How Should APA Guidelines Work?

The guidelines of the American Psychiatric Association (APA) are an interesting story in how guidelines are important if used correctly by professional organizations.  The whole idea behind a profession is that the practitioners in that area have special expertise and that the expertise is standardized to some degree.  Standardization is useful in the case of physicians to assure the safety of the practitioners and so that people have some idea of what to expect in terms of safe and effective care.  Over a decade ago the APA began producing guidelines for practice in various areas of the field.  I thought it was an exciting development.  The guidelines were initially sent along with the monthly copy of the Journal of the American Psychiatric Association.  All of the guidelines are available publicly on this web site, but hardly anyone knows about them.  I make this statement because one of the many red herrings that the critics of psychiatry use is that psychiatry has no standards of care.  They seem quite shocked to find that these guidelines exist and address their complaints directly.  

I was asked to critique one of the existing guidelines and suggest how these guidelines could be used more effectively.   In looking at the guidelines web site, it is apparent that some of the guidelines have not been updated in quite a while.  Publication dates range from 2000 - 2010.  Given the pace of clinical research 5 years might be somewhat acceptable, but 10 - 15 is probably not.  Another issue that the APA needs to grapple with is the diagnostic manual versus treatment approaches.  There is widespread confusion about whether or not the DSM-5 is a guidebook for treatment as opposed to a guidebook for diagnoses.  The APA actually two approaches to treatment guidance - the guidelines themselves and a text entitled Treatment of Psychiatric Disorders (TPD).  TPD is currently in its 4th edition and it has gone from a series of two volume detailed text to a more basic single volume text.  That text was published in 2007.  Some of the chapters in the previous editions provide some of the most detailed information on the pathophysiology and treatment of certain disorders that could be found anywhere.  At that level of analysis, the APA has gone from providing outstanding information on the pathophysiology and treatment of psychiatric disorders to a relative vacuum over the past 10 years.

For the purpose of a more detailed analysis I will consider the Practice Guidelines on Substance Use Disorders and the associated Quick Reference Guide and Guideline Watch - a 2007 update of the original 2006 guideline.  I looked at the Guideline Watch first because it should reflect the latest literature reviews and treatment guidelines.  The document reviews medication assisted treatment of tobacco and alcohol use disorders with varenicline, naltrexone and acamprosate.  The document was a good summary of the literature at the time but it needs a serious update.  Since then there have been more extensive studies of the genetics, combination therapies, re-analysis of existing studies and side effects of naltrexone, acamprosate, and varenicline including use in specific psychiatric populations.  In at least one case, the current literature supports a course of action that is exactly the opposite of what is recommended in this document.  That course of action is: " Given its high potency and partial agonist activity at central nicotinic acetylcholine receptors, varenicline should not be combined with alternate nicotine replacement therapies."  An inspection of the references for varenicline notes that additional research has been done in this area and should be discussed.      

The Quick Reference Guide contains extensive tables from the original guideline so I will go directly to that document.  At first glance it looks like a significant document more than 200 pages long.  But about 177 of the 276 pages of the document are relevant text.   The rest are references and polls of various expert groups on what they consider necessary for a guideline.  Looking at the Table of Contents, the first thing that is apparent is that only a subset of substance use disorders is being considered.  Although it is likely that nicotine, alcohol, marijuana, cocaine and opioids represent the majority of abused substances psychiatrists treating addiction see a broader array of compounds being abused.  The full gamut of abused compounds should probably be addressed in the guideline whether or not there is a consensus about treatment methods or not.  The safety of users and treatment setting considerations will still need to be considered as well as the need for further assessments.  A good example would be Hallucinogen Persisting Perceptual Disorder and what might be the best assessment and treatment.  If the guidelines are supposed to apply to clinical practice then patterns encountered in clinical practice need to be addressed.  If the APA does not address them - governments and managed care companies will, most frequently to the detriment of patients.

The guideline uses the following conventions for the treatment recommendations.  They are conventions frequently see in professional guidelines:

[I] Recommended with substantial clinical confidence.
[II] Recommended with moderate clinical confidence.
[III] May be recommended on the basis of individual circumstances.

The introductory section does not suggest who the guidelines are written for.   This is a critical aspect of the document.  There is an implication that it is for psychiatrists based on the statement about a comprehensive psychiatric evaluation but I think that needs to be more explicit.  It is not uncommon for managed care companies to send letters that deny care to psychiatrists.  The letter often contains a list of guidelines that an insurance company reviewer used to deny the care.  The APA needs to be explicit that these guidelines are intended for use by the psychiatrist who has personally assessed and is treating the patient and not by an insurance company employee or contractor who is sitting in an office reading through paperwork.  Somewhere along the line professional organizations seem to have lost track of the concept that only direct assessment and treatment of the patient was considered the correct way to do things.  Putting it in all guidelines is a critical first step.

The next thing I would change in terms of guidelines is breaking out the treatment setting recommendations into separate sections in table form.  For example the Hospitalization guidelines are copied into the Supplementary section of this post.  They are all very appropriate and I doubt that there are any reasonable clinicians that would have a problem with them.   The problem is that these services are rationed to the point that it is difficult for any reasonable clinician to implement them.  By that I mean that a psychiatrist cannot get a patient meeting these criteria into an inpatient detox or treatment setting based on these criteria.  As an example, consider the patient who says they are drinking 1 liter to 1.75 liters of vodka per day for 6 months.  They describe uncomplicated symptoms of alcohol withdrawal (shakes, sweats, hangover symptoms and drinking in the morning to suppress these symptoms).  I think the person in this vignette meets criteria 2 for hospitalization and detox at least.  A significant number of patients presenting to emergency departments with this pattern of findings are not hospitalized.  Many are sent out with a supply of benzodiazepines to detoxify themselves.  Many are sent to county detox facilities where there is no medical coverage or so-called social detoxification settings.  None of these non-hospitalization options are realistic approaches to the problem.  Giving a person with an alcohol use disorder a bottle of benzodiazepines for home detox ignores the uncontrolled use and cross addiction aspects of the primary disorder.  It is highly likely that person will ingest the benzodiazepines all at once or use them to treat the morning withdrawal symptoms of the disorder.  Social detoxification is an equally suboptimal approach.  It depends on probabilities.  It is more likely that the person transferred to that setting will leave due to the adverse environment and go back to drinking or undergo withdrawal and not experience delirium tremens or withdrawal seizures.  Over the past 30 years, the managed care industry has refused to consider admissions in practically all of these situations often whether there was psychiatric comorbidity or not resulting in the rationing of care at the initial assessment in the Emergency Department.  There must be an awareness that clinical guidelines don't operate in a vacuum.  Having a guideline in place that nobody can use is not the best approach to providing quality care.   Managed care companies can deny inpatient care on practically any of the 7 inpatient criteria simply by saying that they do not exist.    

On the treatment side there are inconsistencies noted in the recommendations and editing problems.  For example, there are 49 references to "12-step" and 2 references to 12 steps.  One of the first statement one encounters is:  "The efficacy of treatment is related to the amount of psychosocial treatment received. The 12-step programs, hypnosis, and inpatient therapy have not been proven effective."  That characterization of 12-step recovery is inconsistent with just about every other reference in the document.  Where it is suggested it is footnoted with a "I" designation or "substantial clinical confidence."

Rather than critique other sections based on data that was not available at the time that this guideline was posted, I thought I would end with a comment on the process and general philosophy of professional guidelines.  Right at the top of this guideline is a section entitled "Statement of Intent".  The crux of that argument is contained in the paragraph (p. 5):

 "The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed
or to serve as a standard of medical care. Standards of medical care are determined on
the basis of all clinical data available for an individual patient and are subject to change as scientific
knowledge and technology advance and practice patterns evolve. These parameters of
practice should be considered guidelines only. Adherence to them will not ensure a successful
outcome for every individual, nor should they be interpreted as including all proper methods
of care or excluding other acceptable methods of care aimed at the same results........"

I don't really agree with that approach.  The concerns about saying that these are standards of care is a medico-legal one and I have rarely found that to be a sufficient basis to practice medicine.  An example would be litigation against a psychiatrist for not following the stated standards of care in a malpractice suit.  This may seem protective of psychiatrists for varying practice styles but it also has the more insidious effect of basically allowing any standard of care to apply.  A walk down the street to a different hospital results in an admission for medical detoxification when the first hospital discharges the patient with a prescription of lorazepam and a promise to follow up with their primary care MD.  The resulting business incentive practice creep results in a complete lack of detoxification and a lack of any standards of medical care.  The default standard is whatever businesses decide to pay for.  My observation is that results in an unacceptable level of medical care.  And further:

"The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment
options available....." 

I agree with the statement but let's face it,  the judgment of the psychiatrist frequently has very little to do with the judgment of the psychiatrist or what options are ultimately considered in the working alliance with the patient.  Practically all inpatient and residential care these days is dictated by managed care companies and insurance companies irrespective of what a psychiatrist would recommend or a patient would accept.  These are standards of care that are forced on psychiatrists and patients rather than the prospective quality based standards.

Stepping back from that fact medical standards play a peripheral role to what businesses want and that unacceptable standard has been present to one degree to another for the past 30 years, I don't think a new approach in guidelines is too much to ask for.  I don't think it is too much to ask that APA guidelines be up to date, internally consistent, inclusive, actually apply as a standard of care as opposed to using business standards as the default, and be used to advocate for the best possible treatment settings for psychiatrists and their patients.  There are a number of specific methods that can be used and I will discuss them when the draft version of the latest  Practice Guidelines for the Psychiatric Evaluation of Adults comes out this year.


George Dawson, MD, DFAPA


References:

Work Group On Substance Use Disorder.  Practice Guideline For TheTreatment of Patients WithSubstance Use Disorders,  Second Edition.  American Psychiatric Association.  This practice guideline was approved in December 2005 and published in August 2006.


Supplementary 1:   These are the hospitalization guidelines from the APA Substance Use Disorders Guideline.

"Hospitalization is appropriate for patients who 

1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting

2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 

3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 

4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 

5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 

6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; 

or 

7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health [I]."      (p.  11).

Objectivity? A Role For Emotion In Decision Making

One of the reasons I like listening to Public Radio is that they provide a lot of clinicopathological case material that is usually quite illustrative, and frees me from the huge hurdle of being suspected of disclosing confidential patient information on this blog.  Just a note on the historical context.  When I started out, deidentified clinical information was a mainstay of teaching.  It was presented at case conferences and in medical journals.  At some point that became a lot less likely and in my opinion that adversely affects teaching in a way that could be dangerous to the health of patient.  The best physicians depend on pattern matching to recognize diseases and many of those patterns are recalled not just from live patients but also pictures, images, and numbers that are remembered independent of any real contact with a live patient.  When an administrator did not allow me to use deidentified MRI scan images for teaching residents, those residents end up knowing a little bit less, not in terms of book learning but in terms of the experiential aspects of medicine.  The most unique technical skill that your physician has that nobody else does is access to a vast array of patterns that were experienced in medical school and post graduate training.

I was driving around today, listening to public radio when a show came on called Radiolab.  I have heard it before and it is interesting because it tried to present science in interesting ways and in many cases that involves medicine.  Today's show was all about choices and I happened to pick it up about 1/3 of the way in or roughly the 20 minute mark.  At that point Antoine Bechara, MD, PhD began discussing the case of Elliot, a young accountant.  Elliot was working for a corporation as a successful upper level manager.  He was married and had children.  He was considered to be smart, successful, and religious.  One day a small tumor was discovered in his orbitofrontal cortex and it was successfully removed.  Post surgical neuropsychological testing showed that was still in the 97th percentile in terms of IQ testing.  He returned home and then went back to work.

What occurred following the successful neurosurgery was unexpected.  He was no longer able to make even routine decisions.  As an example, when he tried to decide what pen to use to sign a contract, it took him 30 minutes to decide whether to use a black pen or a blue pens.  All possible permutations of the decision were explored and evenly considered.  In the case where many more choices were available (the program used the example of a breakfast cereal aisle in the grocery store), the decisions became more impossible.  He was so disabled by this problem that he lost his job and eventually his marriage and family.   He got involved with a con man.  He lost his savings and went back to live with his parents.  Somewhere along the way he was seen by the behavioral neurologist Antonio Damasio, MD, PhD who tested him with visual stimuli designed to elicit strong emotional responses.  These visual stimuli failed to elicit these responses in the patient.  Damage to his orbitofrontal cortex had caused this disconnection.  Disconnecting the emotional response resulted in an impairment in decision making rather than an expected improvement.  Without the feeling state he was pathologically indecisive.

Major Anatomical Connections of the Ventral Medial Prefrontal Cortex from:  Euston DR, Gruber AJ, McNaughton BL. The role of medial prefrontal cortex in memory and decision making. Neuron. 2012, figure 3 with permission.

When I heard Dr. Bechara talking I remembered an excellent presentation that he gave on how people with addictions tend to respond to the Iowa Gambling Task (GT) and how some responses in that paradigm are consistent with increased risk for substance use.   This test looks at subjects attempts to optimize a $100 bet on choices from 4 decks of cards (A, B, C, and D).  The subject is to make 100 card selections in any order from any of the decks.  A selection from deck A or B results in a $100 reward.   There are unpredictable punishments so that the subject loses $1250 in every 10 cards selected from deck A or B.  Selections from decks C and D result in a $100 reward with unpredictable punishments resulting in a loss of $250 in every 10 cards from decks C and D.  The penalties are not fixed and some of them are substantial.  Take a look at this video for an example of how it works (the initial sum used in the video is substantially higher than quoted in the research literature).  Normal subjects eventually learned that they are more likely to get punished choosing from decks A and B and they will gravitate toward decks C and D.  The Iowa group used this test paradigm and modifications to investigate aspects of decision making in the ventromedial prefrontal (VM) cortex (bilateral lesions to the gyrus rectus, mesial half of the orbital gyrus and the inferior half of the medial prefrontal surface).

Subjects with lesions in the VM do not reduce their selection of decks A or B or increase their selection of choices in decks C and D.  The impairment in decision making can be replicated over time.  In order to investigate whether any emotional process was involved, the investigators looked at skin conductance resistance (SCR) associated with the decisions.  They looked at a window of +/- 5 seconds on either side of the decision to examine anticipatory, reward and punishment SCRs.  Normal subjects develop anticipatory SCR and they are more pronounced before selections from the disadvantageous decks (A and B).  Even the 20% of normal subjects who are self professed risk takers develop anticipatory SCRs but they are lower in magnitude when selecting for the disadvantageous versus advantageous decks.   VM subjects had no anticipatory SCR suggesting that these patients had a compromised ability to change their somatic state (skin conductance) in anticipation of an imagined scenario in an uncertain condition.

The researchers also looked at the question about whether biases in this paradigm were conscious or not.  The experiment in this case used the same decks A, B, C, and D but the task was broken up into 4 different zones.  The subject was asked about their explicit knowledge of what was happening in the game after every 10 cards.  The 4 periods included:

1.  Pre-punishment period before encountering punishment.
2.  Pre-hunch period as punishment was being encountered by the subjects till had no ideas about the game.
3.  Hunch period where guesses about favorable decks begin to appear.
4.  Conceptual period when they have a clear idea about the advantageous versus disadvantageous decks.

In normal subjects the SCRs were absent pre-punishment but began to build and was sustained.  Although 30% of controls never got to the conceptual periods they all had SCRs and played the game correctly.  50% of VM subjects got to the conceptual stage in that they could explicitly state the deck types.  That did not result in them correcting their choices.  In real life this means the patient with frontal lobe damage has an awareness of what is right and what is wrong but the correct choice is not made.  The authors use the example of a person with a substance use disorders balancing the choice between taking a drug as an immediate reward and the long term reward of a stable home, family and work life they choose the drug.  The GT has been used to study the issue of substance users and impairment in decisions is noted.  

The wiring and impact of various signaling systems on the vmPFC is complex.  It is hard to imagine methods that would allow the isolation and correlation of any of these systems suggested in the clinical vignette about the patient with the brain tumor.  The neuroanatomy is also complex.  Many of us were taught to consider the supraorbital area of frontal cortex to be typical frontal cortex,  It turns out that the most medial gyri that represent the vmPFC and are more appropriately considered limbic cortex.   Looking at a recent post on the involvement of the nucleus accumbens in decision making now provides two avenues for advancing decisions - emotions and reward pushing these decisions forward.

Apart from psychiatric disorders and addictions, these brain systems have profound implications for everyday life and the illusion of free will.  Many of the biases in everyday life that many of us would deny that we have, may be the product of the reward and/or emotional valence assigned to that string of associations through these mechanisms.  Many of these biases are unconscious.  I think there is widespread confusion that emotions compromise objectivity (as in rational decision making).  One of the main outcomes of these studies is that emotions are necessary make a decision and do not necessarily compromise the rational aspects of that decision.  The other approach I see written about is the idea that there is a reptilian brain lying deep inside the human brain and this has a characteristic response pattern (anger/rage).  It was popular to talk about reptilian brains when I first learned neuroanatomy, but a lot less was known about the integration of the human brain at that time.



George Dawson, MD, DFAPA


References:

1:  Radiolab:  Choice

2: Bechara A, Damasio H, Damasio AR. Role of the amygdala in decision-making. Ann N Y Acad Sci. 2003 Apr;985:356-69. Review. PubMed PMID: 12724171.  From a special ediction of the journal called: THE AMYGDALA IN BRAIN FUNCTION: Basic and Clinical Approaches

3: Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cereb Cortex. 2000 Mar;10(3):295-307. Review. PubMed PMID: 10731224.  This is from a special edition of this journal called:  The Mysterious Orbitofrontal Cortex

4: Euston DR, Gruber AJ, McNaughton BL. The role of medial prefrontal cortex in memory and decision making.  Neuron. 2012 Dec 20;76(6):1057-70. doi: 10.1016/j.neuron.2012.12.002. Review. PubMed PMID: 23259943; PubMed Central PMCID: PMC3562704.

Supplementary 1:

Figure 3 above was reprinted from Neuron, Vol. 76 edition number 6, Euston DR, Gruber AJ, McNaughton BL. The role of medial prefrontal cortex in memory and decision making, Copyright (2012), with permission from Elsevier.  License # 3542200221086 License date Jan 04, 2015 per the Copyright Clearance Center.

Supplementary 2:

I use the following human neuroanatomy text by Paxinos and Mai with the accompanying Atlas of the Human Brain by Jürgen K. Mai, Joseph Assheuer, and George Paxinos.  It was recommended to me by Lennart Heimer after I took one of his courses in brain dissection at Washington University.  I requested permission from the publisher to use some of these figures for teaching purposes and the fees were astronomical.  So the text and atlas are primarily useful to clarify your own thinking rather than preparing presentations.

JAMA Psychiatry Suicide Article, Statistics and AI

Suicide Rates - Selected OECD Countries

Suicide is a very important problem for psychiatrists.  Even though it is a rare event, it seems like most of our time is focused on preventing suicide.  There are many days where many high risk patients and patients with chronic suicidal ideation are seen in clinics and hospitals.  Most of them are treated in outpatient settings and very few are treated on an involuntary basis in hospital settings.  Since suicide is diametrically opposed to self preservation it is assumed that any rational person would want to get help with those thoughts and impulses.  Like most things in psychiatric practice it is almost never than simple.  Psychiatrists encounter a wide range of of reasons for suicidal thinking.  At times, the suicidal thinking was not obvious until it was declared after a suicide attempt.  Many people decide to see psychiatrists after a first suicide attempt.  Even at that point it is common to find a person who is disappointed that they did not succeed.  It is more common to find a person greatly relieved that they survived but even then that does not assure the cooperation necessary to prevent another attempt.

The standard of practice for assessing suicidal thinking or ideation and potential risk is risk factor analysis.  This has been the standard of practice for as long as I have practiced over the past 30 years.  To do this analysis, it requires making a diagnosis or a series of diagnoses and looking at associated factors and how the patient describes his/her mental state at the time.  Major psychiatric diagnoses like major depression, schizophrenia, bipolar disorder, panic disorder, borderline personality disorder and chronic substance use disorders all have significant lifetime prevalences of suicide varying from 3 to 15%.  Psychological autopsies of series of suicides find that nearly all of the patients who have suicided in these studies had a significant psychiatric disorder.  There are also studies done from a social science perspective that emphasize the social risk factors for suicide including sex, martial and relationship status, economic factors and loss.

Suicide is a widely misunderstood problem sometimes even for the patients who are experiencing the thoughts.  It is common for example to encounter people with suicidal thinking who say that their only deterrent to suicide is that they don't "have the guts" to do it.  An associated worry might be that it is "too painful."  They feel a need to explain why they cannot carry out an irrational act.  I take this to mean that at some point in time, the suicidal person's conscious state has changed.  They are no longer a rational person and that is why they must explain away the fact that they cannot carry out an irrational act.  Another common observation that speaks to the conscious state is that many people will say "I never understood how a person could be suicidal until I finally felt that way."  That suggests that the altered conscious state is associated with a mood state of depression or many times a mixture of depression, anger, and anxiety resulting in an agitated state that led to the understanding about suicidal thoughts.  A final observation is one of the most stressful parts of psychiatric practice and that is:  "Can I believe this person when they tell me they are not going to kill themselves?"  Much of acute care psychiatry hinges on that ultimate question.  The risk factor analysis is essentially nullified if the patient is in an emergency department and their diagnosis and past suicide attempts are known.  The only thing left to go on are the standard questions about current state of mind, deterrents, safety plans and whether the person seems reliable and says they will not kill themselves.   It is widely known that people kill themselves after leaving emergency departments and hospitals.  People have killed themselves in hospitals while under direct observation.

Many of these assessments become adversarial.  By the time a psychiatrist sees a patient in a hospital, a lot has already happened. In all of the hospitals where I have practiced, crisis teams, paramedics, and the police have assessed the person in the community and brought them in to the hospital.  Very few people were under psychiatric care at the time of that intervention.  Friends and family members of the patient were the people who called the first responders.  The patient is usually there out of some concern for their welfare that they may not be aware of.  The psychiatrist comes around sometime in the next 24 hours and the interaction unfolds.  Very few people seem interested in the fact that they might kill themselves.  Getting out of the hospital may be the priority.  Their approach might be one of non-disclosure or denial: "I really did not say I was suicidal." or "I did not mean it",  or "I was drunk or high at the time".  Even those responses can vary from very unlikely (as in a patient with a serious self inflicted gunshot wound) to unlikely (a patient with delusional depression stopped in the midst or a suicide attempt) to possible (the intoxication history with no suicidal ideation while sober).  The interview dynamic is also quite variable.  A person may be sullen, irritated, and not wanting to discuss much information.  They may express concerns about self incrimination: "I know what I can and cannot say to psychiatrists.  I know if I say the wrong thing you will lock me up and throw away the key."  They may blame their problems on the psychiatrist: "Look - I know you don't care about me.  The only thing you care about is covering your ass.  You are going to do whatever you want to do."  They may be more hostile and sarcastic: "Look if I was really going to kill myself I wouldn't be sitting here talking to you.  I'd be dead.  I wouldn't be talking about it."

All of these statements ignore the fact that the person is sitting in front of the psychiatrist as the result of the actions of several other people including persons affiliated with them and having their best interests at heart.  That situation is so intense and uncomfortable that it prevents physicians from going into psychiatry.  I  have had many physicians tell me they could not go into psychiatry because:  "Guessing about whether or not a person will kill themselves is too stressful."  There are many ways to reduce the guesswork involved but the point I am trying to make here is that all of these behaviors are consistent with the patient having undergone a change in their conscious state.  They are no longer acting like a person interested in self preservation, but they are now a person who is contemplating self destruction and taking active measures to hide that thought pattern.  That is the main reason why psychiatrists can't predict suicide over long periods of time with any degree of certainty.  When a person's conscious state changes that completely, their actions are less predictable even to the point that they may be potentially self destructive and want to cover it up.

That is also why risk factor analysis is so imperfect.  In the case of the diagnosis, a lot of clinicians are under the impression that if a person satisfies some written criteria for a diagnosis that provides a lot of critical information about the potential for suicide.  Many clinicians seem to miss the point that a patient can have the exact same written criteria for major depression with psychotic features and the same chronic markers on a suicide risk assessment and suddenly be much more likely to attempt suicide.  The only thing that has changed has been the patient's conscious state and their awareness that suicide is an unwanted state.  The evidence that this happens is clinical and ample.  Patients will report back to their psychiatrists that they were in this conscious state and the psychiatrist did or did not miss it.  Either way, there is no clinician in this situation who could make the correct call.  Without any clear markers, there is no way to figure out if this change in conscious state has occurred.  The patient usually recognizes it only in retrospect.

This clinical information on the assessment of suicide is what makes this JAMA Psychiatry article interesting.  In this article the authors attempt to determine predictors of suicide by soldiers in the year following psychiatric hospitalization within the Veteran's Administration hospital system over a 6 year period.  That was a total of 40,820 hospitalizations or 0.9% of the total Army personnel in any 12 month period.  During that time there were a total of 68 deaths by suicide.  That is number is 12% of all US Army suicides.  The authors consider a long list of potential risk factors that are largely demographic in nature to determine concentration of risk of suicide.  That list includes a law enforcement data base that clinicians do not have access to.  Their overall goal was to determine of it was practical identify high risk patients for post hospitalization intervention and whether that might be a cost effective way to prevent suicide.  They were able to identify the highest risk group - the 5% of hospitalizations in which 52.9% of the suicides occurred.  Like many similar studies the authors also comment on  how their "actuarial" methods usually trump clinicians making the same predictions.  I found very limited commentary on that fact that it is generally possible to illustrate what you want with enough variables or as we used to say "a large enough spreadsheet".  In this case they looked at a large number of variables to come up with 421 predictors for further analysis.  I have reviewed hospital records consisting of the printout of the electronic health record where there were scarcely 421 words and it was usually impossible to determine an admission or discharge date.  Any information on even a short term assessment of suicide risk is scant and it frequently says basically that the patient told us he or she was not going to make a suicide attempt.  In some cases a rating scale approach like the Columbia is used.  Clinicians using these scales are often surprised about how few variables change after the initial rating and how the numerical risk does not necessarily reflect an inpatient versus and outpatient population.

As I read through the article, I was also impressed with the amount of alien statistics and fairly esoteric statistical terms.  If JAMA Psychiatry wants to include these methods, I think an example of the calculations and a bibliography of additional reading would be a minimal requirement.  The addition of statistical reviewers' comments or an independent statistical discussion of the pros and cons of these methods would only enhance the quality of the discussion.  One of my concerns is that as the statistical methods get more abstract and vague notions about big data are more accepted, clinical complexity and wisdom are completely diluted down and out.  I saw a headline the other day that Internet sellers know more about your "personality" than your spouse.  It should be fairly obvious from all of the healthcare research done that is based on HEDIS (The Healthcare Effectiveness Data and Information Set) information, that demographic variables and product choices are not the same thing as clinical assessment and treatment.

If the headlines about artificial intelligence replacing doctors ever comes true, it will only happen if the machine can implement the required knowledge.  The performance of computers sifting through text based findings and diagnostic criteria has been know for 20 years (reference 3).   Those data points were generally far superior to demographics.  I owned 2 of those programs and they don't bother to sell them anymore.  In terms of the assessment and treatment of suicide a knowledge base included in the Harvard  Medical School Guide To Suicide Assessment and Intervention might be a step in the right direction.  A lot of that knowledge depends on the skill of a particular clinician and that includes the personality factors of clinicians who continue to do this impossible job day after day.      

Trying to predict suicide and prevent it can't currently be done with an algorithm.  If I see an algorithm I will consider why the high risk people aren't being seen in follow up from the hospital rather than who should get an intervention.   And I would not mind errors on the false positive side.


George Dawson, MD, DFAPA

1:  Kessler RC, Warner CH, Ivany C, Petukhova MV, Rose S, Bromet EJ, Brown M 3rd, Cai T, Colpe LJ, Cox KL, Fullerton CS, Gilman SE, Gruber MJ, Heeringa SG, Lewandowski-Romps L, Li J, Millikan-Bell AM, Naifeh JA, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Stein MB, Wessely S, Zaslavsky AM, Ursano RJ; Army STARRS Collaborators. Predicting Suicides After Psychiatric Hospitalization in US Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2015 Jan 1;72(1):49-57. doi: 10.1001/jamapsychiatry.2014.1754. PubMed PMID: 25390793.

2:  Douglas G. Jacobs, editor.  Harvard  Medical School Guide To Suicide Assessment and Intervention.  Jossey-Bass Inc., San Francisco, CA, 1998.

3:  Berner ES, Webster GD, Shugerman AA, Jackson JR, Algina J, Baker AL, Ball EV,Cobbs CG, Dennis VW, Frenkel EP, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994 Jun 23;330(25):1792-6. PubMed PMID: 8190157.

Hand Washing

I washed my hands 40 times yesterday and used disinfectant hand cleaner at least 10 times when I did not have immediate access to water and soap.   My hand washing technique was validated by  an infection control nurse who was trained to monitor appropriate hand washing.   I also wiped down the table in my office and the chair about 3 times with disinfectant wipes.  I am careful not to touch my food or my face.  I have an air cleaner running in that office from about 8AM to 6PM that has a UV lamp designed to kill viruses.  Despite all of that I am in day #5 of a flu-like illness (cough, myalgias, fatigue, but no fever).

I don't have obsessive compulsive disorder.  I live in Minnesota and it is peak season for the annual influenza epidemic.  I actually take more precautions.  During flu season, I avoid the public.  I used to belong to a gym, but set up my basement so I could do my workout routine at home.  Exercise equipment is a known reservoir of viruses and bacteria.  I have also been in a gym when it sounded more like a hospital ward due to the hacking and coughing.  I avoid movie theaters for the same reason.  I have been doing these same rituals for the past twenty years, initially because I thought I was allergic to influenza vaccine and did not want to catch the flu.  I have been fairly  successful in avoiding the flu, but not so successful in avoiding practically every other respiratory virus.  For twenty three years I worked in an old building that was designed to contain heat rather than clear respiratory viruses.  In that environment, once a virus is introduced there is a predictable epidemic (sometimes within a few days) affecting the entire staff.   Modern employment disincentives (the finite paid time off with no sick time system) keeps all of the ill people working.  They would rather work than lose vacation time.  That keeps the epidemic going.

 Throughout the flu season people at risk are told the same things.  Wash your hands, cough into your sleeve, stay at home if your are ill and get the flu shot.  Unfortunately all of these measures is not enough to prevent infection by airborne viruses.  Face masks help.  A study of college dormitory dwellers showed that hand washing and wearing a mask only offered modest protection against influenza like illness relative to a control group.  They used the term modest, but I would call about a 10% difference in infection rates weak at best.  In their study they looked at three groups of students in college dormitories.  The groups and the attack rates of flu-like illness (FLI) included controls (no intervention) 117/552, face mask only 99/378, and face mask and hand hygiene 92/367.   The authors tried to control as many measures as possible but there are a lot of reasons why experimenting on college students is problematic.  In terms of the basic methods hand washing or use of hand disinfectants is considered to have a small but significant effect on the transmission of respiratory viruses.  The effectiveness of masks depends on the fit of the mask, the physical characteristics of the environment and the virus itself.  One study (4) showed that a tightly sealed N95 respiratory mask would block 94.8% of influenza virus and a poorly fitting mask blocked only 56.6% of the virus.  

The process of creating infectious droplets is an interesting physical process.  There are  current estimates that show normal breathing for 5 minutes creates a few droplets through the process of atomization.  A single strong nasal expiration results in a few hundreds droplets with a few in the 1-2 µm in diameter.  Counting loudly creates a few hundred droplets in the 1-2 µm range.  A single cough produces a few thousand and a single sneeze produces a few hundred thousands to a few million 1-2 µm droplets that can contain viral particles.  There is a a video of what happens to those millions of sneeze generated particle in an airplane.  It might be a good place to wear a mask but that assumes that you have it on before the sneeze.  Atomization can also occur from vomit (10⁷ viral particles per ml) and feces (10¹² viral particles per gram).   Those routes of transmission have been important for SARS and Norwalk Like Viruses.

The most recent estimate of costs due to building influenced communicable respiratory infections was about $10 billion in direct treatment costs and indirect costs of $19 billion in lost productivity and $3 billion in performance losses.  Asthma is significantly affected and possibly caused by airborne respiratory viruses and that is another $18 billion in costs ($10 billion direct and $8 billion indirect).  My interest has been in trying to promote more attention to the problem especially at the environmental levels.  Just altering airflow characteristics or making other changes in the humidity and air temperature can reduce the infectivity rates by as much as 50%.  Apart from the cost, it has an immeasurable effect on employee morale.  It is difficult for anyone to work knowing that at least one month out of the year they will have significant symptoms of a respiratory syndrome.

Why did I post this and in particular on a psychiatry blog?  In my 23 years of inpatient experience, respiratory viruses plagued the staff and the patients we were treating.  Any attempt I made to change that from a non-medical environmental perspective was met with no response.  I think that is the standard response of our culture and most employers.  Mental health settings tend to be located in older buildings and older parts of health care campuses and respiratory viruses is likely a bigger problem.  Health care settings should be leaders in developing environments and infrastructure that is hardened for the airborne respiratory virus problem.  It is imperative as a healthy environment for workers and patients and it provides reserve capacity in the event of a more widespread pandemic.  I have also made some observations about the impact of FLI on psychiatric symptomatology - both improvements and worsening.  There is a increasing literature on the effect of cytokine signaling on brain function and I suspect that is what I was seeing, but more research is needed.    

In the meantime, keep washing your hands.  Keep in mind that this post is only about airborne infections.  Any physician with direct contact with patients needs to wash their hands after seeing a patient and before seeing the next patient.  Most hospitals have a rule that hand washing needs to occur every time a physician enters or leaves a room.   For airborne respiratory viruses, it is not enough but it decreases the risk of respiratory infections to a slight degree.  My guess is that the more highly infectious airborne viruses are much less containable with hand washing and that environmental measures involving airflow, relative humidity, and possibly filtration and UV sterilization is what is required.  Anyone planning new construction should focus on these measures and obtain appropriate heating and air conditioning consultation with an emphasis on reducing respiratory infections.


George Dawson, MD, DFAPA

References:


1:  Aiello AE, Murray GF, Perez V, Coulborn RM, Davis BM, Uddin M, Shay DK,Waterman SH, Monto AS. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. J Infect Dis. 2010 Feb 15;201(4):491-8. doi: 10.1086/650396. PubMed PMID: 20088690.

2: Verreault D, Moineau S, Duchaine C. Methods for sampling of airborne viruses. Microbiol Mol Biol Rev. 2008 Sep;72(3):413-44. doi: 10.1128/MMBR.00002-08. Review. PubMed PMID: 18772283; PubMed Central PMCID: PMC2546863.

3: Morawska L. Droplet fate in indoor environments, or can we prevent the spread of infection? Indoor Air. 2006 Oct;16(5):335-47. Review. PubMed PMID: 16948710.

4: Noti JD, Lindsley WG, Blachere FM, Cao G, Kashon ML, Thewlis RE, McMillen CM, King WP, Szalajda JV, Beezhold DH. Detection of infectious influenza virus in cough aerosols generated in a simulated patient examination room. Clin Infect Dis. 2012 Jun;54(11):1569-77. doi: 10.1093/cid/cis237. Epub 2012 Mar 29. PubMed PMID: 22460981.

5. ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) ASHRAE Position Document on Airborne Infectious Diseases Approved by ASHRAE Board of Directors January 19, 2014 Expires January 19, 2017.  - This is an interesting approach that looks at how to look at engineering approaches to airborne infectious particles and come up with a better approach.

Supplementary 1:  Various inhalers used over the past year following a probable rhinovirus exacerbation of asthma in January of 2013.  This is a rapid way to meet your annual deductible.

Supplementary 2:  Graphic of pathogens detected per week is from the Minnesota Department of Health web site.

2015 and......

I was going to try to post about alcohol consumption prior to New years Eve, but am still working on that post.  Instead, I found myself reacting to a post on LinkedIn entitled "10 Warning Signs That Your Psychiatrist Is Not A Good Fit" by Amanda Itzkoff, MD.  Look for it on LinkedIN if you are a member and see what you think.  I found it fairly stark and negative.  I found myself immediately typing up my own top ten list on how you know you have found a competent psychiatrist.  That may not fit the usual blogger message that critical statements that apply to only a few is the only reason for commentary.  One of my reasons for writing this blog is that the tremendous number of colleagues who I personally know are all very competent and the list is a composite of what anyone would find walking in to talk with any one of them.  That list follows.

I had thought about posting a list of what I plan to continue to do here in the coming year but decided that was unnecessary.  You can certainly go to any number of blogs to find out what is wrong with psychiatry or psychiatrists.  Much of it is hyperbole.  I hope that you will find what I write here is a realistic antidote to those other sites.

    Top Ten Signs Your Psychiatrist Is Competent

1.  You are understood.

Your psychiatrist makes it very clear to you that he/she understands the problem and all of the mitigating factors by formulating the problem and treatment plan, restating it to you, and giving you useful advice.  That also includes discussing the relationship that you have with the psychiatrist and any concerns that you have about it.  That is one aspect of seeing a psychiatrist that differs from seeing other physicians.  You should be comfortable bringing up any concerns and clarifying any potential misunderstandings.  Your psychiatrist should also be able to answer the basic question about whether you have any diagnosis or problem that requires treatment.  Your psychiatrist should be focused on a discussion of your problems and your best interest should be the focus of treatment.

2.  Your psychiatrist is an expert.

Your psychiatrist has technical expertise in the field and is comfortable discussing new treatments and innovation in the field ranging from psychotherapy to brain science.  That includes an awareness of the current limitations of treatment.

3.  Your psychiatrist knows medicine.

During the initial assessment and beyond, your psychiatrist pays close attention to any other medical problems that you have and how the treatment he/she prescribes might affect those conditions.  That includes being able to diagnose new medical conditions that can lead to psychiatric presentations and ordering the appropriate tests to follow potential complications of any new treatments or how new treatments might impact existing conditions.  That includes a willingness and an ability to talk with the other generalists and specialists providing your medical care.

4.  Your psychiatrist takes enough time.

The assessment and treatment of complicated problems takes time.  Many psychiatrists are in clinics where there are allowed only brief periods of time (10 to 20 minutes) for assessment and treatment.  Many people are satisfied with that amount of time, but if you are not - a different treatment setting may offer more time.  That can be discussed with the current psychiatrist and a referral to psychiatrists practicing in different settings can be obtained.

5.  If medications are involved your psychiatrist thoroughly explains the risks, benefits, and limitations of treatment.

Like most areas of medicine, medical treatments have their limitations.  That includes medications that are not completely effective in alleviating symptoms, side effects, and occasional very serious side effects.  Your psychiatrist should be able to help you negotiate that area and provide you with more detailed information for further study on request.  You should believe that your psychiatrist is taking any concern you have about side effects very seriously.  The discussion of side effects is as important as a discussion of potential therapeutic effects.  Any informed discussion of medical treatment should also include a discussion of non-medical approaches.  Many people are surprised to learn than non-medical approaches are more effective than medications in the treatment of several severe mental health problems.

6.  Your psychiatrist knows about addiction.

A significant number of people being treated by psychiatrists have problems with addiction.  Addiction can cause psychiatric problems and complicate the care of psychiatric problems.  Even if your psychiatrist is not an addiction specialist, he/she should be able to advise you in how to get well and not increase the risk for relapse if you are sober.  Your psychiatrist should also be able to advise you in approaches to your problems if you are not sober.  Chronic pain is also an associated problem and your psychiatrist should be able to make an assessment of your chronic pain problem and how it affects associated mental health and addiction problems.   

7.  Your psychiatrist is able to tell you about things that you do not want to hear.

That can cover a broad range of topics from your expectations about medication and psychotherapy, to unrealistic expectations, to boundary problems involving what appear to be straightforward problems like filling out a disability form.  One example would be concerns about a diagnosis of Attention Deficit-Hyperactivity Disorder (ADHD).  A lot of adults seek treatment for this problem and in many cases they are also expecting an approach that leads to enhanced cognition.  A consulting psychiatrist should be able to say that they do not have ADHD and that stimulant medications are not currently indicated for cognitive enhancement.  

8.   Your psychiatrist is concerned about your safety.

One of the characteristics of some mental health problems is that the safety of the person involved is compromised.   Psychiatrists are trained to make these assessments and determine a plan to address the problem.  Many psychiatric disorders result in impaired insight and judgment that is restored once the primary problem is treated.  It is often useful to have a discussion about that in advance.  Some states have a psychiatric advanced directive that is useful to direct your care in the event of an acute episode of illness that affects your judgment.  We live in a litigious society and physicians are often accused of “covering” themselves by making very conservative decisions.  These decisions are most likely driven more by safety concerns than malpractice concerns.  

9.   Your psychiatrist is willing to talk with your family.

You should be certain that your confidentiality is protected at all times per an explicit agreement with your psychiatrist.  That agreement should include emergency contingencies and advise you about the statutes in your state that affect confidentiality.  You should also expect that when you want your psychiatrist to talk with your family that he/she will do that.  For certain aspects of treatment planning such as discharge planning from hospitals and gathering diagnostic information, discussions with family are critical.

10.   Your psychiatrist is mindful of your financial concerns.

Mental health services are the most rationed services in medical care in the US.  That typically results in more out-of-pocket costs for people receiving psychiatric care than other types of medical or surgical care.  Your psychiatrist should be able to discuss the cost aspects of all forms of care.  That includes medication costs and also the cost of ongoing psychotherapy. Cost effective alternatives for both psychotherapy and medical assessment and treatment should be as easily discussed as any other aspect of treatment.  Your psychiatrist is often placed in an impossible situation by the insurance industry.  The insurance industry often makes it seem like your psychiatrist is responsible for decisions that are really the result of insurance industry rationing.  Any concerns you have about the financial basis for decisions should be clarified with your psychiatrist.

Happy New Year!

George Dawson, MD, DFAPA

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