It’s Not The Heat – It’s The Wet Bulb Global Temperature (WBGT)!

Despite the current election cycle and massive denial of climate change by the MAGA party – the average temperature of the Earth is getting much higher. The ten warmest years on record are the last 10 years (see graph above).  That is corresponding with the expected melting of glacial ice, increasing sea surface temperatures, and higher sea levels. It is equally obvious that the necessary measures to reduce carbon dioxide in the atmosphere are not being taken.  We can therefore expect future generations to experience the burden of excessive heat, unstable weather patterns, flooding, crop shortages, and all of the economic and international instability that will occur.  I don’t think it is a stretch to see this as potentially catastrophic to civilization.

Of all those weather related phenomena – extreme heat and humidity are the number one cause of death.  Mortality due to heat stroke is increasing every year. This was the first year that I heard frequent stories about hikers perishing from the heat.  The CDC estimates that about 1200 people a year die from extreme heat and they have a web page dedicated to providing resources about this public health threat. The EPA has a site that looks at heat related deaths over the past 20 years and although they are higher – they discuss the issue of variable reporting, largely due to inconsistent criteria about what is called a heat related death.  There is a good chance that heat related deaths are underreported and attributed to other causes.

Modern reviews of heat stroke and heat related illnesses (1-3) suggest that there are two conditions that are clear emergencies and varieties of heat stroke – classic heat stroke and exertional heat stroke. Classic heat stroke develops in people exposed to heat who may be predisposed because of chronic illness, medications, and an environment that is excessively hot.  These patients are typically elderly.  Exertional heat stroke occurs when heat is generated by muscle exertion in hot weather and that leads to excessive body temperature. In both cases emergency cooling is a critical treatment along with fluid volume replacement if that is an issue.  Heat stroke is a multisystem inflammatory disease that leads to a combination of autonomic, cardiovascular, and metabolic responses that can lead to organ failure and death.  Mortality is high - 80% in classic heat stroke and 33% in exertional heat stroke (3) if there is no immediate treatment.  The issue of immediate treatment is problematic because heat stroke can cause compromised mental status including loss of consciousness – further exposing the person to prolonged heat exposure.  Preexisting cognitive compromise complicates both recognition of heat related illness and getting timely care.      

The issue of heat, humidity, and heat dissipation from the human body is an exercise in physical chemistry.  Evaporative cooling is one of the ways that mammals cool their bodies to maintain a stable body temperature.  In humans the other way is skin surface vasodilatation and heat transfer from blood.  Every time water changes phase (solid -> liquid -> gas) there is an energy requirement that is termed enthalpy in physical chemistry. The enthalpy or heat of transition from liquid to gas is 40.67 kJ/mol.  That means that we can calculate the amount of water necessary to maintain cooling at an amount of energy production. The relevant variables include how much energy the person is expending, ambient air temperature, and the relative humidity since the last two affect the amount of water that can transition to the gaseous phase.

All these variables can be considered form a meteorological viewpoint using the concepts of heat index and wet bulb global temperature. On this prototype site you can chose either value, click on your location on the map (it scrolls), and get the heat index or WBGT.  As an example, two days ago the temperature at my location went firmly into the danger zone as indicated by this tracing that I downloaded at the time. Suggested activity levels and precautions are available on the site for the WBGT values on the curve over the course of the day.  Another way to look at WBGT is that it is the temperature where evaporative cooling starts to fail and that is the measure of danger.

WBGT was recently assessed looking at wet-bulb temperature adaptability thresholds in health young research subjects (4).  Under experimental conditions they looked at subjects under moderate metabolic load and determined the critical wet-bulb temp beyond which the heat stress could no longer be compensated for.  The researchers looked at the proposed critical wet bulb temp of 35ºC (95 Fº)(threshold wet bulb temp) and discovered that it could be considerably lower and that it was unlikely that a single critical temperature for all conditions could be found.

Irrespective of the reporting issue, public health officials are concerned about ambient temperatures and the heat island effect of concrete in large cities where emitting energy can raise the ambient temperature up to 7 degrees hotter than the surrounding area.  They have identified high risk populations including the elderly, people with inadequate housing, and people with no air conditioning. That last category can rapidly expand whenever weather conditions effect power transmission and cut electrical power to large populations.  We just experienced those conditions in Minnesota shortly after a burst of peak temperature and humidity conditions.

Many people with chronic mental illnesses are in the high-risk category.  Compromised judgment whether due to effects on cognition or more focal problems with judgment and problem solving can lead to potentially fatal situations at either end of the temperature spectrum. During the recent heat emergency, I witnessed several people wearing excessive clothing and at the same time expending a lot of calories.  They were in a weather zone where the National Weather Service (NWS) suggested minimal activity. Chronic mental illness also creates the risk of no housing or inadequate housing. In extreme heat – the lack of air conditioning can create an emergency situation for many people.  

At the policy level (5) there have been some approaches to try to assure the safety of people that might experience exertional health stroke.  They are in the form of mandated breaks, access to water, and access to air conditioning.  They are far from universal and in some cases there has been political opposition based primarily on anti-science (climate change, human physiology) ideology and ignorance. It is a reckless approach to humanity but consistent with gun extremism views held by the same groups. 

At the individual level, psychiatrists need to be aware of their patients’ living conditions and their theoretical susceptibility to heat related illnesses.  That requires an integrated view of their current health status, medications, cognitive status, functional capacity, physical activity level, and specific access to air conditioning. Assertive Community Treatment (ACT) teams will have an advantage is knowing first hand what the living conditions are. In the past I have worked out a plan for people to go to an air-conditioned shopping mall depending on the weather conditions. Some people will find this difficult and could benefit from a visit and prompts from a case manager. A call list of people who may be at risk could be useful for case management teams.  As more municipal areas develop cooling shelters – a more formal referral process might be possible.

In the short term, a focus on the medical and social aspects of patient care will be necessary to mitigate the potential lethal risks of heat related illness. It is a necessary role for all physicians as the climate disaster unfolds.

 

George Dawson, MD, DFAPA

 

1:  Savioli G, Zanza C, Longhitano Y, Nardone A, Varesi A, Ceresa IF, Manetti AC, Volonnino G, Maiese A, La Russa R. Heat-Related Illness in Emergency and Critical Care: Recommendations for Recognition and Management with Medico-Legal Considerations. Biomedicines. 2022 Oct 12;10(10):2542. doi: 10.3390/biomedicines10102542. PMID: 36289804; PMCID: PMC9599879.

2:  Epstein Y, Yanovich R. Heatstroke. N Engl J Med. 2019 Jun 20;380(25):2449-2459. doi: 10.1056/NEJMra1810762. PMID: 31216400.

3:  Sorensen C, Hess J. Treatment and Prevention of Heat-Related Illness. N Engl J Med. 2022 Oct 13;387(15):1404-1413. doi: 10.1056/NEJMcp2210623. Epub 2022 Sep 28. PMID: 36170473.

4:  Vecellio DJ, Wolf ST, Cottle RM, Kenney WL. Evaluating the 35°C wet-bulb temperature adaptability threshold for young, healthy subjects (PSU HEAT Project). J Appl Physiol (1985). 2022 Feb 1;132(2):340-345. doi: 10.1152/japplphysiol.00738.2021. Epub 2021 Dec 16. PMID: 34913738; PMCID: PMC8799385.

5:  Burton A.  Energy justice for all: keeping disadvantaged populations cool in a heating world.  Federation of American Scientists: https://fas.org/publication/energy-justice-keeping-cool/

6:  Knochel JP. Heat stroke and related heat stress disorders. Dis Mon. 1989 May;35(5):301-77. PMID: 2653754.

This was the first comprehensive review I read on the topic.  I was a subscriber to Disease-a-Month and the Medical Clinics of North America early in my career - based on recommendations from an Internal Medicine resident who I worked with.  This remains an excellent review of the topic.  

Graphics Credit:

National weather Service (weather.gov) for all except for the North Carolina High School Athletics Association as noted. 

 

 

 

Happy Labor Day 2024

 

More labor like I am used to seeing it in the upper Midwest. 

In keeping with the tradition of previous labor days - this is my annual greeting. I started writing these Labor Day greetings as an update on the work environment for physicians.  My rationale is that over my nearly 40 years in medicine that environment has continuously deteriorated.  Like any field there have been obvious improvements and innovation in clinical care along the way.  Even though that has happened the work environment has worsened every year leading to widespread physician dissatisfaction, burnout, and moral injury along the way. 

I was fortunate enough to hang on until about three years ago when I retired.  Compared to working my entire career as an employee - retirement is quite literally a walk in the park. I  stay active in the field by reading, writing this blog, and working on various publications. I get plenty of rest and exercise. I have time for activities that were on hold for decades during my working years. I have not seen or treated any patients in about 3 years. A friend of mine who went back to work told me that he had to work on an inpatient unit for 2 months because the organization he worked for had that requirement for anyone who had not seen enough patients in the past two years.  If you were an acute care psychiatrist like myself that requirement makes little sense. Reading all of the notes and plans from the first week of outpatient practice should suffice.  After all we have a Presidential candidate who brags about passing a rudimentary cognitive screening exam - and he has a briefcase with all of the nuclear missile launch codes. 

I do miss the detailed conversations with people and discussions about how to approach their problems.  In some of the discussion formats there is still controversy about psychotherapy in psychiatry.  The only way I can see this as a real controversy is if we are arguing that all psychiatrists should be psychoanalysts.  I don't think that anyone believes that any more. But it has always been clear to me that psychiatric practice needs to be informed by psychotherapy and that includes psychoanalytical/psychodynamic psychotherapy both on the expressive and supportive sides. Psychiatrists need to be able to talk with people in a therapeutic way across a number of diagnoses and settings.  Psychiatrists need to be able to maintain relationships with people who have a very difficult time maintaining relationships with anyone. Psychiatrists need to maintain relationships with people who are actively avoided by their own families and acquaintances.  The only way that will happen is if a psychiatrist is trained in these techniques.  Without them - a person is just talking with another doctor about medical treatments. 

As I have stated many times on this blog in the past - that type of quality psychiatric treatment takes time.  Taking time away from psychiatrists and their patients is one of the functions of modern healthcare administration.  It leads to the previously mentioned problems in the work environment.  I did an update just before typing this post by searching developments in the physician work environment in the past year.  The same concerns about dissatisfaction, burnout, and moral injury were still there.   There was something slightly more specific on the AMA web site pointing out how Medicare reimbursement is not indexed to inflation and does not cover the expenses.  That leads to higher volume work (something that managed care rationing was supposed to prevent) and in many cases lower quality.  It can also lead to a lack of available care as physicians drop out of Medicare or just have too much low reimbursement work to see new patients.  But that message from the AMA is far from optimal.  It seems to imply that if patients were aware of these problems they would lobby politicians to improve working conditions for doctors.  Patients already know the problems - at least some of them.  I had several patients comment on the low reimbursement I was getting from Medicare for seeing them.  It might be useful if physician organizations like the AMA provided information on how to set up a practice that would maintain financial viability.    

I did try to volunteer as a research analyst.  I was involved in a great research project at the time I left my last employment.  I offered to analyze data for a local large healthcare organization (one of the three largest in Minnesota).  I emphasize again that I offered to work for free on this data analysis and any subsequent publications.  The research project I suggested had never been done in a large healthcare organization - but had been done in registry studies in Sweden and Denmark.  There are no national registries in the United States and all of the data is proprietary.  That company was not interested in me working for free even though I did plenty of free work for them when I was an employee working on research committees.  The only difference was that I still had to generate revenue by seeing enough patients while doing the additional work for free.  That offer still stands for any serious research being done in psychiatry.

That is my brief Labor Day message this year.  It is repetitive because physicians have very little leverage against businesses and governments and that had led to the current work environment problems.  I continue to go to conferences and see a lot of people who I know are still actively working.  From their descriptions they are working too much.  Like me they enjoy talking and working with people.  That is probably how a person ends up in psychiatry.  I wish them well in the coming year and hope for developments that will make their work easier.  And as always - I hope all of my colleagues make it to retirement.

George Dawson, MD, DFAPA

Supplementary 1: I decided to include this graphic from about 4 years ago that I made to indicate how much physician/psychiatrist time is diverted away from clinical care basically to satisfy some administrative requirement.  It should be obvious that has increased greatly over time and although other health care providers are also affected the burden is somewhat disproportionate on the physicians.  As I pointed out - during this time frame I replaced 4 full time employees when I was expected to also do their work.  It is also apparent that a lot of this worked is free for other organizations (managed care organizations, pharmacy benefit managers, etc).  

 

Graphics Credit:  click directly on the photo and it will take you to detailed information on the origins, credits, and CC license on Wikimedia Commons. 

Review of Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule

 

Keith Rasmussen is Professor of Psychiatry at the Mayo Clinic and the author of an authoritative text on electroconvulsive therapy - Principles and Practice of Electroconvulsive Therapy.  I noticed the pre-release literature on his book on ketamine and waited for months to get a copy.  After reading it I can say it was one of the best books I have read in psychiatry.

The book is organized into 9 chapters.  The first 4 are on the history and pharmacology of ketamine.  That is followed by 4 chapters on clinical applications including depression, as a model for schizophrenia, chronic pain, other psychiatric disorders, substance use disorders, and ketamine assisted psychotherapy.  There is a final chapter on whether ketamine is a neurotoxin or a neuroprotectant and several experimental applications are discussed.  Many of these chapters could be freestanding reviews of the literature. In writing these reviews, authors will often use table summaries either as an outline or in the body of the review. Rasmussen uses one or two paragraph long summaries of research papers and is aware that can be a tedious approach. For that reason, he omits a long discussion of preclinical research in one chapter.

The initial chapter is an introduction to the molecule.  We learn that it belongs to a class of arylcycloaminohexanes and that phencyclidine (PCP) was the initial drug synthesized from that class. PCP was invented for use as a general anesthetic, but it failed because of severe behavioral reactions.  Additional structures were synthesized from that class and ketamine was eventually developed on a preclinical basis. The molecular structures of both compounds are provided in the book but the structure of ketamine on page 12 is in error (it shows a chlorine atom in position 2 on a cyclohexane rather than a phenyl ring but the IUAPC naming in the caption is correct).  I have posted both structures below.  The purported mechanism of action is discussed in several places – at the level of the NMDA receptor and how pathological processes like excitotoxicity and apoptosis occur and may be interrupted.

 

When I took my first medical school pharmacology course in 1984 – the adverse reactions were noted in the anesthesiology section for both PCP and ketamine.  Rasmussen writes like a chemistry major who experienced organic chemistry as an important course. He discusses detailed chemical structures, reactions, stereochemistry, and the Grignard reaction. These explanations have the purpose of explaining of how compounds are named and why the synthesis of ketamine is outside of the expertise of local meth cookers.  At the same time, he does not get too technical when it comes to receptor binding affinities (I did not notice a single K_i).  Beyond that he details where ketamine is currently produced (China, India, Mexico) and provides two cases of clandestine operations in China that were using 8.5 million tons of ketamine precursor before they were shut down by authorities (see Supplementary 1 footnote).

The book is a thorough documentation of the time course of PCP and ketamine use.  He discusses landmark papers and points out research papers that were probably the original observations and papers that are highly cited.  As I read the book, I went to the references and underscored many of these papers.  The reference section alone is 44 pages long.

Each chapter about the potential clinical applications of ketamine is a through discussion of the existing literature and the limitations of that literature. He discusses the research design of many of these studies and what research is needed in the future.  He discusses the unanswered questions about ketamine. 

Does the book have any shortcomings.  A lot of reviewers seem to describe needing to be entertained by the books they are reading. Almost everything I read is a scientific paper or book.  Some of that content is exciting, but generally I would not see it as entertaining.  The closest this book comes to being more difficult to read were long sections that summarize scientific papers. 

Should you read this book?  Like all books – a lot depends on your level of expertise.  I consider myself to be an expert in both ketamine and PCP based on both my pharmacology knowledge and what I have seen clinically. I learned a lot reading this book and I think practically all psychiatrists and psychiatric residents will find this book useful.  Neurologists are an additional audience for the sections on neuroprotection in cases of traumatic brain injury, stroke, subarachnoid hemorrhage, and status epilepticus.

You will see information in this book that you will not read anywhere else.  It is footnoted to scientific articles and the discussion is even handed – the possible good and the bad.  A thread runs through this book from the very first page that all human drug responses are complicated based on biological heterogeneity and some of that can be age based. That means there are no “miracle drugs” for everyone.  There is an extensive discussion of the substance use aspects of the drug and it is presented as a clear danger.  I think that all acute care psychiatrists and residents could benefit from reading this book and it could form the basis of a journal club or a resident seminar in pharmacology. The style of writing reminded me of a text that I consider to be the most well written – Fundamentals of Biochemistry by Voet, Voet, and Pratt.   

What about people on the other end of the spectrum of ketamine knowledge?  There is plenty of information in this book that may be useful to you.  The book is well organized and researched.  It has an excellent index that will contain references that you do not have.  The information density in the book is much higher than I expected from reading the initial chapter and introduction.  There are interesting historical points including a section of three very well-known ketamine users, their experiences, and publications related to their use.  If you are involved in a research project involving ketamine or PCP – this book is a good source of background information.  This book can also potentially benefit journalists tasked with writing about ketamine and other psychiatric treatments.  

I really like all the details about the medicinal chemistry of ketamine.  It reminded me of some online discussions I have had with physicians who thought that organic chemistry was an unnecessary prerequisite to medical school.  If you share that opinion – chemistry at a more detailed level than you typically see in a pharmacology text might not interest you.  It is still there in an accessible form. 

This is a very good book – well researched and written. Dr. Rasmussen presents a very even approach to ketamine.  He presents the research and clinical findings of what really occurs with the use of ketamine.  No speculation is involved. It took a lot of hard work and accumulated knowledge to write this book and any physician reading it will realize that. With a few modifications the next edition of this book could become a classic text in psychiatry.

 

 

George Dawson, MD, DFAPA

Reference:

Rasmussen KG.  Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule.  Washington DC.  American Psychiatric Publishing.  2024; 295 pp.

Supplementary 1:  The more I thought about the figure quoted for precursor amounts used in the illicit manufacture of ketamine in China - the more skeptical I became.  The specific quote from the book is:  "In 2009, Chinese authorities seized two secret laboratories with a total of 8.5 million tons of precursor material, which is simply gigantic!" (p. 44).  Since illicit production estimates based on precursors are generally in the hundreds of metric tons - millions of tons certainly are gigantic.  From the first reference (1) listed below:  

"China produces massive amounts of ketamine, reliable estimates for the prevalence of ketamine abuse are not available. As of today, five Chinese factories are officially licensed to produce ketamine, but there are reports of illicit production on an industrial scale. In 2009, Chinese authorities reported the seizure of two illicit laboratories producing 8.5 million tons of the immediate precursor of ketamine."

In this case, the total precursor was 8.5 million tons and the UN Drug Report (2) was referenced at the head of the paragraph.  From that report (page 117):

"In 2009, China reported seizing two illicit laboratories processing hydroxylamine hydrochloride, the immediate precursor chemical for ketamine, and seizing 8.5 mt of this substance."

Note that the "mt" designation in this report is metric tons rather than million tons.  A metric ton is usually defined as 1,000 kg reducing the size of this estimate by about 2 million fold (8,500 kg compared with 7.7 million kg), but that is obviously still a significant amount of precursor.

Supplementary 2:  This interview of the author became available in the Psychiatric News on this date (11/5/2024)  

Ketamine: Miracle Drug or Double-Edged Sword?

https://psychiatryonline.org/doi/full/10.1176/appi.pn.2024.11.11.13

References:

1:  De Luca MT, Meringolo M, Spagnolo PA, Badiani A. The role of setting for ketamine abuse: clinical and preclinical evidence. Rev Neurosci. 2012;23(5-6):769-80. doi: 10.1515/revneuro-2012-0078. PMID: 23159868.

2:  UNODC, World Drug Report 2010 (United Nations Publication, Sales No. E.10.XI.13).

Protesting...

I am more than a little fed up with unnecessary wars and deaths. My college days were defined largely by an unnecessary war in Vietnam. I was in the first reactivation of the military draft largely because nobody wanted to go off to Vietnam for no clear reason and fight a war. That first draft was a lottery system by birthday and my lottery number was 215. I was in college at the time and could have received a deferment but I decided to waive it and gamble that my number was high enough to keep me from being drafted. Taking the deferment meant being put in a “second priority group” and continued draft eligibility. I was lucky and 215 was never called. 

On the campuses those days, almost everyone was a war protestor and, in my state, there were some very large protests at the University of Wisconsin. Those protests permanently changed the face of State Street in Madison – where the local drug store was redesigned to look more like a pill box after the windows were repeatedly broken out. The 1960s and 1970s in the US was an era of repeated demonstrations and protests, many of them violent and many resulting in loss of life. On August 24, 1970 - radicals parked a Ford Econoline van packed with explosives next to Sterling Hall at the University of Wisconsin in Madison.  The explosion destroyed the six story building and killed a researcher who was in the building at the time.  The target was the Army Mathematics Research Center.

One unnecessary war in Vietnam, was apparently not enough and the United States went on to prosecute 2 more in Iraq and Afghanistan.  Both of those wars took a tremendous toll in terms of mortality and morbidity to American military personnel and the civilian population and infrastructure of both countries.  Both wars are often rationalized after the fact that Saddam Hussein and the Taliban were not good for the populations of either country, but that is not the reason that either war was initiated. Iraq was invaded on the false premise that it had "weapons of mass destruction".  Afghanistan was invaded because the US military failed to catch Bin Laden as he fled across the country.     

 That brings me to the current era of protests and the expected protests tomorrow at the Democratic National Convention in Chicago. There is a lot of speculation in the press that it may resemble the protests that occurred at the Democratic National Convention in August 1968 – also in Chicago. The 1968 convention followed the assassinations of both Martin Luther King, Jr and Robert F. Kennedy earlier that same year. There were 10,000 demonstrators in Chicago confronted by 23,000 law enforcement and National Guard. The focus of the protests was the war in Vietnam with a secondary issue of lowering the voting age from 21 to 18. Despite violent confrontations between protestors and the police – no deaths or serious injuries were reported. There was subsequent legal action that involved charging 7 of the organizers with conspiracy to riot – and those charges were eventually dropped. In that original protest, many of the organizers had celebrity status and some of the concepts they presented during the protests gained notoriety.  The more radical and violent groups of the 1970s like the Weather Underground did not participate in the protest.

The overall dynamic of the protest was focused on a lengthy and questionable war in Vietnam. The protest made sense because friends and family members were being drafted, killed, and injured in a war that was unnecessary. There was an immediate impact on the American people and political leaders in the United States were accountable. 

Reviewing the dynamics of the protestors who may be present at the DNC tomorrow. The current armed conflict in Palestine is an active war prosecuted against Hamas by Israel. The war was initiated by an attack by Hamas on Israeli citizens on October 6, 2023. That attack consisted of killing, maiming, and raping civilians as well as hostage taking. The specific details can be found here. Hamas is embedded in Gaza and Palestinian noncombatants are essentially hostages to the Hamas war effort.  Since that time, Israel has counterattacked and waged war against Hamas with the resulting destruction of much of the infrastructure in Gaza as well as over 40,000 civilian deaths. The leaders of Hamas and Israel have explicitly stated that their goal is to eliminate the other side completely. In other words – kill everyone on the other side and eliminate any state that they might occupy. These are explicitly stated goals and not my speculation. 

 Along the way, there has been a protest movement in this country that started on campuses. It has characterized the war in Gaza as genocide perpetrated by Israel. The precipitating event by Hamas is either rationalized or ignored. There have been many cases of Jewish students who are US citizens being harassed and threatened. The situation on campuses led to the resignations of University Presidents who had a difficult time determining the boundaries of free speech and antisemitic hate speech. At the same time, the situation in Gaza is a horrific human tragedy in terms of lives lost, war time injuries, families disrupted, starvation, lack of medical care and disease. The Israeli army routinely kills noncombatants – not just civilians but aid workers, and journalists. There have been many cases of deaths where they were no obvious military targets and there is a statement about an investigation of what happened. Spokesmen say that Israel is trying to minimize damage to the civilian population, but there is minimal evidence that is happening. 

 At some point, the protestors in this case decided to put blame on President Biden and Vice President Kamala Harris. I anticipate seeing varying degrees of this at the DNC tomorrow. As a war protestor from the 1970s, these protestors seem to have it all wrong. The current White House staff has been trying to broker an immediate cease fire and peace agreement for several months now. The US government is behind stopping the bloodshed and advocating for peace in an area where there have been decades of senseless wars. There is no more senseless war than one where each side is actively working to completely obliterate the other. That is a mode of thinking from before civilization existed and it may end up threatening to end civilization. 

 If you really want to protest something – protest the primitive thinking of total war promoters in both Israel and Hamas. Hold the leaders with that line of thinking accountable. Their goal of annihilating the other side as a solution is unrealistic and serves only to fuel future terrorism and state sanctioned revenge. It makes no sense at all to protest the peacemakers and call them names.  Protest the real warmakers here - the leaders of Israel and Hamas.

And don't fool yourself into thinking that the leaders of both Israel and Hamas are not looking at the American presidential election and trying to figure out how they can use it to their advantage.  That may include what happens at the DNC protests.

  

George Dawson, MD, DFAPA

Addendum 1:  I heard a protestor interviewed today (August 19) on BBC World News.  Unfortunately I cannot locate a transcript or audio clip so this is my recollection of what he said. He said that both parties in the US were responsible for supplying arms to Israel for a long time and that meant that Biden and Harris were currently responsible.  He had not heard anything new from Harris and therefore he remains hopeful but suggested that people will not vote for her unless she changes positions on Israel.  When the interviewer asked him if he wanted Trump to win he said: "Oh no - I don't want Trump to win but if he does it is because of the policies of Biden and Harris."

Well no it is not. Trump wins if there are insufficient votes for Harris and the situation is more complex than trying to resolve and Arab-Israeli dispute that has been going on for decades in a few months before the election. The protestor is also overestimating the leverage that the US has in this situation as well as the fact the combatants here are sworn to obliterate the other side and at no time have given a hint of becoming more reasonable. 

I am in the process of reading a book on how the US has become a grievance culture. Pick a cause, feel aggrieved, and go on the attack. It has become a cultural norm probably best exhibited by the stolen election meme used by the MAGA Republicans. This protest appears to have humanitarian motives, but it really minimizes the work that the Biden-Harris administration in concert with other countries are doing to secure a cease fire and take steps to end the hostilities.  Either way the additional point is missed that unless the needle is threaded with this agreement - it can easily become an election issue.  The protestor in this case does not want Trump, but he also does not want to do anything to help Harris. That is a conveniently unrealistic viewpoint. Deciding to not vote probably hurts Harris more than Trump because the GOP has the leverage of the electoral college - they have won the presidency with fewer popular votes.

George Dawson, MD, DFAPA

Update (9/2/2024):  The citizens of Israel seem to have no problem placing the accountability for the ongoing war directly on Netanyahu and his refusal to negotiate.  I hope this was noticed by American protestors placing blame on the Biden-Harris administration who are advancing the peace plan. Palestinians and Hamas have no luxury of influencing the leader of Hamas because there is no democratic process.  

https://www.yahoo.com/news/hostage-deaths-pushed-israel-breaking-155646402.html

Graphic Credit:  From WikiMedia Commons per their user agreement and CC license. Click for details.

Combinatorics Revisited…

I critiqued a paper that purported to show that Diagnostic and Statistical Manual criteria produce an impossibly large number of possible combinations and that this somehow invalidates their use.  As a refresher, combinations are basically any pool of n elements combined k at a time.  For example, in the case of major depression, the diagnosis requires at least 5 (k ≥ 5) of 9 (n=9) elements.  That would lead to a calculation of C(n,k)  = C(9,5) + C(9,6) + C(9,7) + C(9,8) + C(9,9) or  126 + 84 +36 + 8 + 1 = 255     I have illustrated the total combinations for the first expression at the top of this post.  In each case the elements 1 – 9 are the DSM diagnostic criteria for depression.  Note that adhering to the diagnostic criteria eliminates the last column of combinations to the far right since elements 1, 2, or 1 and 2 are required for the diagnosis. 

Reading the actual diagnostic criteria illustrates that this is a crude measure because there are implicit unknowns – most significantly the total number of medical unknowns suggested by the criteria “The episode is not attributable to the physiological effects of a substance or to another medical disorder.” Historically reviews of those disorders suggest that they are in the 200 to 300 range with some being far more common than others. If all those conditions were included in the combinatoric expression it would be very large – but not necessarily that much more inclusive because of the low frequency of many conditions.  Additional exclusion criteria include psychiatric disorders with depressed mood as a feature and any previous episodes of mania.  Since they are exclusion criteria – it is reasonable to say that there may be only 255 combinations of rule in symptoms, but being able to make the calculation is no assurance that they exist in practice.  

Following the authors assumption about the combinatoric possibilities we can substitute short had for criteria 1-9.  In the following manner (as noted in their Table 1):

1. Depressed Mood

2. Loss of Interest or Pleasure

3. Appetite/Weight Disturbance

4. Sleep Disturbance

5. Psychomotor Change

6. Loss of Energy

7. Worthlessness/Excessive Guilt

8. Concentration/Indecision

9. Death/Suicidal Thoughts

A further restriction is included in criteria A: “…at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.”  That eliminates any combination that does not include 1, 2, or 1 and 2.  That changes the above expression to 105 + 77 + 35 + 9 + 1 = 227 possible combinations just based on the numbers.  The authors were interested in seeing how many of these possible combinations exist in the clinic and that was the goal of this paper.   

The sample for the paper was 1,566 subjects with a diagnosis of major depression out of a total sample of 3,800 evaluations.  All subjects were being seen on a clinical basis and the Structured Clinical Interview for DSM-IV (SCID) was administered by trained examiners and the interrater reliability was sampled and posted for all of the depressive symptoms.  The number of subjects in each group of combinations was determined and the results were interesting.

For starters – 57 of the 227 combinations or about 1/4 did not occur in a single patient. In the case of 5, 6, and 7 criteria the combinations that did not occur are listed in tables 3, 4, and 5.  The most common combination was all nine criteria and that occurred in 10% of the sample (N=157).  The authors were able to observe that 9 combinations from the 9,8,7, and 6 criteria categories accounted for 40% of all diagnoses. They suggest that these might be prototypical combinations in a field of diagnostic heterogeneity. Apart from diagnostic prototypes the authors suggest that it may facilitate the search for biological markers but they conceded that those would need to be very large and expensive studies. 

As I thought about that proposition, a few things came to mind.  First, Mayo Clinic multi-omics studies. Some of these studies have already identified biomarkers and possible genetic markers on heterogenous groups of subjects with major depression.  The subjects were all administered standardized DSM based interviews and the combinatorics could be determined.  This would be an efficient way to see if symptom combinatorics match the biomarkers.  Second, why would we expect there to be any correlation between symptoms and biomarkers?  Most medical illnesses would not have a  correlation and in fact the more complex illness can be expected to produce significant non-specific symptoms like fatigue and malaise.  Some authors have suggested that very specific subtypes of depression are more likely to produce reliable biomarkers.  Taylor and Fink (2) have written extensively about melancholia and biomarkers associated with that illness.  I also recall work done by Linkowski and Mendlewicz (3) that they published in the endocrine literature.  Their work was almost exclusively on subjects with very severe forms of depression (HAMD ratings > 30) and their neuroendocrine biomarkers were more robust.  Third, is there a time domain consideration with the combinatoric groups?  For example, do the people meeting 8 or 9 criteria have depression that has persisted for a longer period and does attempted treatment or not treatment affect that group?  Fourth are some of these symptoms complexes generated by others - are they secondary to sleep and appetite disruption?

Either way, the application of combinatorics to some of these situations is very interesting in the field.  As noted in my previous post, combinatorics reflects biological scaling at some point. That occurs at the molecular as well as the evolutionary level.  Large numbers of combinations should be expected when combining either molecular components of organisms, metabolic networks, or the organism wide effect.

Thinking about these combinations clinically is also an interesting exercise.  During my tenure as an acute care psychiatrist it was rare to see anyone without most of the symptoms in an inpatient setting.  Doing consults on medical and surgery wards there were often more novel symptom combinations.  Looking at the author’s tables and the combinations they did not see in their study is an interesting exercise.  One example would be the combination 1,2,3,4,5,7,9 from Table 3.  That would be a person with depressive symptoms except for loss of energy and concentration problems. According to this study that person does not exist.  And of course all of the combinations that lack depressed mood, anhedonia, or that combination have been eliminated by definition.

I hope to expand my look at combinatorics to the genetic, evolutionary, and molecular levels in subsequent posts as well as trying to see if there are mappings from one level to the other.  I am also interested in any books or papers that use similar analyses so please send those references my way,      

 

George Dawson, MD, DFAPA

 

References:

1:  Zimmerman M, Ellison W, Young D, Chelminski I, Dalrymple K. How many different ways do patients meet the diagnostic criteria for major depressive disorder? Compr Psychiatry. 2015 Jan;56:29-34. doi: 10.1016/j.comppsych.2014.09.007. Epub 2014 Sep 6. PMID: 25266848.

2:  Taylor MA, Fink M.  Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness. 544 pp. New York, Cambridge University Press, 2006.

3:  Linkowski P, Mendlewicz J, Kerkhofs M, Leclercq R, Golstein J, Brasseur M, Copinschi G, Cuater EV. 24-hour profiles of adrenocorticotropin, cortisol, and growth hormone in major depressive illness: effect of antidepressant treatment. The Journal of Clinical Endocrinology & Metabolism. 1987 Jul 1;65(1):141-52.

 

Apps:

Very good apps are available for calculating combinations, permutations, and the varieties.  For example – if you think back to your probability and statistics course in college at one point the professor was talking about combinations occurring where elements could be used more than once (with repetition). That is typically demonstrated by taking numbered balls out of a container and replacing them in one situation and in the other cases leaving them out. Those are different calculations.  For the above calculations the assumption is that each k element can only be used once (no repetition).  There are apps that give you both calculations.

 

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.