The Freak Show

 

When I was a kid my aunt and uncle took my siblings and me to a multicounty fair about 70 miles from our home town. I was probably about 11 years old at the time and withdrawn and introverted – just trying to make sense of the world. When you live in small towns, fairs are always a big deal. It is a rare approximation of big city life. The only place where you could see that many people in one place. There were the usual carnival rides, carnival food, carnival smells, and carnival people. An odd mix of farm life with the exotic. Felliniesque is a description that comes to mind not so much for the surreal atmosphere but the jarring presentations of unusual appearances and behaviors.  And keep in mind this was all about 40 years before the Internet.  In my town at the time we had 3 very grainy black and white TV networks and on any given day only 2 out of three were working. They all broadcast standard network TV and signed off the air at midnight.

The most Felliniesque location at the fair was the Midway – a long thoroughfare bordered by tents and trailers on each side.  Vendors were selling cotton candy, caramel popcorn, snow cones, and hotdogs and the odor of that food was always in the hot, humid air. It was a noisy place due to the carnival barkers shouting to get people to come to their attraction. My only experience with carnival barkers before that was my well-travelled Grandfather’s imitation of one and he was right on.  There were games of skill that involved tossing rings or baseballs at targets, or shooting air rifles.  In those days it was typically 35 cents to try and if you won – the prize was some sort of stuffed toy animal. The games clearly favored the house.  There was usually an obvious gimmick that made it very difficult to win. It was common to see a young couple at one of these games, with the guy spending a lot of money in order to get one of these prizes for his girlfriend. The idea that these strangers were in town to unfairly take your money added to the excitement of wanting to beat them at their own game. Some of the carnival workers knew how to add commentary to keep people coming back without getting them too excited or angry.  I watched all of that at a distance and did not take a chance on the games.

The most disquieting aspect of the carnival was the Freak Show. At the time – I am sure the term had fallen out of favor replaced by “human oddities” or similar terms, but everybody still called it The Freak Show.  In just a few years it would be appropriated by the hippie generation and reinvented as a positive social term as in “let your freak flag fly.”  Those attractions had colorful and primitive graphics adding to the bizarre cartoon like appearance.  “Man-eating Amazon rats” displayed 7 or 8 rats chewing on a horrified man. Similar signs proclaimed significant alterations in appearance or deformities. Superlatives were everywhere as the “World’s tallest, fattest, strongest, shortest….”  In order to get people to pay the price of admission to the trailer there was typically stage with an introduction where you could get a glimpse of the attraction. I remember watching a middle-aged man extrude his eyeballs out at the crowd to a mixed reaction of amazement and disgust.  He was the most animated and expressive.  All the other human oddity performers seem bored and they were expressionless. I listened to the local people coming out of the attractions talking about how they were disappointed that the part human, part canine man was just a paper mâché creation in a glass case or that the bearded lady was just a short obese man wearing a dress.

I found the entire Freak Show atmosphere very unsettling. It just seemed wrong to me. I was always taught to mind my own business and treat everybody the same no matter what their appearance. In a Freak Show – those norms go out the window.  The social norm suddenly becomes excitement, excessive commentary, and mixed derision some due to people feeling like their expectations for the unusual were not met and some feeling like they were ripped off. It was an embarrassing display of a lack of empathy and I was embarrassed to be there.  In today’s parlance some might say I was traumatized by the event but I won’t go that far. I went home and thought about it for a long time.  What that lifestyle would be like. What it is like to consent to participate. I would see occasional TV shows with similar themes about these potential conflicts.  Workers were who coerced into these positions based on their appearance  and overworked, but I never saw any real-life stories where that was true. Eventually the memory faded.

As a freshman in a liberal arts college, English literature and composition was a year long required course. Kafka’s A Hunger Artist was one of many required readings. In this short story Kafka describes a man who is basically a side show attraction based on his skill in fasting. He sits in a cage on straw and fasts initially to the accolades of an observing public who admired him at a distance.  He is managed by an impresario who limits the fast to 40 days based on entertainment rather than health concerns – public interest fades at that point. Eventually public interest fades altogether and he signs on with a circus where he is eventually ignored during his fasting.  Even though he always knew he could fast much longer than 40 days and was past that point - both he and the circus staff stopped counting.  He was eventually discovered near death when the apparently empty cage was inspected. He speaks briefly about wanting to be understood and how his fasting was easy because he never found a food that he liked. A definitive interpretation of Kafka’s essay is not available and there are multiple interpretations.  Food seems like a metaphor for the attention of others and that we need more than literal food for sustenance. It speaks to the general case of people who are marginalized in society and may need to take desperate measures for social contact. In the end the Hunger Artist rejects food/social contact.  He dies and is buried with the rotten straw in his cage.

Was a Freak Show a similar attempt to establish social contact? A more typical interpretation is the practical one – it is just a way to make money or more commonly a way for these people to make money. If there were societal safety nets, would these shows need to exist?  It seems that there is a top-down way to deal with the problem and that is just banning these venues or making them so culturally unacceptable that they would not exist.  A societal safety net would be the bottom-up approach - adequate income, housing, medical care, and empathic support.  The reality today is that I don’t see either of those approaches happening.

I have not been to a fair in at least 10 years.  The last one I attended was the second largest state fair in the country.  There were no Freak Shows or human oddities, but they still exist, usually on television where much more biographical content is provided.  The sensationalism associated with them has been taken over by the Internet where any observer can basically see whatever they want ranging from 3 minutes clips of soft (or hard) core pornography to watching Komodo dragons swallow livestock whole headfirst to watching someone split firewood.  

Various authors have suggested the dopaminergic effects of watching sensational videos and the importance of taking a break from all that dopamine. Like most neuroscience in the popular press that is undoubtedly an oversimplification.  Flashing back to my childhood experience – there is a right and a wrong way to do things.  Even as a kid I did not need to be shamed into avoiding freak shows, but one of my colleagues assures me that some people need to be and that shame is not necessarily a bad thing.  

Widespread acceptance of high frequency and indiscriminate sensationalism does not seem like a good development for society. Instead of attending a rare annual event - people can engage in this activity all day long and every day.  It has occurred with the expansion of exploitation from just the marginalized to everyone and resulted in a much coarser general audience for public discourse. There is some discussion about the lack of critical thinking skills - but that critical thought starts upstream from the cognitive processes with emotion and some clearcut ethical rules and knowing that your excitement may be clear violation of those rules.

We need to figure out ways to move beyond the Freak Show existence.  We already know some of those rules. We need to do it before AI makes things a lot worse. 

 

George Dawson, MD, DFAPA  

 

 

 

Image Credit:

Jack Delano, Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Freak_show_1941.jpg "Freak show 1941" https://upload.wikimedia.org/wikipedia/commons/thumb/1/19/Freak_show_1941.jpg/512px-Freak_show_1941.jpg

Killer Mike's Gun Recommendations for Families

I watched TMZ Live yesterday. They interviewed the rapper Killer Mike. Harvey Levin was his usual overcomplimentary self. He asked the rapper about his recommendation that every family should have "multiple guns, all sorts of guns" and this is what he said:

"5 - 5. I have always just said 5. You should have a revolver, a semi-automatic pistol, you should have a shotgun, you should have one bolt action rifle, and you should have a semi-automatic rifle."

When questioned about the semi-automatic rifle:

"I said semi-automatic, military is fully automatic. It's not military - it just looks cool. It can look like a race car but it doesn't go 200 miles an hour. My thing is simply this - the founders of the Constitution saw a need to fight tyranny at some point and they believed that that could happen again so they wrote that provision so to get to the ultimate answer you got to dig up those old white guys and ask them. I'm simply applying - I'm going by the rules that were given to me in the Constitution - nothing more-nothing less."

When asked about the risk of an increasingly armed and divided population, Killer Mike points out that the fastest growing group of gun owners is black women and he does not want to get in the way of black people enjoying their freedom.

In terms of stopping gun violence he was in agreement with curfew and an exception for working adolescents. He believes that no new gun laws are needed and echoes the line that there are enough laws to take care of the problem already on the books and that criminals are not going to follow the laws anyway. That ignores the fact that almost all mass shooters have no criminal record and in many cases have recently purchased firearms that they use in the mass shooting crime.  Instead he recommends "Stop the Bleed" classes and joining gun associations or gun clubs. His rational is that if you have a tool that can cause harm you should be educated about what to do for that harm.  Unfortunately if you get hit anywhere in the body - the education you will need is how to be a trauma surgeon and even then you had better be at a Level 1 trauma center. 

Consistent with the previous writing on this blog Killer Mike is clearly behind gun extremism and normalizing it as a constitutionally derived right. Obvious gun extremist rhetoric includes the claim that just because an assault rifle is not fully automatic it is somehow less worrisome. Anyone who has fired an AR-15 knows that you can fire as many high velocity rounds just as fast as you can pull the trigger and if that gun is discharged in a residential community that bullet is going a long way and in some cases through multiple buildings.  In fact, all of the weapons he recommends for the family will penetrate multiple walls and are a potential risk for the entire neighborhood.  The normalization of assault rifles by the NRA and Republican party was a move away from the use of guns for hunting to the use of guns for killing people and there is no way around it.  From the testing link this was a quote about the assault rifle result.  It speaks to the mechanism of assault rifles as a combination of high velocity and bullet deformation and tumbling:

"Though the 5.56 bullets showed the most deformation, they were also terribly penetrative (19 panels, or nine walls) and, beyond the first two or three panels, created relatively large holes as they tumbled along their paths."

Just as a reminder this is the full text of the Second Amendment:

"A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed"

Nothing about tyranny. Gun extremists ignore the preamble. The "well regulated militia" these days is each state's National Guard.  This country went through a period of gun regulation that was widely accepted and reasonable until one political party realized they did not have many ideas to run on and decided to make guns a part of that culture war. I don't know Killer Mike's political affiliations.  There may be a subcultural effect since this same show regularly reports gun violence and deaths within the rapper community.  

The problem with all forms of extremism is that it is an appeal to emotion and it typically ignores the facts. Killer Mike sees the problem as encroaching on the rights of black people but that doesn't address the problem that firearm homicides have increased in the black community by 39% from 2019-2020 (1). We know that the political rhetoric that more guns for defensive purposes does not put a dent in those numbers and that these are almost always impulsive homicides based on gun availability.

The answer to how to reduce gun violence is not increasing guns and I don't care what your rationale is - but that is the residue of this interview that started with that question.

George Dawson, MD, DFAPA

References:

1:  Kegler SR, Simon TR, Zwald ML, et al. Vital Signs: Changes in Firearm Homicide and Suicide Rates — United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2022;71:656–663. DOI: http://dx.doi.org/10.15585/mmwr.mm7119e1

New Onset Headaches In An Old Man - What Should Be Done?

 

 

In November of 2022, I started to experience headaches that were new and unusual. They would start out as a dull ache behind the left eye to varying degrees and generally persist until I took 1,000 mg of acetaminophen. Acetaminophen (APAP) works like a miracle for me for most kinds of pain and it would reliably knock the headache out in 1-2 hours. Back in my early 20s I experienced more severe headaches that were quite debilitating and most likely cluster headaches. For a couple of years, I would get them every spring and would have to take aspirin (ASA) or APAP and take a nap until they went away.  I make that diagnosis in retrospect after learning quite a bit about headaches and learning how to treat them. The new headache was nothing like those cluster headaches.  I could still read, exercise and function well. I also noticed that sleep alone had no effect on the new headache. I would still wake up with it if I did not take APAP.  Only recently I had an episode where the new retroorbital headache worsened with coughing and that seemed to be an isolated event. The headache could occur at any time of the day, was not related to stress, or any activity.

I was seeing optometrists at the time – initially for an annual eye exam and then for severe dry eyes. I asked both optometrists if any of the eye diagnoses (Meibomian gland dysfunction, ocular rosacea, blepharitis, punctate keratitis, dry eyes, and astigmatism of the left eye) could be causing the headaches and was told it was a possibility but that I should follow up with primary care and neurology. By January of 2023, I tried to get an appointment to see a neurologist – but could not get in until September 2023.  I saw my primary care MD twice during this period and his diagnosis was tension type headaches because I had no other neurological symptoms. The plan was to keep taking APAP.

Digressing a moment to diagnosing and treating headaches as a psychiatrist. As an acute care psychiatrist, I was in the position of diagnosing and treating many people with severe chronic headaches. They were typically admitted because of associated severe depression, suicidal thoughts or behavior, or a complete inability to function at home. Many of those patients started out with migraine headaches that were eventually complicated by medication overuse headaches. Frequent use of medications like APAP, triptans, and non-steroidal anti-inflammatory medications (NSAIDs) resulted in a headache that would not longer resolve. That diagnosis led to a different treatment plan that was moderately successful until a better plan for headache prophylaxis could be established. I had excellent back up by neurology and often consulted with a friend of mine who is a local neurologist and pain specialist.

Diagnosing headaches is not too far removed from making a psychiatric diagnosis in that the phenomenology of the headache it critically important.  What is the pain like, how is it described, does it radiate, are there any associated events or sensory phenomenon?  History is a critical part of the headache evaluation. The physical exam can contribute in the case of autonomic findings, making an underlying diagnosis that is a cause of the headache, or in some cases  a finding that suggests an underlying pathophysiological mechanism.  An example would be tenderness in the facet joints of the cervical spine (C-spine) for cervicogenic headaches.  Associated testing can be diagnostic but in most cases it is supportive.  That is degenerative disk disease and arthropathy of the facet joints of the C-spine supports the diagnosis but other elements need to be there like the characteristic pain distributions associated with this headache. A complete list of the common forms of headaches can be found at the National Headache Foundation and much more detailed discussion in headache specialty texts. The list is not exhaustive since headaches can occur across many settings and can be the general result of chemical alterations (alcohol, alcohol withdrawal, medication side effects, etc) and inflammation (influenza, coronavirus, etc).  As far as I know neurologists have not embraced the transdiagnostic term that we see cropping up in the psychiatric literature, but headaches are both a disease and a transdiagnostic symptom.

An illustration of the complexity of these headaches uses my specific example.  The table below illustrates the onset and frequency of these headaches from October 2022 to June 17, 2023).  Headaches are recorded only if they were treated with APAP.

 

	Generalized Bilateral	Left Retroorbital
OCT	7	1
NOV	8	4
DEC	1	6
JAN	2	4
FEB	5	5
MAR	4	3
APR	3	14
MAY	3	10
JUN (to June 17)	0	5

 

I will attempt to correlate various comorbidities to see if there are any possible explanations:

C-spine disease – I was diagnosed with C-spine disease by clinical exam and MRI about 20 years ago. The MRI showed stenosis but EMG studies were normal and physical therapy resolved the neurological symptoms I had at the time – primarily numbness in the C7-C8 distribution of both arms.  I have been doing the PT exercises for the past 20 years.  From the chart I do get episodic bilateral occipital headaches that radiate up from the neck and I attribute these to C-spine disease.  I typically treat them with physical therapy maneuvers and occasionally APAP.  Cervicogenic headaches have three reported pain distributions - occipital, occipital temporal maxillary, and supraorbital (most common).  Other sources say that the pain can be experienced anywhere on the face (1).  Retroorbital headaches from this cause seem unlikely.

BPPV- my only other MRI of the brain was done when I developed benign paroxysmal positional vertigo about 25 years ago.  Although that brain scan was normal, a polyp was noted in the frontal sinus but no further evaluation or treatment was recommended. I typically have episodes that seem to be improving over time.  Not debilitating.  

Astigmatism- severe in the left eye – causes visual distortion and seems to contribute to vertigo.

Dry eyes – multiple diagnoses as noted

Paroxysmal atrial fibrillation – have had about 20 episodes lifetime.  Much better control recently with a brief episode every 1-2 years. On an antiarrhythmic for 16 years. The main non-cardiac risk is embolic stroke.  I have had highly variable experiences with the physicians I have consulted about this disorder over the years.  There appears to be no consensus on the time frame necessary for cardioversion to prevent strokes.  I have been cardioverted initially in time frames of up to 15 hours both with medications and electrical cardioversion. In one case, I was anticoagulated and in other cases not. I have had patients who were in permanent atrial fibrillation and were not anticoagulated. Primary care seems to have a fairly casual approach to atrial fibrillation possibly because early studies showed there was no difference in outcomes based on rate control or rhythm control (normal sinus rhythm). Since then, studies have shown that people with rhythm control may have a higher quality of life. I decided to start anticoagulation 18 months ago because the pandemic had seriously compromised physician access and I did not want to end up in atrial fibrillation with no access to cardioversion. For the purpose of this post the question is: “Is it possible that a silent stroke occurred and caused this headache?”  At least one reference suggests that silent strokes are common in the elderly but not a cause of headaches, but deep white matter lesions on MRI may be. (2)

ATM and other risk genotypes- In a previous post I explained the ATM genotype and how it significantly increases the risk for pancreatic cancer.  I also have genotypes associated with increased risk for epithelial cells cancers.

Migraine Aura without Headache- I have experienced this in the past but not recently as a single episode of visual phenomenon.  The ophthalmologist I consulted with knew what had happened immediately and no specific treatment was recommended.

 Obstructive sleep apnea (OSA) – Diagnosed 18 years ago and I have been 100% compliant with CPAP/APAP ever since. I get a daily report on hypopneic episodes/hours and they are always well withing the target range.  OSA can be a cause of headaches, typically in the morning (3) but improve with treatment and are unlikely in this case.

Not all these factors were considered by the physicians I consulted about these headaches. The protocol was basically a cursory (or detailed) neurological review of systems and neurological exam.  In all cases I was told that it was a “non-focal” neurological exam.  My primary care physician saw that as a reason for no imaging and continuing the current treatment with APAP for a diagnosis of “tension headaches”.  The neurologist initially said he thought I had a migraine but on further consultation the diagnosis was “inflammatory headache” and I was given a standard tapering dose of methylprednisolone.  I filled the prescription but decided not to take it until after the imaging study.  None of the physicians suggested that it could be pain due to C-spine disease and I have found that unless you are talking with a rheumatologist, a lot of physicians do not spend a lot of time discussing or treating arthritis. The neurologist also ordered an MRI scan of the brain and two of the images are at the top of this post.  It was read as a normal MRI scan of the brain. The headaches persist.

This exercise in the differential diagnosis and treatment of headaches is instructive for several reasons:

1:  It highlights the complexity of medical conditions and everything that needs to be considered.  I could argue that 20 or even 30-minute visits with a generalist or even a neurologist might not result in an adequate assessment just based on the information that needs to be considered.  I described 50 years of medical history as succinctly as possible but it also requires somebody to put that together as rapidly as possible and look for the relevant patterns of disease. There are headache specialists out there who do this – but they are rarer than child psychiatrists and that is rare.

2:  The complexity is compounded by the fact that there can be more than one type of headache present and that each requires a separate diagnosis and treatment. In my case I came in with my own ideas that I had one type of cervicogenic headache and a new headache of undetermined etiology.  There are studies available that attempt to differentiate migraine headaches from cervicogenic headaches by selective injections of various cervical vertebrae.  In some cases that clarifies the source of the headache and in others the patient has both types. Similarities to the psychiatric diagnostic process are noted.  There are some who suggest that there should only be one treatable diagnosis.  If you can have more than one headache I don’t see why you could not have more than one psychiatric diagnosis.  

3:  Testing is a wild card – but should it be?  In this case my primary care physician opted to not order brain imaging but the neurologist did.  The kind of testing done in psychiatry and in much of neurology is non-diagnostic.  In other words, if a lesion is detected there is still a question of whether it is causative. The best example is degenerative disk disease and arthritis of the spine. It is easy to detect degenerative changes but the question is how they relate to the clinical problem. At the same time, the prevalence of serious secondary causes of headaches in the elderly such as tumors, vascular, inflammatory and other space occupying lesions like hematomas is significantly higher than in younger population – making any primary headache diagnosis in an older person - a diagnosis of exclusion.  I have certainly imaged patients in my practice based on various combinations of neuropsychiatric, cognitive, and neurological symptoms for this reason. It is no different in neurology.  In addition to the central nervous system secondary causes of headaches, orbital lesions need to be considered and that list is also extensive.

4:  Are headaches a disease?  With all of the repetitive rhetoric from the anti-science and anti-psychiatry crowd – my mind wandered to this question.  I had also recently encountered the term “Szaszian binaries” in a philosophical paper that was mildly critical of the disease arguments from antipsychiatrists that to this day are based on Szasz’s 60-year-old definition – that diseases must be based on morphology or a known pathophysiological mechanism – like infection from an organism.  It turns out that headaches are indisputably called diseases even though the mechanisms are as speculative and no morphological lesions are seen on brain imaging.  Like psychiatrists – the only positive findings will be the identification of secondary causes and that is no small accomplishment.  As I searched this topic, I found an article written by Ron Pies, MD on this very topic (5).  Szasz never wrote a Myth of Migraine Headache or commented on why headaches were not diseases.  

Where does all of this leave me today?  First relieved that there is no life threatening or debilitating brain pathology and that my brain looks pretty good for an old man.  I previously documented a serious traumatic brain injury in my 20s and my C-spine problems are likely the result of playing high school football and compression injuries transmitted through my helmet and head and into my neck. I was also involved in a collision playing third base that resulted in my neck being locked up for several hours that did not help. Second, it adds to my long-term health plan.  Despite that list of health problems, I have exercise and physical therapy plans to deal with most of it. Maintenance measures will take care of the rest.  I have a follow-up with neurology in October and if the retroorbital headaches start to increase in frequency I might try the methylprednisolone, but I don’t have high expectations. I had an asthma flare after a trip to Alaska about 8 years ago and had to take prednisone at a substantial dose and that did not seem to do much for the cervicogenic headaches.  My primary treatment modalities will remain exercise, physical therapy, and APAP.

It may seem like that is a significant list of problems, but after working in the field for 40 years they seem expected to me.  As long as they are manageable and I am tracking them and making necessary adjustments life is good. I also have a high index of suspicion for future problems and hope to identify any that come up, but I am also not fooling myself that I can control everything or that new problems will always be manageable. 

 

George Dawson, MD, DFAPA

Supplementary on Neck Pain:

I did a previous post of the importance of the spine in psychiatric practice largely because of bidirectional considerations.  I was seeing a large number of people who had sleep problems that were either caused by neck pain or had insomnia that seemed to cause neck pain. My interest in the mechanical and neurological spine dates back to excellent neurosurgical rotations in medical school and the associated radiology rounds with the late Sanford J. Larson, MD, PhD.  Even though neurosurgery was a tough rotation for students, residents, and attendings - every Saturday morning Dr. Larson would meet all of us in the Radiology reading room at Froedtert Hospital and would spend the morning reviewing all of the films from the last week.  I say films because all of the images were on large films placed on a device that could rotate them all in order.  The standard film in those days was 35 x 43 cm (14“ x 17“) so each row on that machine held about 8 films.  I was able to continue that practice when I worked at an acute care hospital but outside of that setting - it was always difficult to access films and later digital images. 

Another outcome of that early experience was continuing to read papers on common spinal problems and way to address them.  The epidemiology of neck pain has progressed significantly over time (6.7). In 2015 it was noted to be the 4th leading cause of disability.  Most acute neck pain resolves in a couple of weeks but in 50% of those cases it recurs over the next year. Annual prevalence is estimated to be 15-50% with an average of about 37.2%.  There have also been some studies of the impact of structured exercises on neck pain that typically show improvement.  I have not seen any estimate on the percentage of people with neck pain who have associated headaches but expect that would depend on risk factors and degree of mechanical and neurological impairment. This also seems to be a medical education issue. In my experience very few physicians know how to do a back and neck examination and interpret the findings. 

 

References:

1:  Al Khalili Y, Ly N, Murphy PB. Cervicogenic Headache. 2022 Oct 3. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29939639.

2:  Fujishima M, Yao H, Terashi A, Tagawa K, Matsumoto M, Hara H, Akiguchi I, Suzuki K, Nishimaru K, Udaka F, Gyoten T, Takeuchi J, Hamada R, Yoshida Y, Ibayashi S. Deep white matter lesions on MRI, and not silent brain infarcts are related to headache and dizziness of non-specific cause in non-stroke Japanese subjects. Intern Med. 2000 Sep;39(9):727-31. doi: 10.2169/internalmedicine.39.727. PMID: 10969904.

3: Verbraecken J. More than sleepiness: prevalence and relevance of nonclassical symptoms of obstructive sleep apnea. Curr Opin Pulm Med. 2022 Nov 1;28(6):552-558. doi: 10.1097/MCP.0000000000000915. Epub 2022 Sep 14. PMID: 36101923; PMCID: PMC9553267.

4:  Vongvaivanich K, Lertakyamanee P, Silberstein SD, Dodick DW. Late-life migraine accompaniments: A narrative review. Cephalalgia. 2015 Sep;35(10):894-911.

5:  Pies RW.  Why Thomas Szasz did not write about the myth of migraine. Psychiatric Times.  July 29, 2021.  https://www.psychiatrictimes.com/view/thomas-szasz-myth-migraine

6:  Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015 Feb;90(2):284-99. doi: 10.1016/j.mayocp.2014.09.008. PMID: 25659245.

7:  Kazeminasab S, Nejadghaderi SA, Amiri P, Pourfathi H, Araj-Khodaei M, Sullman MJM, Kolahi AA, Safiri S. Neck pain: global epidemiology, trends and risk factors. BMC Musculoskelet Disord. 2022 Jan 3;23(1):26. doi: 10.1186/s12891-021-04957-4. PMID: 34980079; PMCID: PMC8725362.

Read This Critique!

 

Today was a good day for psychiatric criticism. An “Umbrella Review” that essentially declared that serotonin was dead in psychiatric research (1) has essentially been refuted (2). I do not want to mischaracterize the authors conclusion so here it the direct quote from the original paper.

“This review suggests that the huge research effort based on the serotonin hypothesis has not produced convincing evidence of a biochemical basis to depression. …  We suggest it is time to acknowledge that the serotonin theory of depression is not empirically substantiated.” (1)

Ron Pies, MD and I (3) noted several problems with the paper on a historical and rhetorical basis and penned a response based on those elements of the paper.  The authors used the terms “serotonin theory” and then “chemical imbalance theory” interchangeably in the paper.  We knew that the former was a hypothesis at best and the latter really did not exist as either a hypothesis or theory in the psychiatric literature. We referenced 4 reviews of the serotonin hypothesis from 1954 to 2017 and the results that the total evidence was inconclusive or inconsistent.  We included historical quotes to illustrate that researchers investigating neurochemistry were fully aware of the complexity of psychiatric disorders and that even clear-cut evidence of a finding implicating a neurotransmitter would not rule out environmental or psychological factors in the etiology of depression.

We also discussed the complexity of serotonergic systems in the brain and the fact that it is an ongoing focus of extensive research and ongoing publications. The only possible conclusion is that the science around serotonin is not settled and that needs to be recognized.  I put a post on my blog and hoped to move to a methodological focus on the paper but never got that far.

A group of scientists and psychiatrists was able to do that in a publication today (2).  This paper is available online and I am not going to repeat their evidence or conclusions when you can read it yourself at the link below. It is a very brief paper and I highly recommend reading it. This group found substantial methodological problems with the paper and concluded that there were substantial errors and misinterpretation of the data in the original paper.  Their conclusion was the errors prevent readers from drawing any “reliable or valid conclusions" and:

“A more accurate, constructive conclusion would be that acute tryptophan depletion and decreased plasma tryptophan in depression indicate a role for 5-HT in those vulnerable to or suffering from depression, and that molecular imaging suggests the system is perturbed. The proven efficacy of SSRIs in a proportion of people with depression lends credibility to this position.”

The most striking aspect of this critique is that it is authored by 35 scientists – many of whom are also psychiatrists. I have read papers written by many of them on aspects of the neurobiology of the human brain in various experimental settings.  There are experts in neuropharmacology and neurobiology.  The word brain trust comes to mind when I think about a group who could have written a response to the umbrella review or even the original review itself.  In addition to the neuroscience expertise – one of the authors wrote the reference on rules for conducting an umbrella review (4). There appears to be no equivalent expertise in the original paper, and in fact very few papers have that level of expertise.  Let me conclude with some observations based on the current critique:

1: Rhetoric is an important part of both general press and scientific literature.  The authors of the original Moncrieff review are all on record as supporting positions well outside of mainstream psychiatric education and practice.  To cite an example, I critiqued a paper by Middleton and Moncrieff on this blog where I also outlined various examples of philosophical, statistical, medical, and neuroscience rhetoric that essentially could have predicted the original umbrella review and both the response by Pies and I as well as the response by Jauhar, et al.   It is probably a good general policy to avoid entrenched positions when doing systematic reviews and if that is not possible to stick to clear guidelines for objectivity.

2:  The paper today was a welcome return to what psychiatrists everywhere know to be accurate and that is serotonergic systems and the brain in general are complex and the story is incomplete at this point. For the public – proclamations about causes and mechanisms are speculative apart from the evidence reviewed in today’s paper.  When you read speculative news stories about psychiatry (they generally all are) maintain a high degree of skepticism – especially if you have found something that is working for you – in this case for depression.  Always discuss what you read in the papers with your physician before making any changes. 

And for professionals, expertise still means something. With a proliferation of meta-analyses and systematic reviews being published it is evident that many authors have never done research in the field they are attempting to analyze. There is no substitute for experience doing the research and being very familiar with the literature and experimental methods in that field.  It is much easier to criticize a clinical trial than to actually do one. That is not just my experience and opinion.  Ioannidis has concluded (5): "The production of systematic reviews and meta-analyses has reached epidemic proportions. Possibly, the large majority of produced systematic reviews and meta-analyses are unnecessary, misleading, and/or conflicted." (see the graph below for an update)

3:  Several people today suggested the “damage has been done” by the original paper and there is certainly some evidence for that.  There were some suggestions that the original paper will be retracted, but I do not see that happening. Critics of psychiatry always get much more leeway than the comparatively fewer critics of other specialties.  There are many glaring examples, most notably the Rosenhan paper about psychiatric imposters - even though it was decisively critiqued at the time of its publication and subsequently shown to have been based on highly problematic and in some cases false research.  That original paper remains in a scientific journal.

4:  The profession and this journal are fortunate for the coordinated efforts by this group of authors.  It will hopefully serve as a template for responding to similar pieces in the future. I read a lot of papers in psychiatric journals and the quality of what I read is generally not very good.  Even flagship journals are publishing articles that are basically opinion pieces that call for significant modification of the entire profession. These are all typically arguments that involve author(s) attempting to control the premise of an argument.  I have read premises that are either blatantly false or unprovable and somehow these pieces are published in journals for psychiatrists. I also read medical literature and apart from the usual pieces claiming proclaiming the greatness of managed care and administrators in the American healthcare system – there are no calls for broadly reforming any other specialty. Like every other psychiatrist out there, I went to work for 35 years and was able to make a difference by helping people, doing research, and teaching in very taxing environments. Editing and peer review both need to improve - but in an environment that encourages excessive publishing it is doubtful that either will occur. 

5:  This is also a teaching and learning moment. Resident and faculty research seminars will benefit from reading both papers and reviewing the implications.  Some of those implications include questions about why it is so easy for people both inside and outside of the professional to suggest major departures in the intellectual trajectory and practice of the field and why that does not happen in any other medical specialty. 

If someone makes a claim that the field needs an immediate change in its intellectual focus or practice – there needs to be a compelling reason.  To paraphrase Carl Sagan – extraordinary demands require extraordinary proof.  We are still waiting for the extraordinary proof for serotonin, but there is some.  Proclaiming serotonin as a dead end was as big a mistake last year as it was 8 years ago.

 

George Dawson, MD, DFAPA

 

 

 References:

1: Moncrieff J, Cooper RE, Stockmann T, Amendola S, Hengartner MP, Horowitz MA. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry. 2022 Jul 20:1-4.

2:  Jauhar S, Arnone D, Baldwin DS, Bloomfield M, Browning M, Cleare AJ, Corlett P, Deakin JFW, Erritzoe D, Fu C, Fusar-Poli P, Goodwin GM, Hayes J, Howard R, Howes OD, Juruena MF, Lam RW, Lawrie SM, McAllister-Williams H, Marwaha S, Matuskey D, McCutcheon RA, Nutt DJ, Pariante C, Pillinger T, Radhakrishnan R, Rucker J, Selvaraj S, Stokes P, Upthegrove R, Yalin N, Yatham L, Young AH, Zahn R, Cowen PJ. A leaky umbrella has little value: evidence clearly indicates the serotonin system is implicated in depression. Mol Psychiatry. 2023 Jun 16. doi: 10.1038/s41380-023-02095-y. Epub ahead of print. PMID: 37322065.

3:  Pies R, Dawson G.  The Serotonin Fixation: Much Ado About Nothing New. Psychiatric Times. 2022 Aug 22.

4: Fusar-Poli P, Radua J. Ten simple rules for conducting umbrella reviews. Evid Based Ment Health. 2018;21:95–100.

5:  Ioannidis JP. The mass production of redundant, misleading, and conflicted systematic reviews and meta‐analyses. The Milbank Quarterly. 2016 Sep;94(3):485-514.  https://onlinelibrary.wiley.com/doi/abs/10.1111/1468-0009.12210

Supplementary:

To update Ioannidis observations on the systematic reviews (SR) and meta-analyses (MA) versus randomized clinical trials (RCTs) I pulled up searches for those types of studies on PubMed and graphed them below.  The 2023 numbers are incomplete and that results in the tailing off of the graph on the right. The numbers of SR + MA compared with RCTs is striking. For the last complete year of data (2022) there were 38,422 RCTs compared with 42,738 SR and 36,614 MA.  As you might be able to estimate from the graph the inflection point where the annual production of RCTs were exceeded by SR + MA is relatively recent in about 2017, but the growth of these two groups has been exponential over the past 20 years.   That suggests to me that it is easier to talk about research rather than doing it yourself.

 

Graphics Credit:

Thanks to my colleague Eduardo Colon, MD for the sunrise photo.

 

The Neuroscience Center

 

Back in the 1990s and early 2000s I was part of a Memory Disorder Clinic that eventually became a Memory Disorder and Geriatric Psychiatry Clinic. When I joined there were 3 physicians a neurologist, a geriatrician/internist, and myself.  We also had a social worker and an RN. We did detailed evaluations of cognitive problems of people in people ranging from their late 40s to their 90s. We saw a significant number of people with brain injuries and probably the most people with hypoxic brain injury that I had seen anywhere. We had multidisciplinary conferences and met with families in those conferences to discuss our recommendations. We also offered some research protocols and tacrine – the first centrally acting acetylcholinesterase inhibitor (ACEI) until safer medications from that class became available.  We saw and followed a unique group of people with chronic delirium who we followed until they improved.  I was developing a resource for people with aggression and dementia and thinking about how to do telepsychiatry at that facility for rapid access.  At the time there were no facilities that dealt with that problem and it typically resulted in discharge or prolonged hospitalization.  Since most of those patients were admitted to my acute care unit it would also decrease inpatient utilization. We had a small number of examination rooms, a nurse’s office and a shared conference room in a large medicine and medical specialties clinic.  Nothing fancy - I went there for my own care but I may have been seeing it through the rose colored glasses of an altruist. After all - we were on a mission - all of us. We had a good referral base and many primary care physicians liked our service, referred patients to us, and consulted with us by email or phone.  At the time we were all part of a private multispecialty group in a Level I trauma center – dedicated to provide care to anyone in our metro area.

Flash forward a few years. We have been acquired by a managed care company. The details of that acquisition were never clear to me but it did not take long to impact the clinic.  The inpatient neurology service was eliminated.  They were not a source of referrals for us – but that change had an impact on my neurology colleagues. I had a personal connection to that service because a few years earlier I did the neurology rotation of my internship there and had many positive memories. There was also a rumor that neurology would no longer be consulted on strokes but they would be done by a hospitalist who “had an interest in strokes.”  Both of those developments had a profound impact on morale. There were rumors of early retirement and looking for jobs elsewhere. We lost our geriatrician and then our social worker.  It was down to me, the neurologist, and our RN who gathered a significant amount of collateral history before the patients came to the clinic.  Word eventually came down that “we can no longer afford the RN.”  The neurologist and I looked at one another and decided that would be the end of the clinic.  We both had other jobs and did not have the time to spend additional hours rooming patients and collecting preclinic data.  We also knew we needed that data to do an adequate job. It is impossible to assess and treat people with significant cognitive problems without collateral information. About a year later, the neurologist left to head an Alzheimer’s Clinic at a major university medical center.  

Flash forward to today.  I am standing in front of a shiny new Neuroscience Center. For the past 9 months – I have had a new onset of headaches on top of rather chronic headaches that are related to cervical spine problems that probably date back to when I was a kid playing football. I set this appointment up myself after being assessed as having “tension headaches” and a “non-focal neuro exam.”  This post is not about the differential diagnosis of headaches (although it could be) – so I am not going to elaborate on the symptoms.  I will only say that I have street cred in neurology and had additional thoughts on the headache type and whether you should image the brain of an old man with a new onset significant headache.

Refocusing on the neuroscience center it is immense and obviously very expensive.  I go the neurology clinic on the 3^rd floor and it is a large airy atrium with southern exposure glass.  It is so large that the entire medicine and medicine subspecialty clinics that contained our little memory disorder clinic could fit inside of it – it could possibly contain 2 or 3 of them.  The other striking feature was that there were hardly any people there. There were 4 demarcated pods with seating for about 24 people in front of each pod.  It was 2 o’clock and only two of us were sitting there.  I happened to be there only because I got on a cancellation list – my original appointment made in January was not until September.

The patient waiting area was impressive but as I was called to go into an exam room – I was not prepared to see the staff support on the other side of that door. There was a sea of cubicles stretching to the back of the building – many containing staff who all seemed very busy. As I sat in the exam room – I watched the big screen TV on the wall proclaim that this was the largest free standing neuroscience center in the Midwest.  I noticed that they did not specifically refer to physicians or medical doctors only “clinicians” despite naming every other profession on the team.

The examination itself was uneventful and “non-focal.” A couple of minor errors were made but nothing to mention here.  I am scheduled for brain imaging and a follow up appointment.

What was prominent on my mind?  What happened to my Geriatric Psychiatry and Memory Disorder Clinic?  The same management that decided one nurse was too expensive for my clinic sharing space with internists and minimizing neurology, was providing a raft of support in a $75 million state-of-the-art building for neurologists, neurosurgeons, PM&R and associated specialists.  Of course at that time there was considerable confusion and spin about the relative value unit (RVU) system of physician work units. Did work RVUs or total RVUs count? At one point they tried to tell us that only one psychiatrist in our large department was covering their salary. That went to RVUs needed to pay for rent and other staff.  It seemed like there was always plenty of Hollywood accounting.  It is another mystery of modern healthcare management and how middle managers increase exponentially in number.  There is probably something to be said for market concentration as well and how American governments tend to provide corporations with much more leverage than individuals or smaller businesses. 

At any rate it seems like they finally figured it out....

 

George Dawson, MD, DFAPA

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.