The Phenomenological Suicide Assessment – The Legacy of Dr. H.

 

Warning:  This post is about suicide and the assessment of suicide.  It is intended for mental health professionals and people who not distressed by this topic.  Avoid reading this if you find the topic of suicide distressing.  

 

Suicide assessments constitute a major part of psychiatric practice.  According to standard guidelines it is a recommended part of any initial assessment.  Acute care psychiatry selects for these assessments largely because hospitalization and crisis care is focused on it and aggressive behavior.  Over the past 30 years insurance companies and governments have made it virtually impossible to treat people in a secure environment unless there is a risk of suicide or aggression. 

Most suicide assessments are taught as an exercise in risk factor analysis. Patient traits, demographics, and diagnoses correlated with suicide or suicidal ideation are collected across studies and applied to current evaluations.  Decisions about treatment are made on that basis.  The decisions may also have implications about continued risk despite what is said in the interview.  It can be a basis for court ordered involuntary treatment.

For example, let’s say I am asked to see an 80-year-old man on a surgical service.  He is there because he tried to cut his throat and underwent surgical repair of his esophagus and trachea as a result.  He describes feeling better at the time of the interview but says he has been depressed for years.  He lives alone after his wife of 45 years died last year.  At some point he noticed that there was a foul smell covering his body.  He thinks the smell comes out of his mouth at night and covers his entire body.  He is a heavy drinker and consumes 500 ml of vodka per day.  He prefers to return home without treatment as soon as the surgery team clears him for discharge.  His labs show elevated transaminases and prolonged coagulation parameters.

This is an example of a person at high risk for ongoing suicide attempts based on risk factors.  In this case depression, psychosis, alcohol use, a serious suicide attempt requiring surgical repair, age, and lack of social support all define him as high risk.  It is unlikely that any psychiatry service would discharge him untreated to go back home and potentially experience the same series of events that led to the attempt. 

That was state of the art assessment back in 1982 when I started my residency and it is not much different now.  A few months ago, I sat through a very long presentation on an artificial intelligence (AI) based approach to suicide assessment.  It consisted of analyzing the patient’s word frequency during the assessment and deciding suicide risk based on that.  The qualifier was that it was not a substitute for clinical judgment.  It reminded me a lot of the quantitative electroencephalogram (QEEG) research I started doing in 1986.  The technology claimed to be able to separate psychiatric diagnoses based on fast Fourier transformation (FFT) analyses of EEG frequency bands. The problem was the analysis also depended on clinical features that had to be added to the diagnostic algorithm.  It was not a true test without that additional input. The AI analysis of suicide was no different.    

The problems with assessments for suicide potential are essentially two-fold.  First, the conscious state of the individual changes and they go from a person who would never consider suicide to one that would.  Before that change you are talking with and gathering data from a person who is not contemplating suicide.  Second, suicide attempts are generally impulsive.  Many people interviewed after surviving a suicide attempt are glad they survived.  In many cases they regretted to committing to suicidal behavior almost immediately.  A good example are the young men who survive jumping from the Golden Gate Bridge (1).  They experienced instant regret after jumping away from the railing.  An additional complicating factor is that the person sitting in front of you may want to be released to make another suicide attempt and they either do not want to discuss it or they want to conceal that fact from you.

I had all these things on my mind when I was doing consults on medical-surgical patients at the hospital where I trained back in 1982.  I was a first-year resident and my job on this rotation was to show up and do all the preliminary evaluations on the consult requests that day and then present and discuss them with my attending Dr. H.  Dr. H had been an attending for about 6 years at that point.  She had returned to work in the county hospital from private practice.   I had worked with her for a few days and things seemed to be going well.  We generally agreed on diagnoses and treatment plans and there were no personality conflicts.  That is about as ideal as it gets for a resident.  Then one day – Dr. H showed me an interview technique that I never forgot.

I had just presented the case of a young man who had overdosed on antidepressant medications.  He seemed mildly depressed and irritated.  I ran down his history and probable diagnosis to Dr. H and we walked in his room so that she could interview him.  It went something like this:

Dr. H:  “Hi I am Dr. H and I am the staff psychiatrist here.  Dr. Dawson was just telling me a few things about what happened.  Would it be OK if I asked you some questions?”

Pt:  “Sure.”

Dr. H:  (after clarifying the demographic and medical data): “Can I ask you about the overdose”

Pt:  “Sure”

Dr. H:  “Do you remember the details?  Do you know the pills you were taking?”

Pt:  “Yes they were amoxapine.”

Dr. H:  “How did you take them? Did you take them all at once or one at a time?”

Pt:  “I was taking handfuls.  I would take a handful at a time and rinse them down with water.  It was hard to do because they are large capsules….I had to take more and more water and eventually stopped.”

Dr. H:  “And what exactly were you thinking at the time?”

Pt:  “I was thinking I wanted to die.  I was thinking that I was a loser and I wanted to die.  I could not see any future.  I did some research on this and knew that this stuff was fairly toxic and that if I took enough of it – it would kill me.  I was throwing them down as fast as I could.”

Dr. H:  “What happened next?”

Pt:  “At some point I started to feel sick and I got really drowsy and passed out. The next thing I was waking up in the Emergency Department downstairs.  They had a tube down my throat and they were giving me charcoal.”

Dr.  H:  “Looking back on what happened yesterday – what do you think?’

Pt:  “I would not do the same thing again but it would not have bothered me if I succeeded yesterday.”

Dr. H:  “Do you feel like a different person today?’ ….

 

The above exchange is a brief excerpt of the interview, but it was not like my interview.  I spent about an hour interviewing the patient about depression, anxiety, and suicidal ideation like they were all third person observable objective facts. He was clearly less engaged with me than he was with Dr. H.  When you interview someone from the perspective of third person objective facts – you invite them to see the world the same way.  They become passive observers to what happened to them.  You can’t really get to the change in conscious state or impulsivity that make suicidal states unique.  Dr. H went on another 20 minutes getting every detail of this patient’s subjective experience of the incident.  It was amazing and we discussed it when she was done.

From that point on my suicide assessments were all based on that phenomenological approach whether I was talking with people who survived attempts or were talking with me because they feared losing control.  I needed to know their emotional state and what they were thinking.  Even in those descriptions there were conscious fantasies and defenses:  “I was pointing the gun at myself but I never pulled the trigger.  It just went off in my hand.”  In the process I heard hundreds if not thousands of reasons why people attempt suicide and exactly what they were feeling and thinking at the time.  In the larger scope Dr. H helped me focus on the subjective.  That is something that you lose in medical school where there is an implicit emphasis on the objective and subjectivity seems like a bad thing.  The reality is that subjectivity dwells within every classification system.

 My memories of the past are so vivid that at times I forget I am an old man.  I recalled the above exchange with Dr. H when I was discussing phenomenologically based approaches to suicide assessments with a new generation of residents.  That happened just last week.  I decided to look her up and see what she was currently doing.  I wanted to thank her for the direction she gave my development and career.  I found out that she died 6 years ago.  Her obituary said she did not want a funeral.  The family requested memories and stories.  I hope this blog serves that function. She taught me about phenomenological suicide assessments when they are scarcely written about to this day.  I am sure she taught many more people than me. 

Passing an important technique along that you can’t find in a book or a paper and making that accessible to a young resident who thinks he is getting the job done is a great legacy. 

 Thank you Dr. H!.

 

George Dawson, MD, DFAPA

 

References:

1:  Nelson K.  ‘All I wanted to do was live’: After years of debate, a suicide safety net for the Golden Gate Bridge is nearing completion. Survivors say it’ll give many a 2nd chance at life.  CNN.  November 19, 2023  https://www.cnn.com/2023/11/19/us/golden-gate-bridge-suicide-safety-net

Psychodynamic Prescribing

 

 

I did a presentation to residents and co-teaching faculty on psychodynamic prescribing last week and decided to post something while it was on my mind.  I also read several book chapters in the process and have recommended reading that readers might find useful.  My introduction to the lecture highlighted the longstanding rhetoric within the field that when sufficiently polarized leads to absurd conclusions.

I used the relative periods of the history of psychiatry and composites from several authors to look at the main intellectual focus of the field.  In the asylum era up to about 1910 – the focus was gross neuropathology, classification, and psychopathology.  There were also clear improvements in asylum care.  From 1910 to 1960, the focus shifted to psychoanalysis and various theoretical schools.  Starting in 1960, the focus shifted to biological psychiatry that is commonly characterized as the study of neurobiology, genetics, and psychopharmacology. The figure below from the presentation was an attempt to name prominent psychiatrists during each epoch who were thought leaders.  The problem that should be evident is that these periods were not homogeneous. During the most recent era for example, there are many biological psychiatrists and at the same time some of the most significant psychotherapy theorists in Kernberg, Kohut, Beck, Klerman, Gunderson, and Yalom. 

How is it that these divisions seem to exist in the field?  In my experience it comes down to competitive environments and the associated politics.  As an example, I did my psychiatric training at two different programs.  The quality of both programs and clinical experience was excellent.  One department was headed by a psychiatrist from the Washington University (St. Louis) school of psychiatry.  That school was known as the neo-Kraepelinians and they favored biological explanations for psychiatric disorders but by no means ignored the psychosocial.  The other school was headed by a psychiatrist who was eclectic and interested in both the biological and social origins of severe anxiety.  He was also surrounded by a staff of biological psychiatrists, psychotherapists of various origins, and medical psychiatrists.  Both programs had plenty of faculty on both the psychotherapy and biological psychiatry sides. 

Both of those training settings were essentially projective tests for psychiatric residents and medical students.  Some identified with the psychotherapy staff and some with the biological staff, but everyone trained in both areas and a wide array of settings.  The real strength of psychiatry is knowing what to do about diagnoses and problems across a wide variety of settings and presentations.  As an example, I could be doing hospital consults and making aphasia diagnoses one afternoon and the next day seeing several long-term psychotherapy patients.  From there I could be doing a shift in a crisis unit and doing appropriate interventions – both therapy and medications. 

The broad training that psychiatrists get is rarely mentioned.  What is mentioned are stereotypes like psychiatrists prescribe medication and financial incentives drive this process.  They do not do “therapy”.  The caricatured biological psychiatrist states: “I am a biological psychiatrist and I don’t do therapy.  If you have a problem discuss that with your therapist.”  Why is that not possible?  And why are things just as difficult on the other side of the equation – the psychotherapist that doesn’t do medications.  There was a time when medically trained psychoanalysts only practiced psychoanalysis.  Over the past 40 years, I have seen many psychiatrists with psychoanalytical training who practice general and even hospital psychiatry.

In terms of either not prescribing medication or providing psychotherapy, the first problem is that it is not how psychiatrists are trained.  The training is focused on the necessary treatment techniques to help people who have the most severe problems.  The large markers are evidence-based treatments these days and there are plenty of them, but all fields of medicine extend into treatments that have little to no evidence.  In psychiatry that zone is broader because we are necessarily focused on subjectivity – it is not a bad thing.  It is harder to measure.  According to consciousness theorists – everyone’s conscious state is different and the same external experiences are experienced differently at the mental level. Meaning (to the individual we are seeing) is important.  Second, even stable people end up in crisis whether they are stabilized on medications or improved in psychotherapy.  The ups and downs of life can trigger a crisis and everything that involves.  That generally does not require a change in medications or psychotherapy plan – but it does involve being able to verbally intervene in a crisis.  That is typically talking and environmental interventions.  Third, there have been rigid expectations for what constitutes psychotherapy that are not realistic.  For example, hour long sessions for a new patient on a weekly basis for weeks or months.  Most psychiatrists these days see 2 to 3 new people per day.  In just a few weeks of practice that type of psychotherapy schedule would be filled. Garret (4) has detailed estimates of how many patients can be seen in a month using 30- and 45-minute visits and they vary from 15 (seen weekly) to 98 (seen less frequently).  In the CMHC settings where I have worked 30-minute appointments at varying frequencies are the norm. Fourth, in an average clinical encounter how long does it take to assess the patient’s state related to medications and make the related decisions.  All of that takes about 10-15 minutes.  Then what?  You can either have 10–15-minute appointments or discuss other areas of that person’s life that are relevant to treatment.

How does this happen across settings where in many cases psychiatrists are expected to prescribe medications in limited periods of time and have an onerous documentation burden.  The Garrett reference (1) has some clear ideas and specific diagnostic codes. I have previously written about it on this blog as supportive psychotherapy being the language of psychiatry and how pattern matching in psychotherapy is not much different than pattern matching in general medicine. In this post I will discuss some additional points in how this occurs across many appointments and within the same appointment.

In the diagram below, I will discuss several dimensions that are operating during every appointment but are most apparent in the initial assessment.  The obvious overview is that there is a psychotherapeutic context for every encounter.  This is evident in any treatment literature that you might read.  Different authors use different terms.  For example, prescriptive therapies can include lifestyle changes (diet, exercise, smoking/alcohol cessation), medications, behavior therapy, and brief manualized psychotherapies.  They all assume that the psychiatrist can see a problem that responds to a specific intervention and no deeper level of understanding is necessary.  When I use the term top down, it means approaching problems at the surface.  To use a mechanical analogy – it is like using stop-leak for a blown engine gasket rather than taking the engine apart and fixing the gasket.  Like all analogies that breaks down at some point.  You could consider behavioral activation a prescriptive therapy but it also addresses deeper processes and patterns.  Most prescriptive therapies probably lie in a more intermediate position between purely prescriptive interventions and deeper explorative therapies.

The beauty of psychodynamics is that it operates at the level of individual human consciousness and that cuts across every domain.  The typical descriptive and classificatory levels of psychiatry give the illusion that all human mental suffering can be classified into neat categories.  Contrary to antipsychiatry rhetoric that same illusion exists in ordinary medical and surgical classifications as well.  In psychiatry, there is probably no better example than a paper last week (2) illustrating how a common DSM based depression checklist is misinterpreted.  This same scale is used on a large-scale basis and used for genomics studies suggesting a degree of phenotypic certainty that does not exist.  Psychodynamics and some other forms of psychotherapy address conscious states that are highly individualized and determine unique pathways to problems.  Psychodynamics also cuts across all treatment interventions.  If you are a consultant it also includes how other physicians are reacting to your patient.    

The interface between medication response and psychotherapy is also not typically considered.  It is known that environmental, interpersonal, and psychotherapeutic interventions can alter both the placebo and nocebo response to medications. These responses can be powerful and they are not limited to psychiatric medication or interventions.   In some cases, the physician patient relationship alone is enough to alter response patterns to illnesses and medications.  It is good practice to use psychotherapeutic interventions that affect both in the desired directions of increased placebo response and decreased nocebo response.

Beyond the placebo-nocebo effects there are also conditioning effects and the environment of the clinic may be a factor. Staff interaction and the overall quality of the environment can be important.  This is thought to be a factor in many clinical trials when patients are seen and treated in clinical settings that seem much more intensive and friendly than their usual clinical settings.  

At the psychodynamic level exploring the patient’s expectations, fears, and fantasies about the medication is an important first step before prescribing.  Was the idea to try a medication their idea or did it come from somebody else?  What does taking a medication mean to them?  Is there a fear or wish for dependence?  Is there a change in the dynamics of the relationship based on allowing the physician to make decisions for the patient?  Does that occur after an adequate informed consent discussion?  Some writers describe this regression as the sick role and suggest it may be appropriate if the patient is very ill, but there always needs to be a plan to restore baseline autonomy.

Prescribing can be seen as a hostile or caring act depending on the meaning of the medication.   Medication can be seen as soothing, calming, a way to restore baseline wellbeing, and eventually regain autonomy.  It can also be seen as a punishment, confirmation of a dreaded diagnosis, or a sign of personal weakness.  At the fantasy level – it can be seen as a magical potion that will cure everything that ails the patient. In some cases, the medicine functions as a talisman warding off symptoms if it is in the possession of the patient – even when it is not taken.

In the intersubjective field, the prescribing physician can also develop countertransference thoughts and fantasies about the medication and because of emotions that occur in the relationship.  Common among them is the healer fantasy of omnipotence that all problems can be treated into remission with medications.  That can lead to over-prescribing, premature prescribing, and other boundary violations.  Various clinical scenarios (errors, treatment resistance, projective identification) can lead to anxiety and dread in the countertransference that may affect prescribing.  There is also the practical scenario that when things are not improving any physician’s anxiety will be going up. In a prescribing scenario that can lead to dose escalation, polypharmacy, inadequate attention to side effects, and inadequate attention to discontinuing ineffective therapies.  Based on my conversations with people – they are often skeptical that a rumored combination of medications will work better than what they have tried in the past.   Prescribing can also be a defense against other factors that are difficult to address.  In the most basic case, prescribing can be seen as a form of intellectualization (these symptoms –> this medication) rather than addressing the complexity of all the emotions and conflicts in the room.

Another form of prescriber anxiety in the countertransference is the fear of harm or liability.  That is often discussed as a medico-legal problem.  I have never found this a useful dimension for analysis in clinical practice, but for many years there was the suggestion that psychotherapy alone without medical treatment may be a risk.  That came from the case of Osheroff v. Chestnut Lodge that was eventually settled and therefore is not established case law.  In this case the plaintiff was an established professional diagnosed with narcissistic personality disorder and treated with psychoanalysis at the Chestnut Lodge – a psychiatric hospital.  When he started to get worsening depression and severe agitation at the 6 month mark a consultant recommended a trial of medication – but the treatment staff decided to continue psychoanalysis.  After another month of marked decline, he was transferred to another hospital where he was treated with an antidepressant and a phenothiazine where he improved and was eventually discharged and resumed working. This case is frequently cited as evidence of the superiority of medical treatment – but from the description it seems that psychodynamic prescribing just needs to adhere to a general rule in medicine – if the treatment is not working try something else. I have not seen any countertransference related factors described that could have led to this inertia – but it is easy to speculate.       

Adherence is often discussed in very basic terms from a prescriber standpoint.  For example, fewer doses per day, long-acting injectable medications, and sustained release medications all improve adherence.  From a psychodynamic standpoint – adherence is a meaningful communication.  Does it suggest ambivalence, resentment, or a challenge to the prescriber’s authority, interpersonal style, or diagnosis?  That can all be openly discussed.   

Although I have listed several psychodynamic factors relevant to prescribing, they are by no means exhaustive.  I am certain that in any practice out there psychiatrists could create a list based on the patients they see every day.  Of those factors the most significant one in practice has been countertransference.  Every psychiatrist needs to be aware of that dynamic more than the rest because it is most likely to affect your judgment and the judgment of your coworkers. If you do team meetings like I did every day for 22 years, it is most likely to disrupt your team and the environment and in the worst case affect the safety of patients and staff.  In that scenario you need to figure it out and figure how to keep a lid on the place.  The same thing is true for consult-liaison docs who are seeing disruptive patients in medical and surgical settings. 

I seem to be stating what is obvious to most psychiatrists. That is probably because most people still do not know what we do and we don't seem to talk about it much.    After all Paul Dewald (1) wrote very well about this over 70 years ago.  Everything in that chapter still applies today.      

 

 George Dawson, MD, DFAPA

 

 

References:

 

1:  Dewald PA.  Psychotherapy a dynamic approach.  2nd ed. New York: Basic Books, 1971.

 

2:  Mintz D, Azer J.  Integrating psychoanalysis and pharmacotherapy. In: Gabbard GO, Litowitz BE, Williams P, eds.  APPI Textbook of psychoanalysis, 3rd ed.  Washington DC: American Psychiatric Association Publishing, 2025: 291-305.

 

3:  Mintz D.  Psychodynamic psychopharmacology. Washington DC: American Psychiatric Association Publishing, 2022

 

4:  Garret M.  Psychotherapy for psychosis.  New York:  The Guilford Press, 2019.

 

5:  Novalis PN, Singer V, Peele, R.  Medication-therapy interactions and medication adherence. In:  Clinical Manual of Supportive Psychotherapy, 2nd ed. Washington DC: American Psychiatric Association Publishing, 2020: 377-391.

 

6:  Wright JH, Turkington D, Kingdon DG, Basco MR.  Cognitive-behavior therapy for severe mental illness. 2nd ed. Washington DC: American Psychiatric Association Publishing, 2020.

JAMA Summit on Reducing Firearm Violence

 

One of my frequent topics on this blog is firearm violence, the likely causes, and ways to prevent it.    When I saw this topic in my most recent edition of the Journal of the American Medical Association (JAMA) – I could not wait to read it.  Now that I have - it is a different story.  

The paper begins by posting some astonishing numbers of gun violence in the United States.  Since the year 2000, there have been 800,000 firearm deaths and 2 million firearm injuries in the US.  Firearms are the leading cause of death in children in the United States.  There were no references to school or mass shootings even though the United States is the only high-income country with this problem.  No other country comes close.

There is a description of the group who produced this paper.  We learn that it consisted of a multidisciplinary group of 60 thought leaders and they were charged with producing an innovation roadmap to decrease firearms harms by 2040. Their recommendations are summarized in this 12-page document and I do not think it will prove very useful. 

The best part of the document is the table Evidence Base for Interventions That Demonstrate Significant Reductions in Firearm Violence.  For 20 years, the Dickey Amendment restricted research on firearm violence and the prevention of firearm violence largely done by the CDC and NIH.  Starting in 2020 funding for research on firearm violence was resumed at both agencies.  This July, the Trump administration cut $158M in gun violence prevention grants (69 of 145 community violence intervention (CVI) grants.   In October, the Trump administration fired key personnel in the CDC violence prevention program that collected data and produced dashboards based on that data.   They also closed the White House Office of Gun Violence Prevention that had been initiated under the Biden administration.  Despite that active suppression of gun violence research except for the last few years – several effective interventions have been discovered and they are included in the table.  They cut across areas involving licensing, violence prevention programs, disarming potentially violent offenders, changing the violence ecosystem, improving the socioeconomic environment, decreasing the availability of alcohol, and an increased police presence and more efficient and targeted policing.

When I think about the people who told me they were saved by their inability to purchase firearms it generally came down to legal waiting periods and federal firearms checks.  They were people considering firearm violence directed at themselves or another person and the only reason it did not happen was that they were prohibited from purchasing a gun at that instant.  In retrospect they were universally thankful that they could not get the gun and when the impulse passed, they did not purchase one later.  This document does not specially mention either of those interventions.

Despite the table, the document focused on a lot of speculative interventions looking at reducing community violence, improving the socioeconomic status, and changing the ecology of neighborhoods where these kinds of crimes occur.  I have no doubt these strategies will be useful to some degree but cannot help but see that most people in these communities are law abiding and are an unlikely source of gun violence.  That does not mean they are immune to the effects of gun violence because just having a gun in the house increases the chances of gun violence death by suicide or accident.

Treating guns as a commercial product is a suggested strategy.  The argument suggests that manufacturers and sellers assume product liability.  When that happens liability suits or the threat of these suits will change gun manufacturers to make safer products.  They provide examples of successful lawsuits.  We should all take a lesson from mental health care in considering a strategy that depends on civil liability.  The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 was supposed to lead to equal treatment of mental illnesses.  It treats insurance coverage as a commercial product.  It has led to lawsuits that (while successful) have had absolutely no impact on the insurance industry.  Their attitude is “if you think you are being treated unfairly – you will have to sue us and win.”   Their basic rationing practices remain unchanged.

There are frequent mentions of technology and artificial intelligence (AI) in the report.  Smart guns that can only be fired by the owner have been talked about for quite some time – but there are not a lot of products. Analyzing data by AI, even if it appropriately designed to incorporate racial diversity and equity does not seem to be a major innovation. The current data being collected lacks the granularity (see below) to properly study the decision making involved.

The authors make the argument that people seem to ignore the fact that violent crime is significantly decreased over the past decades.  They do not describe how this happens but suggest that countering this fallacy is important. It is a difficult fallacy to counter when a major political party uses this narrative daily to rationalize laws that promote gun extremism and gun permissiveness.  Politics is not mentioned at all in the document even though one political party would find it difficult to function without repeated references to gun access and promoting gun extremism.

What is missing?  Just about everything I have written about on this blog.  First, guns are a problem and there is no way around it.  I was concerned to see the following sentence in this paper:

“Firearms are not a cause of violence but, because of their high lethality and ability to injure large numbers of people, result in serious harm when combined with violent acts.”

It contrasts with:

“Primordial prevention addresses the most upstream, root-level causes of adverse outcomes—well before they take shape—by changing the structures and systems that give rise to them. This means transforming the fundamental social, environmental, and economic contexts that foster violence. This upstream approach is relevant to all types of firearm harms and applies across urban and rural settings. The current moment demands bold, systems-level interventions that prioritize housing stability, economic opportunity, environmental improvement, and equitable policies.”

In biological systems theory, a firearm is not conceptualized in isolation as an inert object.  Firing a gun is seen as an emergent property of the interaction of multiple subsystems in the individual, the task, the implement used, and the environment.  There are many examples.  You are not brushing your teeth without a toothbrush or walking with a cane without the cane.  The firearm is an integrated component of that system.  To prevent adverse outcomes from that system, all the components including the gun need to be addressed.  It is guns and people that account for the outcome not either in isolation.

Second, there is not a single mention of culture as a significant factor. There is discussion of changing narratives and all the various groups involved but not a single mention of the cultural aspects of gun violence. More specifically there is no mention of how the US has gone from a culture of firearms for hunting and target shooting in the mid-20^th century to the current culture of carrying firearms with minimal regulation like what existed in the mid-19^th century.  That was before towns in the Old West passed ordinances about not carrying firearms in town.  There is clear current evidence that lax firearm regulation correlates with firearm casualties and deaths.

Third, there is a clear gun extremism culture that I have elucidated in this past post.  The elements are clear and this level of gun extremism correlates with increases in mass shootings and school shootings.  Gun extremists typically take and expansionist view of the Second Amendment while ignoring the preamble.  Many are also strict constructionists who ignore gun restrictions that were in place when it was written. 

Politics is a clear factor in gun extremism since it is promoted by the politicians, judges, and operatives of one political party.  It is really a combination of gun extremism and inaction. After every mass or school shooting – nothing ever gets done.  School shooters are a subset of the gun extremist culture and a clear example of how cultural effects can spread to other people.  At the broader political level gun extremism is heritable and passed on from generation to generation.

Fourth, the neuroscience of human decision making and development is ignored, especially the emotional component.  It has been known for some time that human decision making is more than a purely rational process and that an emotional component is essential (5-8).  Since then, the neurobiological substrate has been partially elucidated but research continues to find new components (9).  The basic observation seen on any true crime TV show – the relationship of anger and gun availability to gun violence has not been adequately investigated.  The epidemiological methods use to examine gun violence gather adequate contextual details for accidental injury and death but not homicide (10).  One of the gun extremist myths is that gun owners and carriers have superior ability to control themselves and avoid making mistakes. There is no reason to expect that is true.  Just having more people carrying lethal weapons in public will increase the chances of a violent confrontation.      

Fifth, the authors recommend strategies to decrease alcohol consumption and there is some evidence that younger generations are consuming less alcohol.  At the same time, we have increased cultural permissiveness for other intoxicants that are as likely to be associated (directly or indirectly) with aggression and violence – specifically stimulants, cannabis and cannabis derivatives, synthetic cannabinoids, and opioids.

Sixth, homicide prevention needs to have a similar path toward resolution that suicide prevention currently has.   To put things into perspective, many people with either problem end up on psychiatric units in hospitals.  Most of them are there because of stated suicidal ideation or making a suicide attempt.  The violent people are typically there because of police calls where they had to contain an aggressive person who has a mental illness.  There are no hot lines comparable to suicide hot lines.  There are no homicide prevention programs for the acutely homicidal person. As far as I know there has been no research in this area.  Aggressive and homicidal behavior needs to be identified as a clinical and public health problem that needs to be addressed in a timely manner. 

These are some obvious unaddressed factors in this report.  It is probably easier to consider general solutions than more specific cultural and political ones.  But we can no longer pretend that maintaining and ignoring these cultural factors will lead to any effective changes.  It also requires adequate expertise in data collection, sociocultural changes, and in clinical settings. More discussion in this area will result in people who are more comfortable talking about the problem.   This is a complex problem but it does have solutions.  Considering the biological and sociocultural factors described – it should be apparent that the sociocultural factors are primary. The current administration is doing nothing to address childhood adversity.  The logical place for intervention is changing the sociocultural environment with legal and public health interventions.  It will take more than what is  suggested in this review.   

George Dawson, MD, DFAPA

 

References:

1:  Rivara FP, Richmond TS, Hargarten S, Branas CC, Rowhani-Rahbar A, Webster D, Richardson J Jr, Ayanian JZ, Boggan D, Braga AA, Buggs SAL, Cerdá M, Chen F, Chitkara A, Christakis DA, Crifasi C, Dawson L, deRoon-Cassini TA, Dicker R, Erete S, Galea S, Hemenway D, La Vigne N, Levine AS, Ludwig J, Maani N, McCarthy RL, Patton DU, Quick JD, Ranney ML, Rimanyi E, Ross JS, Sakran JV, Sampson RJ, Song Z, Tucker J, Ulrich MR, Vargas L, Wilcox RB Jr, Wilson N, Zimmerman MA; JAMA Summit on Reducing Firearm Violence and Harms. Toward a Safer World by 2040: The JAMA Summit Report on Reducing Firearm Violence and Harms. JAMA. 2025 Nov 3. doi: 10.1001/jama.2025.18076. Epub ahead of print. PMID: 41182880.

2:  Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450.

3:  Lin JC, Chang C, McCarthy MS, Baker-Butler A, Tong G, Ranney ML. Trends in Firearm Injury Prevention Research Funding, Clinical Trials, and Publications in the US, 1985-2022. JAMA Surg. 2024;159(4):461–463. doi:10.1001/jamasurg.2023.7461

4:  Zaller N, Brown J, Fischer K, Abaya R, Cardoso LF, Dreier FL. The Critical Role Of Federal Funding In Combating Firearm Violence. Health Affairs Forefront. 2025.  Accessed on November 8, 2025) https://www.healthaffairs.org/content/forefront/critical-role-federal-funding-combating-firearm-violence-public-health-perspective

5:  Bechara A, Damasio H, Damasio AR. Emotion, decision making and the orbitofrontal cortex. Cereb Cortex. 2000 Mar;10(3):295-307. doi: 10.1093/cercor/10.3.295. PMID: 10731224.

6:  Bechara A. The role of emotion in decision-making: evidence from neurological patients with orbitofrontal damage. Brain Cogn. 2004 Jun;55(1):30-40. doi: 10.1016/j.bandc.2003.04.001. PMID: 15134841.

7:  Sanchez EO, Bangasser DA. The effects of early life stress on impulsivity. Neurosci Biobehav Rev. 2022 Jun;137:104638. doi: 10.1016/j.neubiorev.2022.104638. Epub 2022 Mar 24. PMID: 35341796; PMCID: PMC9119952.

8:  Potegal M, Stemmler G. Constructing a neurology of anger. In International handbook of anger: Constituent and concomitant biological, psychological, and social processes 2009 Dec 21 (pp. 39-59). New York, NY: Springer New York.

9: Jung J, You IJ, Shin S. Thalamo-hippocampal pathway determines aggression and self-harm. Sci Adv. 2025 Nov 7;11(45):eady5540. doi: 10.1126/sciadv.ady5540. Epub 2025 Nov 5. PMID: 41191756; PMCID: PMC12588284.

10:  Forsberg K. Surveillance for Violent Deaths—National Violent Death Reporting System, 50 States, the District of Columbia, and Puerto Rico, 2022. MMWR. Surveillance Summaries. 2025;74. https://www.cdc.gov/mmwr/volumes/74/ss/pdfs/ss7405a1-H.pdf

Graphic:  The graphic above is a line drawing of my MRI.  I intend to place it in a larger drawing of all the relevant factors to consider when it comes to gun violence. That is a work in progress and it is an extremely complex drawing.  When I complete it – I will replace the graphic at the top of this post.

Medication Checklist

 

I just completed a modification of my Medication Checklist that I have been using for the past 20 years.  The intent of the checklist was to provide an easy way for patients I was seeing to recall any medications they had been treated with in the past. There was no attempt to classify the medications in a more precise manner.  I found it was successful for its intended purpose and allowed for a discussion of other potentially useful medications as well as the limitations of this kind of classification.  As an example, there are overlap categories between antipsychotic medications and mood stabilizers as well as anxiolytics and antidepressants.

My last update was 5 years ago.  Since then, there have been 24 additions, but very few in terms of new medications.  Most of the changes have all been changes in drug formulations (sustained release, combination medications, a new transdermal patch, and longer acting injectable medications.  I included one GLP-1A agonist – tirzepatide (Zepbound, Mounjaro) because it has a new indication for obstructive sleep apnea and sleep medicine is a growing subspeciality in psychiatry. 

I included a new category of Agitation, because dexmedetomidine has that indication.  The only other medications typically in that class are antipsychotics and mood stabilizers but it is far from inclusive.  In acute care psychiatry, most of the medication used to treat this problem are not FDA approved but are from the same classes as the approved drugs.  The only exception are benzodiazepine drugs that are often combined with antipsychotics. 

The time domain for this list is about 40 years. That means there are several older medications on the list that are no longer manufactured or prescribed. It is useful to retain them because many people coming in for new assessments may have been exposed to them over the years. 

Gepirone is an interesting addition.  I posted previously about how azapirones (buspirone and gepirone) seemed to be neglected compounds in psychiatry. Despite buspirone having an anxiety disorder only indication, gepirone was approved for depression in 2023. The current package insert says it is indicated for depression only.  It is a once-a-day dosing but it has a QTc prolongation warning and may require more intensive medical monitoring for that reason.

Viloxazine is a selective norepinephrine reuptake inhibitor (SNRI) that is structurally dissimilar to atomoxetine – an earlier SNRI used to treat Attention Deficit-Hyperactivity Disorder.  

The most significant new medication is likely to be Xanomeline trospium chloride (Cobenfy).  It is a new antipsychotic medication with a novel mechanism of action. Xanomeline is a CNS M1 and M4 muscarinic acetylcholine receptors agonist.  Trospium is a muscarinic acetylcholine receptor antagonist primarily in the peripheral tissues making it a first in class medication.   

The medication sheet contains several medications that are used to treat symptoms and medication wide effects.  There is a total of 142 medications (not counting various reformulations of the same compound). 

I am currently working on reclassifying the medication on this sheet by two different systems – the Anatomical Therapeutic Chemical (ATC) classification system based on more formal indications and the Neuroscience-based Nomenclature (NbN) based on purported mechanisms of action.  At some point I will also try to put them all on a timeline based on when they were FDA approved.

In the meantime, the list can be accessed and printed out.  It is setup to fit on both sides of a standard piece of paper.  During an interview if a person has a difficult time recalling medications – I will show them the list and point out the section that is most likely relevant.  I never include it in the medical record, but use it as part of my notes to record the clinical encounter or check pharmacy records.    

Let me know what you think and if I missed anything.

 

George Dawson, MD, DFAPA

 

The Medication Checklist can be downloaded at this link.

How To Stop Burning Witches...

 

I was hoping for a timely post for Halloween but just missed the deadline. Witches are considered an icon of the season, although I have not seen a lot of those costumes recently. I came across an important book that analyzed the witchmongering movement in 15^th to 18^th century.   Witchmongering was term was coined by Reginald Scott in 1584 in his book The Discoverie of Witchcraft.  He used it to describe people promoting the ideas and superstitions about witchcraft – specifically those who profited from spreading these ideas.  His book discusses the idea that witches have connections to the devil and Scott’s position was that this was all imaginary.  He studied magic and concluded that the belief in witchcraft was rooted in illusions, imposters, or inaccurate conclusions due to mental disorders.  He sought to prevent marginalized individuals from being attacked as witches.

Despite Scott’s rational approach, witchmongering was actively debated for at least another century.  Thomas Ady wrote A Candle in the Dark in 1656 and took a similar position.  Popular opinion about the existence of witches and their presence began to wane around 1700, but witchcraft laws and executions persisted much longer. In Great Britain the Witchcraft Act was repealed in 1736.  By the late 18^th century most witchcraft prosecutions and punishments were banned in Europe. The last witchcraft trial in the US was in 1878.  There is a detailed history of both witch hunts and executions of witches resulting in the deaths of tens of thousands of women.  Even though most people do not know the details of this dark practice – the concept witch hunt is used rhetorically these days to indicate an unfair investigation.  

There are various ways to analyze the history of witchmongering. Social scientists have looked at anthropological and sociopolitical analyses. Rhetoric seems like a powerful approach to me because humans seem to use the same patterns over time to make irrational decisions.  Rhetoric is a component of cultural inheritance.  In the case of witches – anxiety provoking events like crop failures, illnesses, economic and political instability, religious and sexist biases could lead to accusations of witchcraft.  But once the precedent was set behaviors, social factors, and personality factors could also be included as well as accusations of supernatural phenomenon like sorcery and causing people to disappear.  There is no doubt that some had mental illnesses but that is not currently considered to be a major factor in the women who were persecuted.

Ady describes a common scenario in his era. The poor and disabled went door to door in those days asking for relief. Many were elderly, malnourished, and disabled. If they were denied assistance by the landowner and his crops or cattle failed or one of his family fell ill – that person could be blamed for witchcraft as a source for these problems.  They could be subjected to false tests or torture and sentenced to death as a witch.  

Once these negative qualities were specified as evidence, the sequence of events proceeded in the same manner that can easily be observed in modern American politics.  If enough people are anxious about some matter, it is easy enough to incite them.  Just claim that you are the only person who can solve that problem and find a group that is the modern equivalent of witches to blame.  In recent months we have seen documented and undocumented immigrants, women, non-white minorities, university professors, public health officials, public sector employees, the disabled, the economically disadvantaged, the food insecure, members of the previous administration, and just about anyone who is a critic of the current administration. Scapegoating a small segment of the LGBTQ community may have been the deciding factor in that last Presidential election and it continues to be an issue.

Ady’s book is a tour de force against witchcraft.  He begins his three part treatise by directly confronting popular notions of witchcraft with the Biblical moral code of the day.  He lists 16 – “where is it written” or “it is written” clauses in his introductory “A Dilemma that Cannot bee answered By Witchmongers.”  In the subsequent text he elaborates on how references to witches have been misinterpreted to fuel witch misinformation.  An excerpt of the Dilemma is reproduced below.  Note that the original spellings are preserved:

 

 

At the end of this this volume he gives two excellent counterfactuals to falsify witch mongering. It is clear from these examples that any misfortune can be erroneously ascribed to witches and therefore witch mongering and everything that involves adds no explanatory power.  That is made much worse by the fact that this non-explanation resulted in the deaths of thousands.    

 

 Moral reasoning and rationalism was used to discredit witch mongering but they were not the sole factors.  Johann Weyer (1515-1588) was a Dutch physician who argued that witches were mentally ill suffering from melancholia.  He thought that any confessions of witchcraft were based on delusional thinking.  He published numerous works on witchcraft and magic. 

Medicine, science, and rational thought were not enough to immediately correct the practice of persecuting women as witches.  Pseudoscience and various “tests” were used to prove that a woman was a witch.  Many of these tests defy reason like the pseudoscience of the current era.  For example, one test of a witch was to bind them, throw them into a body of water and see if they float.  Certain marks on the skin were taken to be the marks of a witch.  That included puncture marks inflicted with needles by others – if the puncture wound did not bleed it was considered evidence of a witch. Ady provided counterarguments about why these were inadequate tests.  Needless to say there were no control groups. 

Despite Weyer’s direct observations there are competing theories that social and cultural factors were important.  It is likely that both played a part, with psychiatric etiologies as suggested by Weyer playing the minor part.  If you are identified as a physician who works with a particular problem – it is likely that selection bias is operating in the clinical population that you see and treat.  Cultural symbols are often incorporated into psychotic symptoms.  In 40 years of practice – I saw a handful of people who believed they were Christ-like and many more who believed they were the Antichrist. During the time of Satanic Ritualistic Abuse (SRA) I saw many people who were not delusional but believed that they had witnessed homicidal rituals by satanists.  Those are all modern examples of observations that were not accurate and could be scientifically disproven.

If we agree that witch accusations and persecutions were psychiatric, social, and cultural in origins are there some common factors that might account for these patterns?  Anti-intellectualism is a complex societal problem that has been examined by Hofstader, Pigliucci, and others (3-5).  Hofstader traced some of it back to right wing politics and religion in the 1950s where it still resides today.  Hofstader described 3 forms (antirationalism, anti-elitism, unreflective instrumentalism) to which Rigney added unreflective hedonism and Pigliucci added academic post modernism as a fifth (4).  Pigliucci also added a qualifier that post modernism may be an intellectual anti-science field.   

The refutation of witchmongering is an important lesson for people in modern times. Reasoning and moral reasoning based on Christian principles and local laws eventually carried the day – but it took a long time. Science through early observations of mental illness were a small part of the story.  The most significant aspects of this historical period is focused on cultural inheritance and rhetoric.  Neither of those dimensions is necessarily predicated on the truth.  The commonest ignored pattern is the use of a scapegoat to avoid the reality of the situation or in the worst case divert attention to an emotional topic that is really all part of the scapegoating.

We typically see these issues categorized as hot button issues or culture wars.  They are responsible for large scale irrational decision making about guns, abortion, welfare, religion in schools, banned books, restricted access to voting, racism, misogyny, the medically uninsured, and corporate welfare.  They are currently responsible for the dismantling of basic research, health care, food subsidies, public health, foreign aid, the Department of Justice, the Department of Defense, and the layoffs and firings of 200,000 federal employees.  There is an estimated large death and morbidity toll associated with those decisions.

While we are no longer naming witches and prosecuting them – a lot of the thinking behind that process has been passed along as cultural inheritance and the associated rhetoric.  A significant number of Americans react to it in expected ways.  Recognizing the pattern of scapegoating and the associated emotions is a critical first step.  The second is to figure out what science is and what it is not.  Science is definitely not doing your own research unless you have been trained in the scientific method or (ideally) are a scientist.  The ultimate ability is to be able to use reason, moral reason, and science to make the best possible decisions.

That is the best way to avoid more witchmongering.      

 

George Dawson, MD, DFAPA   

 

 

 

Graphic Attribution:

“The Witches' Ride' William Holbrook Beard (1870), Public domain, via Wikimedia Commons

 

References:

1;  The National Archives - UK.  Early Modern witch trials.  https://www.nationalarchives.gov.uk/education/resources/early-modern-witch-trials/

2:  Schoeneman TJ. Criticisms of the psychopathological interpretation of witch hunts: a review. Am J Psychiatry. 1982 Aug;139(8):1028-32. doi: 10.1176/ajp.139.8.1028. PMID: 7046480.

3:  Hofstadter, R. Anti-intellectualism in American life. Vol. 713. Vintage, 1966.

4:  Rigney D.  Rethinking Hofstadter: three kinds of anti-intellectualism. Sociological Inquiry.  1999.  61(4): 434-451.

5:  Pigliucci M.  Denying evolution – Creationism, science and the nature of science.  Sinauer Associates, Sunderland MA, 2002.   

6:  Ady T.  A Candle in the Dark or A Treatise Concerning the Nature of Witches and Witchcraft: Being Advice to Judges, Sheriffes, Justices of the Peace, and Grand Jury-men, what to do, before they pass Sentence on such as are arraigned for their Lives as Witches.  1656.  Theophania Publishing.  

A House of Dynamite

I watched this Kathryn Bigelow movie a couple of nights ago after anxiously waiting for it to hit Netflix.  It turns out that Bigelow and I are the same age and lived through the Cuban Missile Crisis, the Cold War, and the era of public and private atomic bomb shelters – all based on the idea that you can survive a nuclear war.  As I have written on this blog in a couple of places – it was also my job in my early 20s to disassemble the bomb shelter in the basement of our public library.  Nobody ever gave me a reason – but in retrospect it was probably because planners realized that there would be no survivors.  I am not talking about dying in the blast or even surviving the radioactive fallout and fires.  I am talking about the millions of tons of smoke, soot, and dirt blown up into the atmosphere and the effects of that blocking sunlight.  The direct smoke and soot effects are expected to last for 5 years and the resulting greenhouse gases for a century (1).  There will be climate change and an inability to grow crops for a very long time.  That would mark the end of civilization probably within a few years.

There are differing opinions on what it would take to create a nuclear winter. Over the past 30 years several groups have estimated the environmental effects of numbers of nuclear weapons ranging from 15-100 kilotons of explosive force.  The simulations vary from a limited exchange to a large-scale exchange of several thousand nuclear weapons.

This movie is focused on the launch of a single missile from an unknown location and the people responsible for responding to that attack.  There is the suggestion that early warning systems may have been compromised by a cyberattack.  We see a cross section of military officials and civilians at Fort Greely Alaska, in the White House, and via telecommunications monitoring threats to the United States.  They detect a missile launch and initially think that it will splash down in the Sea of Japan.  They eventually see that it is on a suborbital trajectory and it will hit the continental United States.  Chicago is determined to be the target. 

The tension increases greatly when the staff involved realize that this is a nuclear attack on the United States.  There is some initial confidence that they can intercept the incoming missile with Ground Based Interceptor (GBI) anti-ballistic missiles. The GBIs are used to deploy an Exoatmospheric Kill Vehicle (EKV) that is a kinetic energy weapon designed to seek out and destroy the ballistic missile by direct impact. In a tense dialogue between the Secretary of Defense and the Deputy National Security Adviser we learn that the success rate of the GBI system is only 61% and it cost $50 billion.  During these discussions Ft. Greely has 2 GBIs in the air and they both miss.

That leads to increased tension. The alert state is DEFCON 2 and none of the staff has been at that state in the past.  Everyone knows the gravity of the situation.  People are upset, tearful, and trying to contact their families.  A cabinet official jumps off the roof of the Pentagon.  One of the central figures calls her husband and tells him to put their child in the car and get out of town as quickly as possible.  Even though there is only one missile in the air headed for Chicago – the viewer knows only 20 minutes total have elapsed.  There is no adequate amount of time to evacuate most major metropolitan areas.

With the failed countermeasures we see the President in the final frames.  He is with his retaliatory strategy advisor – a Lieutenant Commander.  He has a large book of targets – all specified by certain codes.  The President is anxious and hyperventilating. He is contemplating the gravity of the situation – the human toll, not letting the perpetrator get away with it, what the American people will think of his response, the insanity of selecting military targets when he does not know who launched the missile, and the message it would send if the US does not respond.

This was a very good movie that I enjoyed a lot.  It was well written, directed and acted by some of my favorite actors. Most importantly it contains a solid message about nuclear war – don’t go there.  The anxiety, confusion, mayhem, and desperation portrayed as the product of a single missile launch may be the 21^st century equivalent of that 1964 classic Fail Safe.

But it turns out there is more.  The Pentagon apparently released a memo disputing the low accuracy of the GBI anti-missile system.  I have not been able to access the memo but apparently it claims a 100% success rate in stopping incoming ballistic missiles. 

I was able to see an interview of Joseph Cirincione (2) – a defense consultant with experience all the way back to the Reagan era and the Star Wars initiative.  He said there have been a limited number of tests of the system but you could claim a 100% success rate if you looked at the last 4 tests.  If you look at the life of the program there have been 20 tests and only 11 or 55% were successful.  He pointed out the technical difficulties of trying to shoot down long-range missiles and said the system was more of a sieve than a protective dome and that it could not be counted on to plan a defense.  Further, the total investment in antiballistic missile technology has been $453 billion and that technology in the form of lasers, rockets, or the GBI/EKV will not be adequate for another 30 years.  He alluded to a study of the technology by the American Physical Society (3) but it was not clear that was his reference for the estimate.  When asked about the most significant nuclear threat to the US, Cirincione said it was Russia and that in an attack of a thousand ballistic missiles – the US would be able to “intercept 1 or 2.”  In the Pentagon versus movie accuracy, he rated it: “House of Dynamite 1 and Pentagon zero.”      

Where does this leave us?  Here are a few considerations.  First, if anyone was serious about waste, fraud, and abuse it is far more likely to be found in the Pentagon than in health and human services.  The $453B spent on several antiballistic missile systems to end up with one that is as effective as a “sieve” says it all. And apparently a new contract has been signed even though physicists are saying the technology will not be ready for another 30 years.  Second, the current system is a coin toss in terms of intercepting ballistic missiles from a rogue state.  In an all-out attack by a nuclear power it can possibly intercept a trivial number of missiles.  It makes no sense to advertise it any other way or pretend that the United States is “protected” against a long-range missile attack.  Third, we are right back where we started when nuclear non-proliferation was the order of the day.  Having all the nuclear weapons in the world is a lose-lose situation rather than a zero-sum game if all of humanity goes extinct during the attacks and the aftermath.  You don't even have to be in the game to lose.  If you are a hemisphere away the resulting climate change and ice age will kill you.   Fourth, rather than being focused on non-proliferation we currently have leaders who are bragging (4-7) about weapons systems.  Fifth, there is not even a tip of the cap to cosmopolitanism at this point.  Billions of people around the world work every day and strive to get home safely to their families every night.  In the meantime, we have a handful of old men with a limited stake in the future playing a dangerous game of brinksmanship – often for no reason other than playing the game.   

When exactly are world leaders really going to work in the interests of their people?  Nuclear war, nuclear winter, and the extinction of humans is the last thing any rational person wants.

 

George Dawson, MD, DFAPA

 

Supplementary 1:  Precedents for holding your nuclear fire:  There was one brief allusion in the movie to a nuclear early warning that was ignored during the Cold War.  There were two – in both cases commanders from the USSR ignored in one case a radar error suggesting an attack by the USA and in the other a direct attack by the US Navy on a Soviet submarine.   This is interesting because the Soviets were typically considered war mongers by Americans at least that was the political hyperbole.  In fact, two of their commanders exercised good judgment under fire and probably prevented an all-out nuclear war.   

Supplementary 2: Kathryn Bigelow responded to Pentagon criticism of the movie about the accuracy of the Ground Based Interceptor missiles (8).  She described the film as realistic and authentic. In The Guardian version of this story a nuclear physicist said that the scenario was “about as easy as they come.”  That same article said the US has 44 GBICs in Alaska and California and has contracted for a new system for $13.3 billion.  Bigelow said she hopes the film will create discussion and cultural change that may produce a more rational approach to the problem - like arms reduction.  Kathryn Bigelow has produced art with a beneficial message to the American people.  It is a message that nobody else is sending.  She deserves credit for this work rather than criticism.  

Supplementary 3:  The Bulletin of Atomic Scientists published a brief essay on what the immediate consequences of a nuclear explosion in Chicago would look like:

Jaworek P, Williams I.  The “House of Dynamite” sequel you didn’t know you needed. October 31, 2025  https://thebulletin.org/2025/10/the-house-of-dynamite-sequel-you-didnt-know-you-needed/

References:

1:  Toon OB, Robock A, Turco RP. Environmental consequences of nuclear war. Physics Today. 2008 Dec 1;61(12):37-42.  https://climate.envsci.rutgers.edu/pdf/ToonRobockTurcoPhysicsToday.pdf

2:  Cirincione J.  TMZ Live October 28, 2025  Link to video

3:  American Physical Society.  Strategic ballistic missile defense. Challenges to defending the U.S.  March 3, 2025  Links to 3 different reports

4:  Wittner LS.  Nuclear arms race intensified during Trump’s presidency.  The Hill. July 5, 2024  https://thehill.com/opinion/4755721-trump-nuclear-arms-race/

5:  Cancian MF, Park CH. Trump Moves “Nuclear” Subs: Negotiating Tactic or Escalatory Gamble?  August 6, 2025.  https://www.csis.org/analysis/trump-moves-nuclear-subs-negotiating-tactic-or-escalatory-gamble

6:  Megerian C.  Putin boasts about new nuclear-powered missile as he digs in over Russia’s demands on Ukraine.  October 27, 2025.  https://www.pbs.org/newshour/world/putin-boasts-about-new-nuclear-powered-missile-as-he-digs-in-over-russias-demands-on-ukraine

7:  Associated Press.  Trump suggests the U.S. will resume testing nuclear weapons.  NPR October 30, 2025.  https://www.npr.org/2025/10/30/g-s1-95725/trump-testing-nuclear-weapons  

Historical note:  The US had not tested a nuclear warhead since 1992.  Many experts agree it is unnecessary and there is a nuclear test ban treaty. 

8:  Shoard C, Pulver A.  Kathryn Bigelow responds to Pentagon criticism of A House of Dynamite: ‘I just state the truth’.  The Guardian October 29, 2025  https://www.theguardian.com/film/2025/oct/29/kathryn-bigelow--pentagon-house-of-dynamite-netflix