Coming to Love My Darkest Places: Poems by Jennifer Kelley

 

 

This is a review about this book of poems.  The author Jennifer Kelley has a brief biography in the book and she is listed as a writer (fiction and non-fiction) and poet with several accomplishments.   The book is autobiographical and written in free verse.  The physical structure of the poems is altered at times in the familiar manner of poets who use free verse. The overall structure of the book is interesting with 3 chapters of 11 poems each followed by a final chapter of 16 poems in the final chapter for a total of 49 poems over 107 pages.

The organizing theme of the collection is what she has endured and overcome in her life – including depression, bipolar disorder, psychosis, post-traumatic stress, grief, love and loss, and childhood epilepsy.  Like most important life experiences it is not a question of overcoming but recalling them over time and the changing relationship to those memories.  That can lead to different assessments and different emotions - experienced with age. 

The opening chapter is a clever James Bond metaphor (The James Bond Series) with childhood epilepsy as a equivalent of Bond’s martini.  She conveys her unique situation in 5 stanzas culminating in her observation that the only place she felt unique as a child was waking up in a hospital after a seizure.  It was the only place that she felt carefully attended to.  From my training as a physician this was interesting because it also parallels what I was told on both pediatric and child psychiatry rotations.  Some children with a lot of hospital exposure may prefer the setting because of the level of care that they receive.  The idea is developed that the only way she felt exceptional was due to the seizures, but later that same feeling could be recreated by drinking alcohol.

The poems raise questions for the reader and may lead to associations from the past. As I read her descriptions and imagery about her grandmother and the loss of her grandmother – I had the immediate association to remembering my grandparents earlier that day and the similar catastrophic circumstances. But more than that the hope that they knew the way I felt about them when they were alive.  It was perfectly captured in this phrasing:

“You were always a place as well as a woman

Did you know that?

I hope I told you.

One million times over the green polyester tablecloth,

I hope you knew.”

(p. 67-68)

There is an interesting element of timelessness in this experience. Many of us have conscious experiences each day where we are emotionally anchored in time even though the events occurred decades ago.

One of the tasks of poets is to pay close attention to the events of life as we pass through them and come out the other side.  What was it like?  What was learned? Is it a shared or more unique experience?   Many of the poems are universal experiences – like being with your grandparents when you are a kid and realizing there are problems but you are not quite sure what they are. And later driving down the road late at night and thinking of how that distance out past your lights closes far too slow – then thinking about that as a metaphor.

I noted a technique using lead off quotes with references to them in the body of the poem that I had not seen before.  The references are both to the original author and in some cases include stanzas written by that author.  As an example, she opens the poem Light using two lines by Fatima Ashgar and closes with two lines by Emily Dickinson.  Between that opening and closing was a poem about grief and the stark contrast between all the memories of that very real person and the hollowness of grieving them.  Rereading that poem many times it is clear the lines by Ashgar and Dickinson were perfectly used in the body of the poem written by Kelley.       

In the final analysis, this is a collection of unique but common experiences. The author does a good job of characterizing both. There is an implicit spirituality contained in many passages – her experience in 12-step recovery is one example.

I recently saw a presentation on the meaning of art and how it differs from other human endeavors. The presenter contended that any form of art is the perceptual and conscious experience of the artist as they go through life. Should it just be a description or there are rhetorical elements?  Is the author trying to persuade you to accept a certain viewpoint about life – or will you naturally come to a viewpoint based on the artistic expression.  I thought this book of poems was an excellent example of the latter.  Kelley describes vivid interpersonal and emotional experiences that may or may not resonate.  If not, it will increase your appreciation of the human experience.  

Read this book if you like poetry and free verse.  Read this book if you like stream of consciousness writing and can relate to it at any level. But aside from the technical aspects read this poetry if you are a student of human consciousness and spirituality and how both of those dimensions come into play when dealing with adverse experiences whether they reach the threshold of a diagnosis or not. Certainly read this book if you are a psychiatrist or psychiatric trainee – this is a glimpse into real human experience at the highest level.

 

George Dawson, MD, DFAPA  

Reference:

Jennifer Kelley.  Coming to Love My Darkest Places.  Kelsay Books, American Forks, Utah.  2023.  Kelsaybooks.com

 

Mass Shooters - The American Gun Extremist Superman

I had dinner the other night with a long-time friend and psychiatric colleague.  She and I ran an acute care unit for many years where we were charged with assessing and treating some of the most difficult problems in psychiatry. By definition, that also means the associated social problems.  That work included a significant number of civil commitments and in Minnesota associated hearings about medications.  The conversation turned to politics and then the recent attempted assassination of Trump.  Before I could say anything, she commented about how absurd it was that there was endless speculation in the media about “motive” and the fact that there was no motive. I agreed with her completely on that point.  What motive can you have for picking up a high-capacity military weapon and deciding to shoot and kill someone and anyone else who happens to be around?  And of course – why does it predominately happen in the US? 

As I pondered our conversation over the past couple of days and what I have written here about it – I came up with the idea of the American Gun Extremist Superman. This is not a traditional superman role or even the antihero role.  It is a superman role that can occur only in a culture of gun extremism.  I have written in the past about how this is quite definitely a cultural problem and the people who have been the source of the culture – extremist politicians, judges, and other gun extremist advocates largely blame everything else.  Incredibly they blame the lack of an armed staff in schools, a shortage of firearms in the most heavily armed country in the world, and more recently law enforcement and parents. They never examine the fall out of gun extremist policies that have been accumulating over the past 40 years.

Here are the features of the gun extremist superman that I have so far.  They are not diagnostic criteria by any means.  This is a societal and cultural problem more than anything.  It obviously exists only in the US.  There are undoubtedly people with psychiatric disorders who acquire these traits – just like people with psychiatric disorders assimilate other social and cultural traits.  But a psychiatric disorder does not explain most of these shootings.  I am using the pronoun he in these cases for the obvious reason that practically all of the shooters are men and boys.   

He is disgruntled and dissatisfied:  This is a common nonexplanation for mass homicide. It is basically a marker for what causes an unexplainable behavior.  When you study human behavior, these changes can occur from internally driven psychological states, external states, and all points in between.  To what extent is their insight, judgment, and decision making affected? To what extent does their moral decision making have an impact on what is occurring?  It is complicated by what is known about a person’s baseline.  For example, are they quiet and non-disclosing about their internal states or are they more demonstrative?

He has no problem at all attributing his state to the actions of others even when that is completely displaced.  In other words, displaced onto completely innocent coworkers, bystanders, school children, etc.  In psychiatry we call this projection and historically it is listed as a defense mechanism.  It is typically seen in persons with psychotic disorders and moderate to severe personality disorders.  It is a common experience to feel like you are being unjustly blamed during interactions with people using this mechanism or in the extreme case where that person is reacting to you as though their accusations are true.  Even though it is difficult to research this mechanism in mass murders – it seems intuitive that it has to exist at some level given the discrepancy between their real victims and the purported abusers (if any).

He knows that there is a burst of fame associated with each shooting and endless speculation about his motivations.  Although there is little information about the Trump shooter – it is known that he had details about a previous mass shooter on his electronic devices and this has also occurred with previous mass shooters. Anybody experiencing the news cycle in the US following a mass shooting notices a flood of information and speculation about that shooter that can go on for weeks followed by other bursts from associated court cases, documents, computers, web sites documenting mass shootings, legislation, and scientific literature.  Mass shooters seem to be guaranteed immediate and sustained notoriety – despite some concerns expressed in the literature that this is reinforcing the behavior.  The psychology of mass shooters is difficult to investigate, but I would not be shocked to learn that revenge fantasies go hand-in-hand with the expectation of notoriety from the act. 

He feels some justification by identification with previous mass shooters and cultural revenge themes.  As noted above many aspiring mass shooters have immediate access to the mass shooter literature as well as a wealth of revenge-based video games and movies.  The preponderance of this information depicts the shooter as the good guy meting out justice and revenging either his own victimhood (real or imagined) or that of his loved ones.  A secondary theme is that the usual channels of justice – law enforcement and the courts are too weak, do not apply to him, are too slow, or too negligent to be useful.

He sees it as a singularly masculine activity – especially with the use of firearms.

Most of the cultural figures engaged in this activity are men.  Armed men are typically the graphic elements of disaffected groups of society but their rhetoric has creeped into the political mainstream.  You don’t have to look too hard to find opinion that in the battle over “gun rights” – the correct interpretation of the Second Amendment will go to the winners of an armed insurrection or that the more heavily armed political party will “win.”  In that atmosphere was it an accident that we witnessed an insurrection on January 6^th?  Nobody steps back to point out that gun rights are there in the Second Amendment and the real battle is between gun extremism and common-sense guns laws.  In the common discussion nobody has advocated to take guns away from law abiding and responsible citizens.  At this point the US is awash in guns to the point that collecting all of those guns or buying them back is impractical.

Societal reinforcement of the Gun Extremist Superman. 

At first that seems like an extreme idea.  How can American culture and society reinforce this behavior? I have touched on the very real aspects of gun extremism and the cultural aspects that are reinforcing but there are others. Whenever mass shootings occur – politicians show up make the typical statements about “sick individuals”, offer “hopes and prayers”, and in some extreme cases have encouraged the affected communities to “move on.”  Mental health becomes a distraction, when politicians use it as a cause for the incident but never do anything constructive to address it.   The condemnation of the shooter is trivial compared with what has occurred. And no effective measures are ever suggested or accomplished. If anything, many politicians come up with a series of rationalizations about why the shooter was not stopped – the teachers were not armed, law enforcement response was inadequate, the only way to stop a bad man with a gun is a good guy with a gun, etc. Specifically, no measures to counter gun extremist laws are ever suggested and we are supposed to pretend that getting as many guns out on the street is a remote problem from the problem of mass shootings.  The real message to mass shooters is that “we are not going to do anything to stop or interfere with you.”

There is an additional message that is the direct result of gun extremism and that is – shoot first and ask questions later. Stand your ground and castle doctrines or statutes are a relatively recent development in the gun extremism landscape.  Stand your ground statutes basically say that there is no duty to retreat before using deadly force. Before these laws self-defense laws included the provision that the person who is unlawfully attacked needs to exercise judgment to try to avoid the use of deadly force by retreating if necessary.  Stand your ground laws were passed initially in 2005 in Florida and since then these laws exist in 38 states. The details are available at this site, including references to the fact that it probably increases the crime and homicide rate.  Although these laws were passed primarily in the past 20 years, they are the culmination of gun extremist rhetoric that has emphasized the need for people to be armed and dispense justice with firearms.  My conceptualization of the mass shooter is that he likely believes he is dispensing justice, even though nobody would agree with that premise.

The additional cultural change that preceded stand your ground was the idea of the armed citizen.  In the 1960s, the people who owned guns were predominately hunters.  The focus of the National Rifle Association (NRA) was hunter safety. When I took that course one of the mainstays was never pointing a gun at a person and always assuming a gun was loaded.  As firearms become more important as political rhetoric there was a sudden shift to the idea that there needed to be more guns out there for personal protection.  Since then there has been a steady escalation in gun extremist rhetoric and the idea that there are defined preconditions for shooting someone.

Psychosis is not an exclusion from societal or cultural factors:  Although the majority of these shooters are not mentally ill there is a lot of confusion over whether mental illness excludes the person from societal and cultural factors - making the psychosis in itself an explanation for the behavior.  It does not.  Just as computer chips, microwaves, and surveillance satellites were incorporated into delusions as they became incorporated into society - gun extremism has the same effects.  There is no reason that they and the folklore of mass shooters cannot be incorporated into a delusional system of thinking and acted upon.  In other words - there is no de novo psychosis of mass shooting - it happens in a gun extremist society.

All of the above elements are more important to him than self-preservation.  Many mass shooter incidents occur with the death of the shooter by homicide or suicide.  The high mortality rate suggests that mass shooters are unconcerned about their own life in carrying out their actions. This information is readily available to potential mass shooters and I would argue is part of the Gun Extremist Superman stereotype.  

He has easy access to high-capacity firearms – both handguns and rifles. Easy access to legally purchased firearms is well documented in many of these cases.  In some cases the firearms are borrowed and in other cases they are purchased from licensed firearms dealers.  One of the common gun extremist slogans is “if guns are criminalized only the criminals will have them.”  It is obvious that firearms are legally available at this point to anyone who wants to commit a serious crime like a mass shooting. It is also obvious that there are loopholes that allow gun purchasers to bypass existing laws.

What I have described here is a Nietzschean superman who clearly rejects traditional moral values of society and adopts his own – even though they are morally reprehensible to almost everyone else.  There are currently numerous patterns in American culture and society that reinforce this pattern of activity.  We are on a course for that to continue unabated.  It may worsen as the pattern of gun extremism worsens.  There are two potential solutions as far as I can see.  Reverse gun extremism back to the gun rights laws of the 1960s or preferably the 19^th century.  If the 19th century seems  too radical - see the Tombstone ordinance at the bottom of this post.  A second more public health focused measure would be on mass homicide prevention – by identifying the problem and trying to intervene while researching it.  

At the time I am writing this - neither intervention seems likely.

 

George Dawson, MD, DFAPA  

Supplementary:  If you have any doubt about the lack of motive for most firearm related homicides - I suggest watching crime TV like The First 48.  These shows typically have investigations by experienced homicide detectives that include interrogations of  suspects, witnesses, and family members.  In some cases court proceedings are included. The majority of cases are attributed to senseless violence and that typically means somebody got angry, there was a firearm available, and it was used to commit homicide.  Mass homicides can be viewed as taking the senseless violence theme to the next level.  Senseless violence is a predictable outcome of widespread gun availability and gun extremism. 

The Map Is Not The Territory

 

I ran into a quote this week that I must have read and forgotten from the past – because it was referenced in Bateson’s Steps to an Ecology of the Mind.  That was a book I read back in the hippie era after seeing it referenced in the Whole Earth Catalogue.  It happens at a time when I was writing about the usual philosophical rhetoric used to criticize psychiatry.  The circular logic argument I have encountered frequently by philosophers seeking to either destroy the profession or portray psychiatrists as unthinking buffoons.  That quote was “A map is not the territory” and it is attributed to Alfred Korzybski.

When I saw it – I associated immediately to the map I know the best and that is Hwy US2 running across northern Wisconsin between Minnesota and Upper Michigan.  I have travelled that road hundreds of times.  In fact, in 1988 I drove it over 200 times that year to keep a small inpatient psychiatric unit open. Maps these days are much better than they used to be.  For the old road maps to have the same scale and sufficient detail meant a large size that had to be folded and refolded to get it back into the glove compartment.  The above map is a clip from Google Maps and it can be scaled down to the individual house level and from there a street view that is regularly updated.

Thinking about old maps and new maps it is easy to see Korzybski’s argument. Driving US 2 late at night it is common to encounter characteristics of the territory that are not listed or even included in your GPS updates. The territory at night is much different than the territory during the day.  A major difference is deer on the highway.  There are the occasional deer crossing signs but I have suddenly found myself driving among a herd of 30 or 40 deer running next to my car and alongside the road.  The Google camera cars fail to update the video information fast enough to account for social and cultural changes that happen in the small towns along the way.  Am I going to encounter a large influx of out-of-staters for the Blueberry Festival in Iron River or the Strawberry Festival in Bayfield?  Is that small general store still there or is it finally gone? Is the posted or suggested speed limit accurate or do I have to correct for the weather?  

In the era of climate change even modern maps have uncertainty.  Highway 2 has been washed out and under water – both events that have never happened at any other point in my lifetime.  Using modern GPS guidance – I ended up on what appeared to be a dirt wagon trail that eventually got me back to Minnesota.  Every inch of that terrain looked like it had been seen by very few people in the last 50 years and no Google camera cars.  Most people unconsciously adapt to the terrain on the drive home – that sunken manhole cover or pothole to avoid.  We automatically adjust to the hazards even though they are not indicated on any map.  

Korzybski’s argument is basically twofold. First – no matter how far you drill down with a map – even a much-detailed map you will not find what you are experiencing – what your perceptions tell you is there. The map after all is an abstraction by someone and that is not a perfect representation of geography but also not your reality.  From consciousness science - your reality or experience of it is not my reality.   From information theory – the human brain is acquiring much more information going forward than you can get from one derived across a series of finite dimensions and time.  Second – this has clear implications for the ideas of subjectivity and objectivity.  In medicine we construct clinical trials – with exclusion and inclusion criteria that eliminate large real populations and at this point cannot account for the heterogeneity in the remaining research subjects. That does not preclude progress but it should introduce humility into the eventual results. No matter how broad or narrow those selection criteria are – they are only an approximation of the real population who will be treated.

Lest these connections be seen as speculative – here is what map makers and geographers have to say about the situation.  Basic geographic data is a space-time location. In addition, there is other relational data that contextualizes a location.  Data and relationships are discussed in terms of model and how the model is a simplified representation of reality but not reality itself.  A good example was John Snow’s map of cholera during the 1854 epidemic in London and how he used that to determine the source and isolate it. Cartographers are aware of these relational loops to space-time location as well as the limitations that are due to the large number of contextual features.  The map cannot account for them all.  

What does it say about philosophy and rhetoric applied to psychiatry?   

It says a lot about classification systems.  Much research today is preoccupied with ideal classifications.  The DSM for example is criticized for not being a perfect diagnostic system when in fact (like all medical classifications) it is a crude system with additional landmarks.  The graphic below illustrates the problem and how the assumptions made for the diagram on the left do not reflect the reality of the diagram on the right. That diagram is more complex – but not nearly as complex as the real clinical situation. After all – if the clinical situation was accurately reflected in the diagram on the left everyone with schizophrenia would be the same.  Psychiatrists would not have to concern themselves with a developmental history, a social history and life narrative, a medical history, and a family history.  They would not have to consider critical psychological events in a person’s life and putting all that together in a formulation about what is unique about that person.  The territory of that person would include supportive people and important contacts. Like the map of Highway 2 – the DSM gets us into the ballpark but it is not specific about what we will find. 

Korzybski has been described as an independent scholar.  He is credited with inventing the field general semantics.  There is a research institute founded on his ideas. There are not a lot of scholars taking his work forward.  There is an excellent online biography of Korzybski that describes the controversies associated with his writings and varying degrees of acceptance.  Interestingly he wrote about psychiatry and in his biography, there was apparently a group of psychiatrists interested in his work.  He referenced “neuropsychiatry” as a field that had generally been ignored by the rest of medicine.

 

Irrespective of the complexity and controversy of general semantics – I am still focused on the map is not the territory concept for several reasons.  First it reflects what is going on in the DSM classification system.  Second, it describes limitations of any classification system and how that abstraction differs from reality. That is probably the reason that medical diagnostic systems die hard, especially after decades or centuries of the same observations.  Is there any reason to suspect a dimensional or sub phenotyping system would be any better?  Probably not at least until very detailed observations can be made.  A classic paper (4) suggested that hundreds of true/false questions identified psychological traits and that this was an actuarial method superior to clinical judgment.  Despite that alleged superiority many of the methods suggested in that review like the Minnesota Multiphasic Inventory or MMPI have fallen out of use and are no longer used for screening purposes or making diagnoses.  Machine learning and artificial intelligence can produce these results faster and on a larger database but continue to have limited applications.   Third, it reflects expert opinion by at least one of the top theorists in the field (5).  Fourth it reflects good clinical practice that includes a formulation with additional commentary on psychopathology, associated observations and theories. 

At the minimum I hope that you find Korybski’s observation as interesting as I do.  I probably will not read his voluminous works – but I am always aware of the fact that no matter what classification system you are using it is always an abstraction with various degrees of precision.  Further it is an abstraction by one person or a group of people.  The way the DSM (and all of medicine) is structured the precision of both the diagnosis and treatment of a particular patient depends on what occurs during the encounter and the experiences and abstractions of that physician.   

George Dawson, MD, DFAPA

 

Supplementary: Doing research for this post, I encountered another quote that expresses a similar idea:  "The menu is not the meal".  Alan Watts is credited with that quote. 

References:

1:  Korzybski: A Biography (Free Online Edition) Copyright © 2014 (2011) by Bruce I. Kodish.  See chapter 30 for Korzybski’s contact with psychiatry including Harry Stack Sullivan and William Alanson White:  https://korzybskifiles.blogspot.com/2014/06/korzybski-biography-free-online-edition.html?spref=tw

2: Doerr E. General Semantics. Science. 1958 Jul 18;128(3316):156.

3: Gardener M. General Semantics. Science. 1958 Jul 18;128(3316):156.

4:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74

5: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

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What Do Readers of This Blog Want To See?

 

I thought I would ask basically to see if I can be more helpful.  My interest in writing this blog came about because I had many people ask me what I was reading.  They seemed to find my information sources to be interesting. A secondary interest of mine is making sure that the best possible information is available to clinicians who are on the front lines making decisions each day.  Thirdly, the analysis of research whether it is basic science or clinical research is also an interest - both the scientific measures but also the rhetorical aspects.  Many people don't think that rhetoric enters into medicine and science. If you are a psychiatrist we have been contending with rhetoric for decades whether we want to or not and it has extended into literature that most would consider to be scientific.  There are a lot of posts about that rhetoric on this blog.  Fourth - I post about society, culture, and politics and how that impacts us.  I have frequent posts on the cultural effects on behavior - with many posts on my hypotheses about how gun extremism affects us all and is associated with the American mass shooter phenomenon.  Fifth - I have posts on diagnostic reasoning and taught a course to medical students about this for a decade in the past.  I try to tie in diagnostic thinking in psychiatry as a comparison.  Sixth - I have done book reviews on poetry with psychiatric themes and consciousness  and am currently reviewing another poetry book, Keith Rasmussen's book on ketamine, and a book on spirituality where I hope to illustrate a path to connecting that to psychiatry.

My most viewed page recently has been the updated review of systems for psychiatrists.  This is actually a tool I use in clinical practice and there are several other pages like it.  It has recently been viewed over 31,000 times - but I think at some point Blogger (the Google interface that this is published in) - stopped counting page views from virtual private networks (VPNs) by the page and only counts them in aggregate - where there are about 2.1 million views.   Additional highly viewed pages about clinical psychiatry include 2000 Words About the Last Ten Minutes of a Psychiatric Evaluation and Additional Work on the Review of Systems for Psychiatrists.  

Posts that are currently pending include:

1:  Updated post on Neanderthals and why they disappeared.  Paleogenetics is a fascinating read and it has implications for human illnesses, evolutionary aspects of psychiatry, and the evolution of man. 

2:  Review of the poetry book Coming to Love My Darkest Places by Jennifer Kelly. 

3:  Review of The Varieties of Spiritual Experience by David B. Yaden and Andrew B. Newberg.

4:  Review of Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule by Keith Rasmussen.

5:  Continued posts on the rhetoric of medicine and psychiatry including the theory of that rhetoric.

6:  Continued posts on the importance of biological theory to psychiatry.  I am referring to theory that originates in biology rather than the usual biological hypotheses in psychiatry although they are not mutually exclusive. I hope that I give the impression that I am not very impressed with the proliferation of purely philosophical ideas about the field, especially from people who have never been trained in psychiatry or medicine.  

7:  A musculoskeletal case including images (CT, MRI, bone) with a discussion of complex misdiagnosis and how all of that applies to psychiatry.  

I will avoid a top ten list of what is coming, but that is what is percolating right now. I tend to work better when I am thinking (and writing) about many things at once.  My motivation for this brief post is too see if there are any topics that readers would either like to see or like to see elaborated on.  They can be clinical or theoretical - medical or psychiatric. Feel free to send me your ideas either posted here or to my direct email address. 

I would also like to address two related topics.  The first is the use of these blog posts.  I think most people read them for their own interest, but some have been incorporated into books.  Everything on this blog is Creative Commons licensed.  That means it can be shared for no charge in just about any medium that you want it to be.  The only stipulation is that you cite me and this blog as a source.  I have found myself in the awkward situation of being at a conference and seeing my blog pages projected by a prominent researcher without referencing my work. I do not make any money writing this blog.  I have no paid subscribers or advertisers and pay all of the expenses out of my own pocket.  I think one line of 12 point font referencing my work in the bottom corner of a PowerPoint slide is not too much to ask. 

Even better, I am happy to collaborate.  I am willing to research, cowrite, or make graphics for your project for co-authorship credit and nothing else.  In fact, I recently offered to analyze the utilization of psychiatric medications for a large healthcare plan for free.  They declined the offered but I remain very interested in the analysis of real world data in health care setting.  Send me an email if you are interested.

George Dawson, MD, DFAPA

Supplementary 1:  Requests for topics:

 The request for topics has gone well so far.  The following is a list by topic and/or specific question.  If this leads to any other ideas – feel free to send them to me.  I am also interested in learning about any graphics that people would find useful. 

 

1:  ADHD – rates of diagnosis, how people present for assessment, missed diagnoses and other associated problems, diagnosing adults, and neurodevelopmental diagnoses in general.  (see comment below).

2:  ADHD – stimulant treatment and cannabis use.

3:  Antidepressant withdrawal with a focus on gastrointestinal symptoms.

4:  The models of mental functioning that are helpful in psychiatry.

5:  Indications/guidelines for antipsychotic use in children and teenagers.  Data on long term use.

6:  Memory and cognitive problems associated with POTS (Postural orthostatic tachycardia syndrome) – and recommended medical treatment.

7:  How psychiatry was practiced and the current transition – implications for the future of the field.

8:  Dementias associated with Lyme Disease and other infectious diseases

9:  More biological psychiatry!

10: Pharmacology and psychiatric applications of alpha-1 and alpha-2 adrenergic receptor agonists and antagonists.

11:  Pharmacology and psychiatric applications of beta adrenergic antagonists in psychiatry.

12:  What are inverse agonists in 10 and 11 above?

13:  Post Finasteride Syndrome (PFS) – I continue to get treatment requests for this syndrome.  Some of the people sending me emails explain that I am listed on web sites as a treatment resource, even though I have never personally assessed or treated the disorder.  I will probably post a review on PFS in the next year.

14:  Post SSRI Sexual Dysfunction (PSSD)/Persistent Genital Arousal Disorder (PGAD) – I have posted a review of this disorder and I am listed on web sites as a treatment resource. I have also had at least one person try to convince me to remove my post or modify it to their liking.

https://real-psychiatry.blogspot.com/2023/07/post-ssri-sexual-dysfunction-pssd.html

15:  Antidepressant withdrawal/discontinuation:  I have posted on this and my opinions are all consistent with a recent major review.  I am always interested in medication side effects – no matter the medication and how they can be mitigated. I have also had treatment requests to assist with this problem. I will probably add a post on the major review and also continue to comment on the politicization and the associated rhetoric. As well as placebo/nocebo responses.   

https://real-psychiatry.blogspot.com/2018/06/the-problem-of-antidepressant.html

16:  Supportive psychotherapy:  Throughout my career I practiced supportive psychotherapy in practically every clinical encounter and across every diagnostic category.  I consider it to be a necessary skill for psychiatrists – but it is difficult to write about in terms of both observations and techniques.  At some point I will be posting about this.

17:  How to walk down stairs and minimize the risk of falling:  That's right - I am a psychiatrist and old speedskater with an interest in biomechanics. I will post this as soon as I can figure out how to draw stick figures walking up and down stairs.  Let me know if there is software out there that might help with this type of drawing. 

That should keep me going for a while.  Do not hesitate to send more ideas or questions.

A final note on treatment requests.  I have received these requests as noted on #13, #14, and #15 above from many different states.  My response is always that I am retired from clinical practice and no longer provide active treatment since 1/19/2021.  That also means that I do not have access to what is required to provide medical care and meet licensing requirements (records, malpractice insurance, support staff, etc.).  And even if I did – treating people across state lines remains somewhat of a logistic nightmare.  As a result, I cannot provide telepsychiatry services or casual advice.  What I write on the blog has always been educational and for a large part directed at physicians and more specifically psychiatrists.  It is not medical advice and I hope I have always emphasized that the best treatment with continuity is available from your local physicians and specialists.  Proper medical care requires a formal doctor-patient relationship and that cannot be casual advice.  And for the physicians out there I hope I come across as an interested colleague.  Another intent in writing this blog is not to suggest that my knowledge or practice is superior to anyone else.  Life, biology, and medicine are too complicated for that.

Supplementary 2:

Elements of a dynamic textbook:  In my spare time I will be arranging my blog posts from the past 12 years in the general form of a book.   The intention is not to create a book but an outline for a book.  Not all of the posts will translate well but most will.  I would like it to be dynamic - not psychodynamic but useful to all psychiatrists.  Typical texts waste too much space on just technical details and I would prefer to focus on key concepts and approaches including how that evolves. I will post the outline here when I have it - in the meantime feel free to suggest chapters.