to be me sitting in a single seat futuristic car.  The salesperson was describing it to me and suddenly the car and everything else was being swept down what appeared to be a very sophisticated hydraulic roadway. The roadway was bright orange and the salesman shifted his pitch to tell me the advantages of this kind of a roadway with this car.  The roadway was moving at about 20 miles per hour.

I shifted briefly and remembered it was 2018 and I was in my bedroom in Minnesota.

And for a minute I thought about being able to estimate the information necessary to generate that brief full color science fiction scene and the three or four more I would encounter that night.


George Dawson, MD, DFAPA


Some additional examples as they happened:


1. Dream of 11/22/2018:  I am back on my old inpatient unit.  The layout is exactly the way it was 20 years ago (the building has since been razed).  I am working with the same staff.  I walk into the examination room to look at the templates for the day.  In those pre-EHR days I had designed a template with all of the relevant features necessary for the billing and coding requirements.  At the time we were all threatened with legal action if we did not comply with these regulations even though they were totally subjective.  In those days I worked with a physicians assistant who prepared the templates ahead of time before we started interviewing patients and completing the subjective aspects of the evaluation and documenting the progress.

The templates were all stacked in two circular patterns - ten templates in each circle.  They appeared to be the exact temples that we used right down to the blurred fonts from being photocopied too many times.  The precise handwriting of my physicians assistant in the diagnostic section was exactly the way he wrote things down.  The placement of the exam table and crash cart were exactly where they were in reality.  The table we used was circular and about 6 feet in diameter with a laminated blonde wood finish and it was also exactly the way it was in that now 20 year old reality.

I looked at the templates and asked myself: "Why are they all face down?  I can't see the patient's name or identifying data.  I will have to go through them all to find the correct template when I start interviewing patients."

I felt somewhat irritated.

And then I woke up. 

2. Dream of 11/23/2018: I am in a large modern, multi-floor medical facility. It is not one that I specifically recognize, but it seem like there are elements of many that I have been in.  I am rushing around on the ground floor. The impression I have is that I am late for a lecture. It doesn't seem to be an explicit CME lecture but everyone else there (including myself) is too old to be a medical student or resident. I run into the elevator just beating the door as it closes.

I make to to the lecture.  It is basically a large room - maybe 50' x 50' and for some reason I burst through the door running at full speed.  Just before the crash into the back wall, a guy standing on the side wall grabs my arm to slow me down and stop me.

I ask myself if that was really necessary because my plan was just to stop myself by reaching out and planting my hand on the back wall.  I notice that there are several people who I assume are physicians that are standing and sitting near the back wall and they seem a little alarmed about something.

Then I am back in the elevator and headed to the ground floor.  I am walking out of the building and realize that I am chewing something metallic.  I realize that is is a collection of machine screws, nuts, and ball bearings. I realize that is purchased them on the ground floor of this building and that they are sold for that purpose.  I also know that I cannot really chew them or I will break my teeth.  I have to cautiously move them around in my mouth.  They remind me of a chap stick product that is applied with a ball bearing device at the end of the dispenser.

I wake up with a metallic taste in my mouth.

3.  Dream of 11/24/2018:  I am back in my home town. The streets and buildings are identical to the way they look in reality.  I am with a friend of mine and we are looking at a 1960s vintage Buick.  It is large and chalky white.  He tells me that his sister recently bought it and she wants to take everyone for a ride.  He thinks I should come along, but just then I remember something that his sister said to me in the last 15 years that would make me not want to go with them. He is talking about the car as though it is a great buy, but as I walk past the tail end of the vehicle, I notice that it has a new paint job and that whoever did it just painted over the decals of the previous dealers.  You can see them faintly through the paint.

I tell my friend that I can't stay around because I have to go grocery shopping. Just then one of his friends comes out and tells me that he has a lot of groceries he can just give me so that I will not have to go to the store.  I decline but he continues to insist. I reluctantly accept free groceries and sling them over my shoulder in a large garbage bag and start to walk home.

The real path home is just 6 blocks - 4 blocks south and 2 blocks east. It is all residential. But in the dream I encounter a large modern baseball park right next to the street. The game is just completed and they are interviewing the winning pitcher. She is in her mid 20s and short and compactly built.  Her uniform and short brown hair are drenched with sweat.  Just then I notice that it is hot. The announcer asks her if the heat was a factor in the game and she says:

"The hot was so hot that when my hot fingers touched the hot ball - I could barely feel it." 

The ballpark looks real.  There are thousands of cheering fans and the announcer and the pitchers statements are amplified over the PA system.  Everything is in color.

I wake up and feel hot and flushed.

Dreaming of the EHR

The Dream:

I am at the APA convention.

It is in a crummy hotel attached to a mall. I am going down to the street level in an elevator and it stops at a level where there is a big cinema complex. An 8 year old boy runs excitedly into the elevator and jams in to my left. The elevator is crowded. He looks at my name badge and says: "What would George Dawson say if the Watson computer said he wasn't doing a good job?"

I glance down at him and say: "George Dawson would not care."

The kid says: "That's not good" and laughs intensely.......


It is all a dream. I had that dream early Saturday morning. It doesn't require detailed analysis. That last thing I did on Friday was try to review a 22-page paper record that was generated by a modern electronic health record (EHR) system. With the exception of a few paragraphs it was largely unintelligible. It contained bits and pieces of information. I was looking for imaging (CT, MRI, ultrasound reports) and ECG data, but instead could find only a few lines that summarized fewer results. There were no dates - no hospital admission or discharge date.  Although the hospitalization was longer than a week - there was no medication administration record or MAR - showing the specific dates when medications were changed.  There were no comprehensive reports that I am used to seeing for the past 30 years from Radiologists. There was no discharge summary. The documentation was basically unacceptable as a source of clinical information and yet it was created by a very high end, enterprise wide EHR system. It brought back a memory of a mandatory meeting I had with a "coding specialist" about 10 years ago. That person let me know that I had "passed" the documentation review in that I had ticked off the necessary "bullet points" so that documentation specialists would approve my EHR note for the day and the associated billing document that had to be submitted with each note.  She showed me how I could do things faster by ticking off a series of check boxes and electronically signing the note.  She was shocked when I told her that I really could not sign my name to that document because there was no sign that an intelligent human being had seen the patient.  For all of these reasons, very poor documentation in the EHR is always on my mind.

My attempt to read the last report may have been enough of a reason for the dream, but I also spent time on Thursday with a colleague who really dislikes the EHR for additional reasons. We regaled our spouses with tales of incomprehensible reports.  In addition, his reports require a synthesis of many imaging, lab, and clinical reports.  He previously used a system where all of the reports showed up in a queue and he could go down that list in chronological order to dictate the report.  In the new system, he has to go to tabs to find all of the reports he is looking for.  Some of these tabs are hyperlinked and the reports don't load very well.  In the end, he and his colleagues end up printing out all of the reports on paper so they can dictate then more efficiently without having to search for what they need in real time in the EHR.  That reminded me of an experiment I did about 8 years ago with the same EHR.  I went in and read all of the clinical notes looking for chronic diagnoses that were not addressed.  I came up with an additional 8 diagnoses from 340 clinical notes buried in the EHR. There is generally no good way for physicians to mine data on their own patients to make sure that they have done the most thorough assessment of their problems.  On the other hand administrators can get detailed numbers of mouse clicks by nurses in primary care clinics and rate their productivity in terms of mouse clicks, screen views, or tasks completed.  My colleague's theory was that the current EHR is selected for the administrative capabilities like monitoring doctors or nurses rather than any inherent advantage for medical staff.  The major evidence for that is that many EHR vendors have permanent staff in the hospital and they are making constant modifications to the EHR.  In many cases there are meetings of all the physicians in a particular department about these modifications.  The hospitals and clinics purchasing these systems are purchasing incomplete products that require what seems like constant revisions.

It has been about 15 years since the blight of the EHR hit physicians.  It was originally called the electronic medical record (EMR) but I suppose some business type decided that they could really solidify the corporate stranglehold on medicine by eliminating the word "medical" from another phrase.  Corporate psychology also dictates that they give the impression that they are maintaining health rather than treating medical problems.  That is another good reason for eliminating the word medical from the corporate lexicon.

The marketing of the EHR has been masterful.  The political hype promised untold savings.  National candidates seemed to suggest that we could actually "save" enough with the EHR that it would cover a substantial part of American health care inflation.  Any physician involved in the implementation phase of enterprise EHRs knew that was a bold faced lie.  There is no way that annual multimillion dollar a year licensing fees as far as the eye can see are going to save anybody any money.  In fact, I am certain that many clinics and hospitals have had to cut staff and services just to bankroll the EHR. Nobody has ever followed the money on the EHR debacle as far as I know.  Congress is well known to invent businesses and turn people into billionaires overnight.  All it takes is a few Congressional mandates about the need to use an EHR and electronic prescribing.  There is no mandate to keep things cost effective of make sure that independent practitioners can afford it.  There are mandates to implement EHRs and electronic prescribing and the White House brags about it.  The following graphic and text are from a White House document on the EHR entitled: More than Half of Doctors Now Use Electronic Health Records Thanks to Administration Policies.

The problem with the White House statement is that despite spending about $3 billion dollars a year and in some cases $44,000 per physician,  the value of the EHR for the reasons already stated remains in question.  It is very handy to be able to pull up lab results and x-rays on a computer screen.  It is also very handy to be able to send electronic prescriptions to any pharmacy in the country.  On the other hand, it is reasonable to expect that a multimillion dollar piece of software will write a report that any hundred dollar database software from the 1990s could write.  That same software should be capable of allowing physicians to search their own patient results for quality and report writing purposes.  In the end we are left with very expensive, high maintenance systems, and massive amounts of information that is either buried in storage because it is not easily accessible or because it is worthless and generated primarily for justifying a billing document.

That is one of the many real costs of having a health care system run by bureaucrats and politicians.  


George Dawson, MD, DFAPA


Attribution:

Photo at the top of this blog is by Paco Burrola on Flickr and is used courtesy of this Creative Commons license.

Neurotic Kids

I was watching the FX comedy program Louie (Season 5 Episode 5) and encountered one of the funniest scenes I have seen on television.  Louie is a neurosis based comedy, but it is also a show that many people will not be comfortable with because of content that results in the MAL warning.  In this episode Louie takes his 10 year old daughter in to see Dr. Bigelow played by Charles Grodin.  I heard that Grodin came out of retirement to play this character largely because he was impressed with Louis CK's technical expertise in filming the program.  We met him in an earlier season when he was trying to dispel Louie of the notion that he has done anything to get rid of his back pain and instead focuses on the philosophical predicament of the three-legged dog that he is walking.  After an introduction to the state of that animal he asks Louie: "What is the only thing happier than a 3-legged dog?"  I won't give away the lesson but you can find it on YouTube.

In this episode, Louie has brought his 10 yr old daughter Jane in to see Dr. Bigelow.  There are some preliminaries about whether she had a rash on her arm for 2 days or 30 days that has since cleared.  From there Jane goes on to consider: "Weird things in my head."  She is feeling like "I am sweating on the inside of my face" and builds this description with several "and then" clauses until she comes to a fantastic conclusion.  Dr. Bigelow looks at her and without skipping a beat gives her a response that I have both heard from physicians and takes care of the problem.  It also immediately shifts the frame from: "Is there something unusual about the way that Jane thinks?" to this being a completely acceptable exchange between a 10 year old and an old family doctor.  I am not going to disclose Dr. Bigelow's punch line for those who have not seen this episode and I encourage you to watch it.  It is worth it for this one scene that is so artistic, with timing so great, and it is the best acting from a child actor that I have ever seen.   It is incredibly funny.  I laughed out loud when I saw it and still laugh when I think of it.  Dr. Bigelow's comment is an example of the implicit message: "I am taking you seriously at the neurotic kid level and not commenting on your behavior like you are a little adult." It also caused me to reflect on my childhood as a neurotic kid.

Neurosis is an old word these days.  To me it always meant conflicted either in reality or at some symbolic level.  If therapists are involved, the conflicts end up being conceptualizations based on their theoretical models.  No matter how you cut it, anxiety is the common affect and there is usually a lot of it focused around unrealistic patterns of worry.  The child psychiatrists that I know dismiss many of the eccentric behaviors they hear about and are unconcerned about what a lot of parents seem very concerned about.  I have not assessed or treated children in over 25 years.  My work comes at the tail end of childhood neurosis.  The 18 year olds in high school and college students who become suicidal after their first boyfriend or girlfriend breaks off the relationship.  It has given me the opportunity to advise them why they are hurting and about life in general.  They seem to understand that by the time they get to my age that those problems in life will not hit them nearly as hard.  I reassure them that when that happens, meeting me will be a distant memory and I will probably be the only psychiatrist they will have ever met.

But it wasn't that long ago that I was a neurotic kid myself.  I won't disclose the full breadth of what happened to me so bear that in mind when you read about some of these incidents.  The first bad sign was that I have never really slept well.  Sixty years later that is still a problem.   I  am a chronic insomniac.  I also recall vivid nightmares as a kid, with frequent visits from a being I called a "Deathalow."  The Deathalow would just walk into my room at night and look very scary.  It was the kind of behavior you see in a lot of horror movies, so this is probably a common experience.  My parents and everyone else were puzzled because nobody had ever heard of a Deathalow.  But they finally caught a glimpse of the inner workings of my mind when I started pointing at Catholic nuns and screaming: "Deathalows."  Some time later, I pieced together the fact that Deathalows were a composite of a very bad chalk drawing of my grandmother's face in a nun's habit.

Just a few years later I was sitting in our living room watching television and I saw what appeared to be a Sir Walter Raleigh like figure walking up behind my father and preparing to stab him with a dagger.  I shouted out what was happening and my parents freaked out.  My mother was a frequent caller to our family physician and his advice was clear: "Stick him in a tub of ice water."  No visit to the ER to see the crisis team, just ice water.  They did so immediately, and while I was there I watched the comedy/tragedy masks on the walls in the bathroom laughing and crying while snakes slithered up toward the ceiling.  That was at least until I cooled off.   Then all of the hallucinations vanished.  But it was the death of a family member that was all I needed to develop the longest preoccupation that I had in childhood - death and physical illnesses.  For a while I was preoccupied with having cancer, rabies or being poisoned.  I recall one incident after a Soviet nuclear test when we were warned about a large cloud of fallout passing over northern Wisconsin.  We were advised to stay indoors.  At the peak of that fallout, I can recall seeing radioactive particles floating in the air.  The rabies preoccupation was the longest.  I played football almost every day and was always alert to the presence of dogs.  At one point, I thought that a dog may have had rabies and I had inoculated myself with the virus after I fell catching a pass.  For months, I monitored myself for the development of symptoms of rabies.  I would get up several times a night to look in the mirror to see if my physical appearance was changing (I was up anyway).

Around this time, I started to get nightmares about a large glass pyramid.  There were several tiers of panels in the pyramid and on each panel was the face of a woman wearing Kabuki make-up shouting in a shrill voice: "Chinese ghosts!".  In each case, I would wake up extremely anxious and wonder why I was dreaming that dream.  And then... one night I decided that I really did not have to walk into that pyramid.  It had a very long entrance-way.  I thought before I fell asleep that night: "Just wake up if it looks like you are going into the pyramid,  You don't have to go into that pyramid."  And I was right.  I woke myself up before the entrance to the pyramid and it was gone.  I never dreamed that dream again.  But the neurotic behavior in the daytime was harder to get a handle on for a long time.  I had to tell myself that I had no control over if I lived or died.  In some cases, I got some very negative feedback on the poisoning hypothesis as in: "Are you accusing me of poisoning you?"  I eventually forced myself to think of other things.   Eventually that forced aspect was gone as I developed more interests.  As my reading and research in other areas increased, my worries about cancer, rabies, and death dissipated.

Throughout all of this, I never saw a counselor, therapist, or psychiatrist.  I got the "Dr. Bigelow advice" from our family physician with treatments ranging from "throw him in a tub of ice water" to a rather primitive creosote-like nasal lavage that all of the kids in my family got if we went in to see him for a cold.  I am convinced it was an aversive therapy to keep us out of his office.  I have never seen that treatment used anywhere else in medicine.  

This merely scratches the surface of my experience as a neurotic kid.  It may be why I got such a laugh out of Dr. Bigelow's advice.  And of course it also causes me to wonder what would have happened if I had received psychotherapy or medication for these "symptoms."  Would I have encountered one of the wise child psychiatrists I know or somebody who thought I was psychotic?  I was definitely not as calm about it back then as I am recalling it now - there were after all snakes on the walls!

But I eventually turned it around on my own and became a guy who can appreciate the humor in being a neurotic kid and somebody who can relate to them.


George Dawson, MD, DFAPA




Supplementary 1:  No guarantees on how you will find Louie.  I find much of his comedy brilliant, but some is also cringeworthy so as always watch at your own risk.  The segment I am talking about is less than 2 minutes long about 2 1/2 minutes into Season 5 Episode 5.

Supplementary 2:  To all my psychiatric colleagues out there, I did think about these disclosures.  Hardly anybody reads this blog and I don't anticipate doing any transference based psychotherapy.  I think it is also pretty obvious that you reach a point in your life where all of these neurotic behaviors are irrelevant.  All of the other main players are dead or forgotten and there is no emotional impact.  The experiences themselves are history and have been for 50 years.  That is how I chose the disclosures.  In part they were also modeled on some disclosures I have read in books written by psychiatrists who disclosed things that happened to them as adults.

Supplementary 3:  The more I reflected on the historical context of neurosis, the more I realized that it means something different now than when I was a kid.  When I was a kid, it meant that you were crazy in the popular sense of the word.  Nobody had a nuanced appreciation of mental illness and how anxiety or obsessions were different from psychotic disorders.  Today, I think neurotic behavior is reinforced to a point.  For example, the parents who say: "He or she is 12 going on 30" and seem to see their children as small adults who may need some competitive advantage like cognitive enhancement.

Supplementary 4:  The glass pyramid graphic is a download from Shutterstock for non-commercial use only and this is a non-commercial blog.
 
Supplementary 5:   A useful interview question for adults with anxiety and depression:  "There are all kinds of theories about how people get anxious.  One of those theories is that our minds come up with stories to fit the level of anxiety that we have.  That can be transmitted from one person to another.  Looking back on your childhood can you recall anyone who seemed to transmit their anxiety to you?

Violence and Voices

One of my colleagues posted this NYTimes  reference to my Facebook feed this morning.  It is written by anthropologist T.M. Luhrmann.  She has a number of references in Medline relevant to this article.  Her basic thesis is that violent or aggressive auditory hallucinations experienced by people with psychotic disorders are culturally determined.  She concludes with the irony that the cultural factors responsible for a lack of will to initiate any meaningful gun control measures may be responsible for more violent auditory hallucinations than are experienced in other cultures.

What is the evidence?  She sites a cross cultural study of 40 people with schizophrenia in India and the United States.  Across cultures the horrible voice in India were focused on sexual themes and in the US they were focused more on aggression and torture.  There were other directive voices focused on routine directions.  Not a lot of detail.  As a guy who has talked with hundreds of people who were experiencing voices - the common ones are basically background noise like people mumbling or talking at a volume that cannot be understood.  Clearer voices clearly comment on the person experiencing them.  The comments can vary from routine such as what the person is doing to very negative commentary or ridiculing them.  At the extremes voices tell people to harm themselves or others or commit suicide.  Those are the typical voices that psychiatrists are trained to ask about for the purpose of assessing dangerousness, but recent studies show that they are probably poor predictors of actual violent acts in clinical settings.

What about the larger observation that voices would incorporate culturally relevant elements?  It seems to me that would be a given.  As I considered the problem I recalled reading J. Allan Hobson's book The Dreaming Brain when it first came out. He describes acquiring the dream journal of the Engine Man who recorded his dreams in great detail and without interpretation in 1939.  The Engine Man was "fascinated by railway trains" and the content of his dreams that he describes and draws contains a lot of that subject material.  Railway trains were the technology of the day.  They were part of the culture and the conscious states of me interested in technology.  Like the Engine Man it is difficult to conceive of a person experiencing voices or delusions without a cultural context.

It is difficult to imagine scenarios that lead to voices de novo without exposure to a plausible or even science fiction origin.  Hence the common scenario that there is an agency projecting these voices as the most likely cause.  It can also imply motivation for the perceptual changes as well as the content.   I doubt that voices originating as a beam from the police, the CIA, the FBI or Homeland Security occurred before these agencies were invented.

The other association I had is the theory (or axiom) that the prognosis of schizophrenia is much better in the developing world.  This idea came about as the result of a number of World Health Organization Studies and others done in the 1970s to 2000s.  Those studies suggest a better prognosis for schizophrenia in the developing world.  That theory has been called into question based on methodological considerations by Cohen et al.  At the anthropological level, the argument by Dr. Luhrmann reminds me of a similar argument about whether or not primitive peoples were inherently peaceful and became aggressive only after being influenced by social organization.  Large scale warfare only becomes possible as the institutions of civilized society grow.  Primitive man by nature was inherently peaceful and would get involved only in small scale conflicts around issues like marriage and property.  Kealy refers to this as the Myth of the Peaceful Savage.  He dispels that myth in his book War Before Civilization and points out that prehistoric man was as aggressive and violent as modern man.  Violent and aggressive solutions appear to be universal and it is likely that the culture in America is no more violent than what people experience across the world.  The only plausible cultural argument that is rapidly vanishing is the exposure to media violence on a 24/7 basis.  At anthropological level, the basic question seems to be why all human societies seem to regard warfare and aggression as an ultimate solution to unresolved conflict.

The larger issue of course is the fact that the experience of hearing voices is much more than that.  The entire conscious state is affected.  There is not a linear sequence of events that proceeds form a voice to an action.  Practically everyone with that experience has a substantial change in their conscious state.  The usual stream of consciousness is affected as well as mood state and decision making biases.  At times that is detected there can be what appears to be a complete change in the personality of the affected person.  The decisions that they currently make cannot be predicted by your past experience with them.

There are several psychotherapeutic approaches to the problem.  From a psychiatrist's perspective is is generally necessary and advisable to discuss the voices at some level with the patient.  An explanation is necessary that is more than an incomplete biological one as: "You are hearing voices - take this medication and it will get rid of them."  Most people are interested in what it means and culturally and individually based meanings are often useful.  Some of the preliminary cognitive behavioral therapy of hallucinations emphasizes the need to decrease personal meaning and when that occurs the voices may become less intense and disappear.  It should really come as no surprise that talking about voices in certain ways modifies the experience of hearing them or even results in them disappearing.  I would liken it to making a conscious decision to wake up during a dream that you don't want to have and then realizing that the dream is gone.  Although it has not been investigated I would speculate that this ability would be proportional to the degree that a person's usual conscious state has been affected.


George Dawson, MD, DFAPA

Hobson JA.  The Dreaming Brain.  Basic Books, Inc.  New York, 1988.

TM Luhrmann.  The Violence in Our Heads.  New York Times September 19, 2013.

Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787; PubMed Central PMCID: PMC2632419.

Kleinman A. Commentary on Alex Cohen et al: "Questioning an axiom: better prognosis for schizophrenia in the developing world". Schizophr Bull. 2008 Mar;34(2):249-50. Epub 2007 Dec 3. PubMed PMID: 18056682; PubMed Central PMCID: PMC2632393.

Keeley LH.  War Before Civilization - The Myth of the Peaceful Savage.  Oxford University Press, 1996.

Dream recall endophenotypes?

Dreams are important part of psychiatric practice.  A discussion of dreams comes up in a number of contexts ranging from diagnoses like Post Traumatic Stress Disorder to primary sleep problems like Nightmare Disorder.   Dreams can be affected by substance abuse and medications.  Some people are still interested in what a dream might mean or they have their own interpretation that they want to discuss.  Sleep is often a source of stress to people who come in to see psychiatrists and questions about dreams frequently come up in discussion about too much sleep or too little sleep.  As a result, I have done a lot of reading and study about sleep and dreams.  I have the last 5 editions of Kryger, Roth and Dement's Principles and Practice of Sleep Medicine and additional texts and journals.  Since I worked in a residential settings, I see people who have their sleep observed and can tell me if they have apneic episodes or behavioral problems associated with sleep and refer them for polysomnography.  Whenever I ask about sleep there are a significant number of people who tell me: "I never dream."

Is it possible that a person is not dreaming at night?  Since the discovery of REM sleep it is well known that this biological process and dreaming are inextricably linked.  Dream researchers have determined that dream recall is influenced by a number of factors including the setting, whether a person is awakened slowly or rapidly and the sleep stage that they are awakened from.  For example, awakenings form REM sleep can result in 4 or 5 dream narratives per night.  Writing dreams recalled the next morning is not likely to produce that amount of content.

When an article suggesting a marker for differences in dream recall showed up on my Facebook feed I was naturally interested.  The authors in this case had a pool of 1,000 people who completed questionnaires indicating an interest in the study.  They were contacted by phone and asked the question: "on the average, how many mornings in the week do you wake up with a dream in mind?"  That is an important distinction from the people I talk with because they usually say: "I dream a lot." or "I don't dream at all."  For the purpose of this study the authors defined high recallers (HR) as those who recalled dream narratives or images on three mornings per week(4.42 ± 0.25 SEM dream recalls/week).  Low recallers (LR) recalled narratives or images per month (0.25  ± 0.02).   The subjects underwent standard polysomnography and an experimental paradigm that involved presenting a recorded voice saying first names through headphones in the alert and REM state.  Event related potentials (ERPs) and alpha frequency (8-12 Hz) responses to the auditory hallucinations were recorded.        

The authors summarize their data using the above graphics.  The top graphic is a little confusing at first if you are used to seeing similar graphics from QEEG analysis.  It is only alpha spectrum and the white lines represent occurrences of the auditory stimulus.  The bottom row shows the HR - LR power and the significant difference at the Pz electrode.  The black and white graphics at the bottom show ERPs and alpha power in response to first names for HR, LR, and HR-LR.  In general the alpha power decreases during wakefulness and increases during  REM sleep on all graphics.  The HR group had a more sustained decrease in alpha power to first names at 1000 to 1200 ms during wakefulness.

The authors go on to discuss the implications of these findings including the theory that increased alpha power during REM sleep could imply microarousals without awakenings.  A second hypothesis is that increased alpha power during REM sleep implies cortical deactivation rather than microarousal that would lead to decreased processing and less likelihood of awakening.  The authors interpret the greater reactivity in ERPs and alpha activation in the HR state as indicating that alpha is associated with activation in sleep.  They point out that the increased intrasleep wakefulness being great in HR is consistent with that observation.  They go on to point out that this trait may be central to a personality organization and cognitive substrate within the brain.  They pose a larger question about moving from one phenotype to the other.  They make the important observation that a hippocampus needs to be in the loop for dream recall and that there may be a point where functional imaging will be able to provide that level of detail.

I could not help but wonder if dream recall is a possible endophenotype.  What would happen if families were studied on their ability to recall dreams?  Would there be characteristic findings on polysomnography?  What would the pattern of heritability be and what would lead to transitions between phenotypes?  Sleep medicine is one of the areas of psychiatry where there are clear and valid biomarkers and it would be interesting to look at those differences.  In the meantime, it appears that what I have been saying to people about possible REM related dreams seems to be true based on this study.  Microarousals - probably from a number of possible etiologies will probably increase dream recall of characteristic REM type dreams and you may not actually experience interrupted sleep.  There is also the interesting consideration of dreaming without the hippocampus being engaged and have no dream recall on that basis.

George Dawson, MD, DFAPA

Ruby PM, Blochet C, Eichenlaub J-B, Bertrand O, Morlet D, Bidet-Caulet A (2013) Alpha reactivity to first names differs in subjects with high and low dream recall frequency. Frontiers in Psychology 4.

All of the figures in this post are from the above reference and are produced here via Creative Commons license.  Please see the original article for all of the details.