I think it's time
Like Medpundit, I find that I don't have enough time to devote to this blog.
It's been a lot of fun.
musings of a psychiatrist in the pacific northwest
"The Forgiveness Project...has no religious or political agenda. It has no agenda at all apart from the brave, unfashionable wish to turn the blame culture on its head, to share the stories of people who, in extremis, have discovered that 'the only way to move on in life is to lay aside hatred and blame'. It tells of victims and perpetrators from all over the world: South Africa, America, Israel, Northern Ireland.
"...These stories are tremendously moving but they are complicated too. Would it be unfair to suggest that Rice's sentiment sounds precariously close to revenge? Forgiveness can be uncomfortable. It may induce squeamishness, strain, disbelief in the onlooker and, perhaps, in the forgiven. It can seem artificial. It seems to involve an emotional double-jointedness, an ability to bend backwards further than an ordinary person is designed to go. And yet, at other times, something miraculous occurs. People seem to emerge into a new landscape, a clearing where negative feelings no longer consume them. I imagine that it is not an easy place to be. They are exposed, unsupported - for revenge and hatred were, in their ugly way, crutches - but they are free.
"...Adam Phillips, writer and psychoanalyst, suggests: 'Forgiveness is not an act of will, if genuine.' He is quick to see its darker aspect: 'It puts the forgiver in an immensely powerful position. There is word magic here: the belief that if you forgive, people will be absolved of their guilt. At worst, forgiveness is a tyrannical gift: your life in my hands. You'll feel better when I forgive you.'
"Marian Partington, whose sister Lucy was one of the victims of Frederick West, the Gloucester mass murderer, disengages herself from the word: 'I don't like 'forgiveness'. It is completely barnacled with aeons of piety. I prefer compassion: empathy with suffering.' If the word is to be used, she sees it as 'a verb not a noun. I get a bit suspicious of people who say "I have forgiven", as if it is something in the past...'
"After trauma, she believes, people often experience a 'frozen silence with no words. There are no words to describe this place'. Time involves a thaw and 'acceptance' and, in Partington's case, luminous words to describe her feelings, to break the silence."
HENDERSON, NEV. — Treating medication overuse headache involves a three-pronged approach of patient education, teaching pain coping skills, and addressing psychological issues that put patients at risk for relapse, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.
Most patients don't understand that excessive use of opioids can actually make them hypersensitive to pain, said Dr. Lake of the Michigan Head Pain and Neurological Institute, Ann Arbor. “They believe the pain is stronger than the medication, not that the medication is actually making them worse.” This thought process can be the root of ever-increasing medication use, as the patient experiences “pain anxiety” and attempts to forestall pain by premedicating.
The first step is to teach patients how medication overuse exacerbates headache pain, he said. Only when they have a clear understanding of this relationship will they be open to adhering to medication limits.
Sustained opioid use downregulates opioid receptors and upregulates excitatory receptors. This results in increased synthesis of excitatory neuropeptides. “Opioid tolerance is a red flag for induced abnormal pain sensitivity,” Dr. Lake said...
Simply taking away the analgesic isn't the answer, he stressed. Patients need to understand that drugs are not the only way to alleviate headaches, and that they will probably have to tolerate some level of pain. “The evidence, clinically and empirically, shows that it's very difficult for these patients to move to pain-free days. They have to find ways of dealing with headache that doesn't involve drugs.”
Biofeedback, stress management, and antidepressants all may be effective tools in relearning responses to headache pain.
Last fall, Bentley College management professor Tony Buono taught a class on corporate scandals with colleagues pitching in from finance, accounting and even the philosophy department. The four picked through the cases of Enron, WorldCom, Tyco and Shell.Buono, the Bentley professor, suspects the students in his class who got caught misbehaving in the mock trading room considered it a game.
At the end of the semester, the number of students in a simulated trading room who were caught in misconduct or misusing information for insider trading was significantly higher than at the beginning. The students said, "You taught us how to do it," Buono recalled.
"For those of us who've spent our careers teaching this, it's been a disappointing time," said Buono.
1. You would be surrounded by frowning people.
2. The food would be hospital food. If you did not eat it, they would not let you go home until you did.
3. The food would make you constipated or dizzy or wanting more and more and more...
5. The waiters would take notes on your behavior.
6. Voices would tell you that the waiters did not like you and that they wanted to poison you. Other voices would just say things like blab blab blab over and over again.
7. Whenever you lifted a fork or knife, the staff would watch you especially closely...
11. You’d leave the restaurant relieved that you were out of it. When you got home, however, you’d discover that the restaurant had moved into your bedroom.
"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."A crucial point...one that I wish I had made, myself! But Baldrick also says: "To taper meds, do a, b, and c." (You see where I'm going here.) Another commenter vehemently disagrees with Baldrick, and says that such a taper should not even be posted.
"For patients with severe problems discontinuing paroxetine, dosing may need to be tapered over many months (i.e., reduce dose by 1% every 3 days by crushing tablet and suspending or dissolving in 100 ml of fruit juice and then disposing of 1 ml while drinking the rest; 3-7 days later, dispose of 2 ml, and so on.) This is both a form of very slow biological tapering and a form of behavioral desensitization."So if a dose was lowered from 20 mg to 19 mg, that would be a 5% reduction. But he's describing a 1% reduction. (As the dose gets lower, the proportion changes, of course.) He adds:
"For some patients with severe problems discontinuing paroxetine, it may be useful to add an SSRI with a long half-life...prior to taper of paroxetine."He also notes that paroxetine inhibits its own metabolism, making tapering even more problematic for some (i.e., the effect of a dose reduction can be magnified. The patient is not only taking less, he's also eliminating it faster). -Essential Psychopharmacology: the Prescriber's Guide by Stephen M. Stahl, Meghan M. Grady (Editor), Nancy Muntner (Illustrator)
"one of the problems with the internet is that large numbers of people with rare conditions/reactions/discontinuation reactions congregate in one place. They may or may not have atypical ideas, metabolisms or disease presentations."However, I'm afraid that I'm going to have to delete any comment that gives, or appears to give, medical advice. That includes posts that say, "Do this" (whatever "this" is). The issue of whether, and how, and when to stop meds is controversial. Each patient is different. Please speak to your doctor! No medical advice is given on this blog.
Your husband was admitted with extreme pain in the abdomen, which is obviously not our fault...We didn’t want to rule anything out, so we opened him up.
There were no multi-hundred-pound tumors; that’s the good news.
However, it’s a real mess in there. There’s a lot of intestinal tubing squishing around—what you call “guts”—as well as an assortment of small, esoteric organs they don’t spend a lot of time on in medical school. And bear in mind that everything’s pretty much the same color, not like in the textbooks...
"Yesterday I had my first customer come talk to me about his medicare coverage. He spends quite a bit of money in the pharmacy, but he had opted for a plan which had the “doughnut hole.” Now. the details of each plan’s doughnut hole vary, but basically they all revolve around the magic $2250 number. There are some common misconception about this so-called doughnut hole, and he had fallen victim to both!
"...As always, I recommend checking out the Medicare website, particularly their plan search tool. Be sure to be specific, and enter your medications, and dosages so the plan can really help you choose the plan that’s best for you. At the end, it will present you with a list of plans ordered by yearly cost that cover the medications taken. The yearly cost is what it will cost you or a loved one in terms of premiums, copayments, and lack of coverage if a donut hole is ever reached. While you can’t change which company you go with now, you will be able to after November 15 when open enrollment begins again."
36. The poet Yeats wrote:-Ed's Pathology Notes.
An aged man is but a paltry thing,
A tattered cloak upon a stick, unless...
A. He finds a younger woman, has a fling,
And then yells out, 'I never will confess!'
B. He takes Viagra pills, to boldly bring
To his beloved his mighty manliness.
C. He uses Rogaine, and by next spring
Has hair regrowth that's certain to impress.
D. Soul clap its hands and sing, and louder sing
For every tatter in its mortal dress.
E. He burns his 'Path' book, and while it's smoldering,
He shouts out loud, 'I'm DONE with that B.S.!'
...and the world can't wait to see my vacation photos, right? I thought so! This is the Napali coast of Kauai, where I completely and utterly forgot about the rest of my life...(and my blog!). A little misty, perhaps, but so are the memories.
"Medpundit was one of the pioneers in medical blogging. She influenced my blog in many ways and will be missed."GruntDoc:
"I thought I'd made the big time when I got a mention in her blog in August, 2002, and I've been a long-term reader and fan of hers. She's what people think of when you say "medical blogger": she commented on medical news and ideas in a meaningful, substantive way. That doesn't mean she's been opinion-free, far from it, and that made her blog more interesting, not less so."Dr. Robert Centor:
"I have often told interviewers that I would not have become a medical blogger without Sydney Smith as a role model. She showed me that medical blogging could work.Dr. Emer:
"When I started my blog, I always measured my success by comparing what I was doing with her blog. In my mind she was the pathfinder."
"I do pray it is not her final decision. She gives excellent insights on almost any medical issue and current health studies. I hope she still blogs. It need not be regular. It can be once a week or even once a month.Kevin, MD:
"I won't say goodbye, Medpundit.....I'd rather say I would wait until you can blog again. Godspeed!"
"A sad day indeed. She was one of the reasons why I started this blog. Best of luck in the future, Dr. Sydney."
"Happy trails to you,"
"For (s)he's a jolly good fellow" (yes, the kid is singing "he," but it's cute),
and "Happy Trails, again!"
...maybe that's the one positive we can take from this whole sordid steroids scandal. If nothing else, Bonds is a living, breathing, tortured, tormented illustration we can point to when we tell our kids, 'You know, when you cheat, you're only cheating yourself.'NYT reports: "As Bonds crept closer to Ruth's No. 714, fans have heckled him and waved critical signs. One threw a syringe in San Diego. Another dressed as a syringe in Houston."
Bonds has cheated himself out of the adoration and adulation that should have been his Saturday. He cheated himself out of the respect and reverence that traditionally is reserved for our greatest athletes. He may have even cheated himself out of the Hall of Fame.
"I no longer have the time needed to devote to (the blog). The phrase 'declining reimbursement and rising overhead,' is repeated so often in medicine that it seems a cliche, but it's also a reality. I'm spending longer hours at work and seeing more patients to support my office and my family. The 1-2 hours a day it takes to keep up the blog are no longer there. I don't have any hope of that getting better in the foreseeable future. In fact, I anticipate that in the next 1-2 years, I'll be adding even more office hours until I've reached the limits of my physical and mental capabilities."Medpundit, you've inspired so many of us. I'm truly sorry to see you go.
Now I don't just write a blog, I read other people's blogs: it's like throwing Time in the fire and watching it burn.
How'd you like to see yourself 30 years from now? It sounds terrifying to me, but if you fancy looking at an artificially haggard and gnarled version of you then pop over to this site. All you have to do it upload a picture of yourself and they promise to use 'facial transforming software' to age you 30 years or so.Should I try it? Er...you go first!
...And if the service goat flies for free, then my service spouse should fly for free, too.
Roy, I'm gonna need a note.
Given a choice between sitting next to a service goat versus a shrieking service baby, I'll take the goat...
Those shrieking service babies really get your goat, huh? Hee.
As puns go, that one was not baa-aa-aaa-d...
"The world's most popular fruit and the fourth most important food crop of any sort is in deep trouble. Its genetic base, the wild bananas and traditional varieties cultivated in India, has collapsed."(Yes, yes, I know. In the last post, I was restrained. And this post is about...bananas. However, this is a pure and wholesome blog! Do you suppose that my Id is getting feisty again?)
"And so it began—and it happened much more quickly than I had anticipated (although time may simply pass faster when one is actively struggling against five other human beings). I kicked, I floundered, I wriggled, I did my best to wrest myself from their grips. Before I knew it, however, one person each had a hold of each arm and leg. Their hands were placed outside of each of my knee and elbow joints, restricting my excess flailing.
And then they picked me up off of the floor. Which sucked, because then there was nothing upon which I could brace myself. I continued to kick and jerk about—and started getting all sweaty and gross in the process."
The expectation that American soldiers would be greeted as “liberators,” with flowers and sweets was reasonable enough. After all, Iraqis had been savagely brutalized by Saddam’s domestic rein of torture, terror and sadism. Robert Kaplan recently wrote that, “Iraq in the 1980s was so terrifying that going to Damascus from Baghdad was like coming up for liberal humanist air. People talked furtively in Syria; in Iraq, nobody breathed a syllable of opposition. The whole country was like an illuminated prison yard. I was emotionally affected. Recent events make it easy to forget just how bad Iraq was back then. “Dr. Renshaw is "a professor of political science at the City University of New York, and a practicing psychoanalyst." A thoughtful, fascinating blog!
Still, the question remains: What happened? If Americans were truly viewed as liberators, why is it now struggling against a ferocious insurgency? Why did the good will that Americans expected seem to turn so suddenly into suspicion and resentment? These are very important questions whose answers go to the heart of American efforts in Iraq and the public’s assessment of them...
As I was wheeled back to my ER room, Dr. Resident said, "Well, you've had several more strokes. I count at least 8 new lesions. Maybe more. This is very interesting. Let me repeat some of the physical exam. "She reports that her blog-friends have helped her morale. She also has a prayer request.
Oh, so who's the faker now, buddy?
The Neuro ICU is a strange place to be when you don't feel particularly ill. Strapped down by IVs and catheters. People were nice there. I whined to Nurse Scott a bit too much about having to use a commode for a BM. He recommended I go on a walking tour of the ICU to put things in perspective. I was the only nonintubated patient in the unit. My neighbor died over the weekend. She was an organ donor. I can't stop thinking about who got her heart, kidneys, eyes...
"The U.S. Food and Drug Administration (FDA) today approved Chantix (varenicline tartrate) tablets, to help cigarette smokers stop smoking. The active ingredient in Chantix, varenicline tartrate, is a new molecular entity that received a priority FDA review because of its significant potential benefit to public health.
Chantix acts at sites in the brain affected by nicotine and may help those who wish to give up smoking in two ways: by providing some nicotine effects to ease the withdrawal symptoms and by blocking the effects of nicotine from cigarettes if they resume smoking...
The approved course of Chantix treatment is 12 weeks. Patients who successfully quit smoking during Chantix treatment may continue with an additional 12 weeks of Chantix treatment to further increase the likelihood of long-term smoking cessation.
In clinical trials, the most common adverse effects of Chantix were nausea, headache, vomiting, flatulence (gas), insomnia, abnormal dreams, and dysgeusia (change in taste perception).
She is doing fine, we should be heading home Friday. I will let her tell the story as only she can.What can she be going through right now? Hope she's okay...
With Zimbabwe’s official inflation now at 913 per cent, (international accountants say it is closer to 1500 percent,) it’s a pain going shopping. A decent sized whole chicken cost nearly a million Zimdollars this week.
It’s hard getting enough money to pay for a couple of baskets of basics as there are long queues in banks, and the automatic cash machines are always 'run out of funds' or jammed. Imagine being an accountant and checking the overdraft.
Interest rates are officially about 783 per cent. Last week it was 750 percent. A medium sized engineering company had an overdraft of Z$10 billion in December. Now it owes the bank Z$65 billion. It can’t pay. In theory its trading figures should have kept its overdraft manageable as the value of the Zimbabwe dollar shrinks daily....No one knows how high these extraordinary figures - inflation and interest rates - will go, nor what will happen when they continue to climb, minute by minute.
The Reserve Bank, which runs most of the country (the army runs the other part) acknowledges without blushing that it prints trillions and trillions of Zimbabwe dollars, to keep the economy going...
Every aspect of life in Zimbabwe is in a state of collapse. Education, health care, trade, commerce, and of course human rights...
Subjects are given a shock on their foot, after having been given a warning that the shock was coming, what its voltage will be, and what the delay is. Initially, this proceeded without any choices, as a training period.I'm waiting for someone to connect these findings to the "Dread factor" in politics, economics, foreign policy...and in our waiting rooms...
Next, subjects were presented with a choice between receiving a certain percentage of the shock, and a certain delay, or a different percentage and a longer delay. The two voltage percentages might be the same, in which case slightly more than half the time, subjects chose the shorter delay, presumably to get the experience over with. This is what is interpreted as the Dread factor -- that subjects so dreaded the wait that they wanted to shorten the wait...
Now we have two groups of subjects, mild dreaders, who will take the early shock only when it's the same or less, and extreme dreaders, who are willing to take an earlier higher shock.
So now the neurobiologic substrate. Subjects had all this happen while having a functional MRI (fMRI) done, which can then be statistically analyzed... I still have some uncertainty about whether I can make this connection to dread. What is dread? Dread is one of these experiences that we all have, and presumably share with others.
Dictionary.com says that it is "To anticipate with alarm, distaste, or reluctance". Hard to disagree with that, but what is that really? To me it is a complex feeling that cannot be removed from its cognitive aspects, so I'm not sure that the dread identified in this study is necessarily connected to other kinds of dread, like bad news or paying my taxes, yet dread per se has all these flavors...
It was a hard winter. It started even before that, perhaps in October, right before I left to work in Baton Rouge-- one patient had a serious suicide attempt, several were in crisis, even the patients who were fine were having trouble getting out the door at the end of the sessions. "Treatment-Resistant Depression" had become one of my favorite terms, but there were also a few people with mania and psychosis who were having a tough time. So it continued through the winter-- one patient called at least 10 times a day (I finally told her to stop; this improved the quality of my mental health remarkably), another e-mailed, up to 4 times a day, patients called-- or worse, their relatives called-- they cried, sometimes they even sobbed.How did things begin to turn around? She tells us, here. Go, read!
I mentioned it to a few colleagues and they all had the same response: My practice, too! One friend told me her emergency phone line usually gets 2 calls a month, now she was getting 3 a day, including calls from a patient on another continent, all while she'd taken on 3 news patients that week and her husband was out-of-town, leaving her with their 2 young children to negotiate. She beat me out for the Most Suffering Psychiatrist award and I brought her chocolate. Something in the air? Yet one more effect of Global Warming?
I felt discouraged, overwhelmed, and I wondered for the first time if I really loved psychiatry as much as I thought...
Although his writings were not scientific in any rigorous sense, and although he was not the lone pioneer that he claimed to be, supposedly charting a completely unknown psychological continent, there is no doubt that it was he who made us aware, in a straightforward and coherent fashion, just how hidden and contorted human motivation could be, how little reliance we could place on our consciously avowed intentions, and how important, though also how difficult, it is for us to know ourselves.
Freud was not a great scientist, nor did he discover anything in the sense that Robert Koch discovered the germ that causes tuberculosis, and Watson and Crick discovered the double helix. He did not contribute any store of positive facts to human knowledge. Science would be deprived of practically nothing had he not lived. His theories are now universally dismissed, either as having been disproved or, somewhat contradictorily, as being incapable of disproof and therefore not scientific theories in the first place.
Yet his influence on all of us was enormous, and it would be as impossible to return to a pre-Freudian way of thinking as to return to a pre-heliocentric theory of the solar system. Freud is a little like Nature in Horace’s famous line: though you may throw him out with a pitchfork, yet he returns. It is as if he enunciated deep if unprovable truths about ourselves that had never been so clearly enunciated before...
Allow me to tell you about some of the side effects I have experienced over the years.
One drug made me sleep for up to 20 hours a day.
One caused violent headaches and nausea if I forgot to take a single dose.
One made my mouth so dry that no amount of water or chewing gum could prevent my lips and cheeks from constantly sticking to my teeth from lack of saliva.
One caused restless legs. If you have never experienced this, I'm not sure that I could begin to describe the frustration of lying in bed and feeling uncontrollably compelled to shake your legs like a marionette. If you don't, it's like being tickled in restraints...
I owe those horrible pills an awful lot. I would not ask anyone to risk subjecting themselves to the potential side-effects of medication if I didn't consider it necessary. They improve many people's lives beyond measure. Anti-psychiatry opinion that psychotropic drugs do more harm than good is a dangerous myth.
My message is this: Patients - tell your doctor about the side-effects, especially if it's bad enough to make you want to stop taking the medication. I wouldn't advise following my example - don't just quit the medication without a discussion. There may be alternatives. Don't compromise your own health.
Doctors - ask your patients about side-effects, especially the embarassing ones. Most of your patients won't want to say anything about them. Have some empathy. You might think the side-effects of meds are minor in comparision to the alternative, but it is not you taking the stuff. Please listen.
Oh, and by the way - don't bother recommending prunes. They don't work.
"Greetings from a Friend of Bigmamadoc. I'm here to pass along an update for the good lady. Here goes:
"The procedure last night terminated early once they saw how goopy things were in those brain arteries. (Pardon my non-medical translation.) The new plan is to stent the artery on the right side Thursday and the left side on Friday or Monday. She'll be in the Neuro-ICU unit over the weekend. Her husband is with her, her child is well cared for, she's in a pretty good mood and she's receiving excellent care..."
"...if you're like most people, the triangle that is rotated more from the vertical position is the one that is suffering more. The triangle that is vertical, standing on point is stronger.
"In a recent study, Pavlova and her colleagues found that imbalance or instability in a picture of static objects is what leads individuals to attribute emotion to them. In a psychological sense, it is as if we see ourselves as the object. Being vertical and grounded is a state that is pleasing and empowering to us. The shapes that feel off-center evoke an off-centered feeling for us."