Month: May 2021

Arlington National Cemetery 2015

The video below was made from footage of our visit to Arlington National Cemetery in 2015. At the Tomb of the Unknown Soldier, each element of the guard’s routine has meaning, down to the number of steps taken up and down the black mat. According to the website:

“The Guard marches 21 steps down the black mat behind the Tomb, turns and faces east for 21 seconds, turns and faces north for 21 seconds, and then takes 21 steps down the mat. Next, the Guard executes a sharp “shoulder-arms” movement to place his/her weapon on the shoulder closest to the visitors, signifying that he or she stands between the Tomb and any possible threat. The number 21 symbolizes the highest symbolic military honor that can be bestowed: the 21-gun salute.”

Arlington National Cemetery YouTube video music attribution:

Americana – Aspiring by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/

Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1200092

Artist: http://incompetech.com/

Memorial Day Reflection

It’s a cool, sunny afternoon. The lawn has just been neatly mowed by hard-working, reliable people who use power mowers. We used to mow lawns at previous properties using old-time reel mowers. I should say my wife used to do the lion’s share of that while I was at the hospital, working as a consulting psychiatrist. Now that I’m retired, I sometimes just wonder what I’m good for.

But it’s not hard to remember what Memorial Day is for. I was never a soldier. I never knew anyone who died in war. I only talked with military recruiters in a time so long ago, I barely remember being that young. I think they knew I was not ready to die for my country. They didn’t scorn or openly reject me. They treated me with respect.

Though I know what grief is because I am bereft, I cannot imagine what it’s like to grieve the death of any loved one who perished in war.

All I know is that when I was young and thought I wanted to be in the armed forces, there were recruiters who saw through me and knew I did not want to be a soldier.

They knew I did not want to die thousands of miles from my home in a bloody field. They knew I did not want to be buried forever in a foreign graveyard.

They knew I could not be one of them. Yet they did not treat me like an outsider. Now all I can do is be grateful. Now what I can do is honor them in silence.

Crazy Like a Fox

I finally got a picture of a fox not far from our property—but not close enough to get a good image. That said, it led me to do a little reading on the web about foxes. The most interesting item is the idea foxes might be able to locate prey under deep snow by using some kind of magnetic sense involving a protein in the retina called a cryptochrome. I’m not sure if this has been conclusively proven yet, but some scientists have said that this explains why foxes are able to find mice hiding in deep snowdrifts. They use a comical nose dive leap to catch them. It looks crazy, but it might increase their hunting success rate. Maybe that’s the origin of the expression “crazy like a fox”. Other animals, including bears, might be able to use this magnetic sense. Let’s hope not.

Bears don’t have a comical leap when they hunt. They’re anything but comical when they’re surprised. A land surveyor in Alaska surprised a brown bear recently and got badly mauled. The Associated Press news item title was “10 Seconds of Terror: Alaska man survives bear mauling.”

It’s a harrowing story although the man’s telling of it is almost eerily non-dramatic. He’s pretty matter-of-fact about the whole thing. It turns out he’s lived in Alaska for 40 years. He personally knows five other people who’ve been mauled by bears in Alaska. He even sounds like it would have been all the same to him if he’d been killed rather than injured. He didn’t sound like he was depressed or even unhappy, just calmly matter-of-fact.

That’s exactly how several Alaskans talk about what sounds like an absolute traffic jam of UFOs in the skies over the state. I guess I should call them Unidentified Aerial Phenomena (UAP) now that we have a government task force (The U.S. Office of Naval Intelligence) assigned to investigating them. It sounds a little crazy. I sometimes wonder if this might be an attempt to draw attention away from other things happening in the country that’s getting a lot of press. That might be crazy like a fox.

I’ve watched the show Aliens in Alaska a few times. Ordinary, everyday Alaskans tell their stories about the UAP they’ve witnessed. They all describe them in the same way the guy talked about getting mauled by a bear, even the ones who say they’d been abducted by aliens. One guy was pretty frank about his UAP story, and even joked that maybe he was putting himself at risk for getting hustled off to the Alaskan Psychiatric Institute (API). Most of the time, when people are telling these stories on other TV shows, they always seem to be a little hysterical, which makes them a little less convincing. But the way Alaskans tell their stories, it’s like hearing how they got mauled by a bear, no big deal (“…oh, and did I ever tell you how I won 10 straight games of cribbage, all with at least one perfect 29 score?”).

Come to think of it (for no particular reason), I’ve never heard of any episodes of bear mutilations. There are plenty of stories about cattle mutilations, which are often attributed to aliens. How come bears don’t get the same treatment? Maybe because they’d fight back. Getting back to that mauled land surveyor, when I was a land surveyor’s assistant back in the day in Iowa, the only trouble I had with animals was with pesky cows trying to tip our tripods over out in the fields—probably as revenge for cow-tipping. I didn’t tip cows. They never put the salad fork in the right place (rim shot).

Anyway, I saw a commercial recently made by Alaska Governor Mike Dunleavy, talking up Alaska as a major tourism destination, also touting the state as having one of the highest vaccination rates in the country for COVID-19, although that has been fact-checked. According to the commercial, among the many exhilarating experiences you can have in Alaska is to see the bears.

He didn’t mention the aliens (which I’d rather see than bears), even though it could be one of the biggest draws to the place given the soaring interest in UAP. Crazy like a fox.

COVID-19 Long Haul: Pizza in the Pan Again?

I remember a scene in the 1979 movie The Jerk, starring Steve Martin as Navin. He was telling Marie (played by Bernadette Peters) about pizza in a cup. They were both eating pizza in a cup. At the time, this was funny because it was ludicrous to think of pizza being served in a cup. It was almost unthinkable. Now you can find recipes for pizza in a cup all over the web. Things have changed.

But what does that have to do with COVID-19 Long Haul Syndrome? As a retired consultation-liaison psychiatrist, I can tell you that it’s beginning to look like things have not changed when it comes to doctors thinking somebody has a psychiatric syndrome if he presents with symptoms that can’t be medically explained. In other words, it’s easier to invent pizza in a cup then to rethink the mind-body dualism puzzle.

That seems to be happening with COVID-19 Long Haulers. I’m beginning to see the telltale signs of somatoform-type labels eventually getting applied to patients who get mild symptoms that sound like COVID-19 early on, but which often don’t get severe enough to require hospitalization. They tend to be younger, and develop long-term symptoms, some lasting for over a year, that sound a lot like what many doctors used to page me about—medically unexplained symptoms (MUS). They have fatigue, often have breathlessness, and pain for which medical tests often turn up negative results. When doctors substitute other words for MUS that they believe are less stigmatizing, there is a predictable backlash by patients who reject the new, softer label. Pizza in a pan.

Further, I noticed a study sponsored by Beth Israel Deaconess Medical Center listed on Clinical Trial dot gov called Mind Body Intervention for COVID-19 Long Haul Syndrome (first posted April 22, 2021). Participants will be assessed using the Somatic Symptom Scale-8 (SSS-8) which measures somatic symptom burden and was developed in the context of evaluating the DSM-5 somatic symptom disorder diagnosis. Pizza in a pan again.

I also found a comprehensive article on line, “The Medical System Should Have Been Prepared for Long COVID” by Alan Levinovitz, which presented a thorough description of the problem many patients have with physicians telling them their symptoms are “all in their heads.” Unfortunately, this now includes the symptoms of COVID-19 Long Haul Syndrome. In all fairness, I think most physicians try not to give patients that impression. For many years, I was often consulted to assist primary care and specialist physicians in “convincing” patients to think “both/and” about symptoms which could not be medically explained. In fact, that was part of my approach because, believe it or not, some patients were stuck in an “either/or” mindset about symptoms: physical vs psychological, body vs mind, eventually reaching invalidating conclusions like real vs not real. It’s not helpful, partly because physicians tend to get stuck in that mindset as well. We can’t seem to get the pizza out of the pan and into a cup.

Levinovitz mentions that some patients with COVID-19 Long Haul Syndrome have symptoms similar to another syndrome which had been linked to somatoform illness, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). There is a great deal of information about it on the CDC website although the cause is still unknown. The CDC language treads very carefully on the issues of causation and treatment—and manage to draw a sort of dotted-line link between ME/CFS and COVID-19. It’s the same old pan.

Levinovitz also mentions Postural Orthostatic Tachycardia Syndrome (POTS), another poorly understood syndrome. I remember presenting a Grand Rounds about a patient with this POTS to my colleagues in the Psychiatry Department when I was an Assistant Professor. I invited the cardiologist who consulted me about the issue in one of his patients—who he suspected of having anxiety as the primary issue. Years later, I was consulted by another doctor about a different patient who definitely had abnormal test results (Tilt Table) consistent with POTS, did not suffer from anxiety, yet still thought psychiatry might have something to offer. The patient was puzzled but polite about why a psychiatrist was consulted. Pizza in the pan.

It’s very difficult for physicians to convey, in all humility, “I don’t know, but I still care.” The reasons why are complicated. The push for medical certainty, the packed medical clinic schedules, the limited time to spend with patients. It’s easy to say we must reimagine the way we practice medicine. It’s very hard to do. It’s a lot harder than reimagining the path from pizza in the traditional pan to pizza in a cup.

Unmasked Means Fully Vaccinated?

We were on our way home yesterday and drove by a couple of restaurants (Wig & Pen Pizza and Vine Tavern and Eatery) with crowded parking lots. We have not seen that since the COVID-19 pandemic hit a year ago. This seemed to coincide with the CDC announcement of the new mask guidance indicating you can ditch the mask both outdoors and indoors—if you’re fully vaccinated. The updated guideline was a little hard to find on the CDC website, I noticed. It didn’t jump right out at you like the update on the pause of the Johnson & Johnson vaccine.

I checked the websites for both restaurants. They still say you have to wear masks. Pretty soon after that CDC update, news headlines appeared which provoked a few questions. How do you tell the difference between unmasked and masked persons who say they’re fully vaccinated? One headline said something like, “Get vaccinated or keep wearing your mask.”

And I saw a new term today, “vaccine bouncers.” Nobody wants to be a vaccine bouncer. In other words, since you can’t tell by looking at somebody if they’re fully vaccinated, how are you going to confirm the vaccination status of anyone? I don’t think there’s a lot of confidence in the ability to reliably detect the Pinocchio effect. And, regrettably, vaccination cards can be faked.

Some of us are vaccine hesitant. And some of us are unmask hesitant. Even though Sena and I are fully vaccinated, we still tend to wear masks indoors for now. And to be fair, the CDC guidelines stipulate that you should abide by local rules on wearing masks if required by public transportation and stores. But those guidelines are rapidly changing, maybe a little too rapidly for those who paid attention to daily scary news about upticks in coronavirus death rates when people sing too loud.

I feel like telling us to ditch the masks might be another way of offering an incentive to get vaccinated. Most of us hate masks. They’re hot, confining, make us feel too stifled to breathe easily, and so on. On the other hand, getting infected with COVID-19 is the ultimate respiration suppressor. As a recently retired general hospital psychiatric consultant, I’ve been called to critical care units to help manage anxiety in patients bucking respirators, which means they were fighting the ventilator tube. I didn’t have a whole lot to offer.

I think incentives are better than mandates, though (don’t spend it all in one place!). The best incentive is doing something to help all of us recover from the pandemic.

Foreign Accent Syndrome and the Brain

By now I’m sure you’ve seen the news story about the Australian woman who developed an Irish accent about 10 days after she underwent surgery on her tonsils. This seems to be one of those cases of Foreign Accent Syndrome (FAS), which she thinks she might have. Before I retired from my role as a general hospital psychiatric consultant, I never saw a case of FAS.

You can find the University of Texas at Dallas website on FAS, where you learn more about the condition. It’s a very rare speech disorder which usually develops suddenly, causing a native speaker to speak in a “foreign” accent. It can be caused by a brain injury, such as a stroke. The prevailing opinion of neurologists and speech therapists is that most people who have FAS don’t actually speak with a sustained, well-defined foreign accent per se. In fact, they can sound like they have different accents at different times. It’s sort of all in the ears of the beholder, so to speak (pun intended).

What makes FAS even more complicated and interesting is that it can develop in the absence of any clearly identifiable medical cause. It can be a psychogenic disorder, a term which can lead to an immediate backlash from those who have been diagnosed by neurologists and primary care physicians with something called Functional Neurological Disorder (FND)—a relatively new name. It’s intended to be less stigmatizing than other psychiatric diagnoses such as conversion disorder and somatic symptom disorder. As I mentioned above, I’d never encountered a case of FAS, but neurologists and a lot of other colleagues in medicine and surgery consulted me to evaluate their hospitalized patients for other types of FND. Most commonly they were having multiple medically unexplained symptoms including but not limited to hemiparesis or hemisensory loss or spells which mimicked seizures but which didn’t produce abnormal EEG patterns. This was always a challenge, starting from the point of introducing myself as a psychiatric consultant. The patient’s reaction was often that of annoyance because their impression was that their doctors thought they were crazy simply because they called me in on the case.

I always began the evaluation by doing a thorough review of the patient’s medical record, which was often very long and complicated, involving notes from many specialists, many medical tests including surgeries and other invasive procedures, and long medication lists. I listened to their description of their medical problems first, which often included a lot of complaints against doctors who almost invariably were described as invalidating or incompetent or both.

I usually avoided any attempt to convince them their main issues were psychiatric in nature. I ran across one web site which reminded me how counterproductive that approach can be. Occasionally I could connect with someone by simply validating the difficulties they had suffered with all aspects of the health care system. I would ask, “Has a doctor ever implied you were a hypochondriac?” and “Have you ever run into doctors who just didn’t listen?”

Depending on whether the patient and I had developed adequate rapport, I might say that I thought the problem was in their body and that the mind is a part of the body, especially since the mind is connected with the brain. I would also say that patients are entitled to excellent health care and this should be delivered safely, avoiding potentially dangerous and toxic treatments whenever possible.

Because I frequently had to enter a diagnosis of a somatoform disorder in the patient’s chart (which they would eventually see), I would talk to them about somatoform disorder, emphasizing that the root of the word is “soma” which just means body, after all. I would sometimes suggest to patients who abrupt onset of medically unexplained neurologic symptoms, especially those which appeared to be temporally linked to a stressful event (formerly conversion disorder and now FND), I would suggest that the problem would eventually resolve on its own. I couldn’t make up billing codes and I couldn’t please everybody. I discussed cognitive behavioral therapy (CBT), since it was the most well-validated psychotherapy in this context at the time. Many patients were not interested in coming to our clinic for therapy, could not travel the long distance, but accepted a handout about CBT which contained a weblink for FND.

Some patients with FAS are accused of faking the speech problem, but they are not. Any psychiatric consultant who has years of experience will tell you that it’s not accurate to say there aren’t any patients who fake medical and mental illness. There are those who have a rare and controversial problem called Factitious Disorder imposed on self. They fake medical and mental illness in themselves and lie about it to health care professionals. There are others who victimize children and dependent adults by manufacturing illness in them, lie about that to health care professionals and that’s called Factitious Disorder imposed on another. The motivation for this behavior is complex and not well understood. This used to be called Munchausen’s Syndrome or Munchausen’s Syndrome by proxy. Furthermore, there are those who malinger, which is feigning illness for secondary gain, such as avoiding jail or getting disability. Malingering is not a psychiatric diagnosis per se. Both Factitious Disorder and malingering are frequently associated with personality disorders.

That said, anyone exhibiting FAS should get a thorough neurologic workup including but not limited to brain imaging and neuropsychological testing. One of the most interesting early cases involved a Norwegian woman who was hit by shrapnel by German bombers during World War II. She suffered severe left hemisphere brain injury (where the speech control center is located in most people) and began to speak with a German-like accent, which led to her being ostracized in her community.

Another fascinating fact is that sometimes FAS patients can correct or at least modify the speech problem simply by singing or by thinking about what they’re going to say before saying it. In some persons, FAS might resolve spontaneously without specific intervention in weeks or months. Speech therapy is often recommended. For those who exhibit FAS in the context of a mental illness like schizophrenia or depression, exacerbations of which can sometimes be linked to FAS, focused psychiatric treatment should be offered.

You can learn more about FAS and FND at the National Neuroscience Curriculum Initiative (NNCI) website. Registration is free and all you need is a login username and password to access many interesting and informative educational modules.

Selected References:

McWhirter L, Miller N, Campbell C, et al Understanding foreign accent syndrome. Journal of Neurology, Neurosurgery & Psychiatry 2019;90:1265-1269.

Keulen S, Verhoeven J, De Witte E, De Page L, Bastiaanse R, Mariën P. Foreign Accent Syndrome As a Psychogenic Disorder: A Review. Front Hum Neurosci. 2016; 10:168. Published 2016 Apr 27. doi:10.3389/fnhum.2016.00168

Indrit Bègue, Caitlin Adams, Jon Stone, David L. Perez, Structural alterations in functional neurological disorder and related conditions: a software and hardware problem? NeuroImage: Clinical,Volume 22, 2019,101798, ISSN 2213-1582, https://doi.org/10.1016/j.nicl.2019.101798. (https://www.sciencedirect.com/science/article/pii/S2213158219301482)

Aliens Dancing on Remote Controls and Other Causes of Anxiety

I was watching a TV show about UFOs and aliens the other night when I heard my remote control make clicking noises all by itself. Nothing happened on the set; neither the volume nor the channels changed. This has been happening for months and I usually just ignore it. Maybe it was because of the program I was watching. Get this, hundreds of people witnessed UFOs one night several years ago, even called the local radio station about it—yet no one took a single picture or video.

Before you tell me to adjust the gain on my tin foil hat, let me just say I’ve never seen aliens or UFOs—or Bigfoot. But the night I heard the remote control click away by itself, I got off the couch and searched the internet. It turns out I’m not the only one who has ever experienced this. However, Sena has never heard it.

Obviously, I’m not that anxious about it, but I’m curious. I also found an article on the web about alkaline batteries that pop, hiss, whistle Dixie, etc., especially when they go bad and leak.

I checked the batteries (the remote control takes two alkaline AAs) and noticed they were a brand we’d never bought before Universal Electronics (UEI). They have a website, which didn’t look suspicious. Where did we get them and how did they get into the TV remote control? They don’t have an expiration date on them. They’re made in China, which doesn’t bother me. They looked OK, but I replaced them with Ray-O-Vac batteries yesterday and I’m going to wait and see what happens. Maybe it clicked once on its own last night, but I was napping part of the time and watching Men in Black too. In fact, the remote control is on the table next to me as I’m writing this.

But you know, I can see how this might make other people anxious. This kind of anxiety might fuel the development of conspiracy theories in one person. Somebody else might think about poltergeist activity or interference by aliens practicing interdimensional moon-walking or making you order onion rings when you really want French fries.

It got me thinking about how anxious people can be about getting the COVID-19 vaccine. About a month ago, there were news reports of people having puzzling episodes of fainting, breathlessness, sweating, and other symptoms after getting one of the vaccines. The CDC investigated it and discovered that most of those vaccinated had experienced similar reactions in the past after getting vaccination shots. The upshot of it was they were having anxiety attacks, some of which were in the context of needle phobia.

Shortly after that, I noticed there were more internet articles about needle phobia (trypanophobia) which might be part of the cause of recent vaccine hesitancy. There’s a lot of reassurance and advice out there now about the whole thing. There is even a beer commercial (“your cousin from Boston gets vaccinated”) about a guy fainting when he sees the needle.

I suppose you could try using a Neuralyzer, which was used in all the Men in Black movies. You could flash someone in line for the vaccine who is showing signs of anxiety about getting the shot. The idea is to erase his memory of being needle phobic and replace it with a new one (You love getting vaccines!). You can find a slew of DIY projects on line to make one of your own. Several include 3-D printers, which on average can set you back about $700. You have to know how to use a soldering iron (amongst other skills). I flunked soldering in grade school when I soldered my ear lobe to a tin foil hat, back when they were actually made of tin before the switch to aluminum.

There’s just one problem with Neuralyzers—they don’t actually work. And by the way, tin foil hats can backfire, making it easier for the government to keep tabs on you at certain frequencies. Making tin foil hats is a waste of Reynolds Wrap.

There is some helpful guidance for how to cope with needle phobia, which by the way occurs even in some health care professionals. We’ll get through this somehow. There has not been a peep out of my remote control the whole time I was writing this post.

Get the Pink Flamingo

Sena bought a yard ornament. No, it was not a pink flamingo. It’s a Fiery Metal Kinetic Dual Spinning Garden Stake (FMKDSGS). A name like that and right away you know it’s going to be one of those products requiring owner assembly and your skills and patience will be tested. Take my advice and get the pink flamingo.

Our skills were sorely tested, mainly because the product arrived with puzzling and missing instructions and what looked like extra parts. It’s from the Alpine Corporation, a wholesaler based in The City of Commerce, California although the box label clearly says the product was made in China. I usually have pretty good luck with products manufactured in China, but not this time.

The Owner’s Manual does not include a picture showing all the parts needed for assembly, for some reason. On page 2 there are pictures of the rear and front spinners, the stake parts, a connector, and a cap nut. However, there are no pictures for the two sets of nuts, what I think might be some kind of spacers or bearings, and covers that arrived with the product. There are no instructions for what to do with them. The post was crooked because the sections didn’t screw in straight.

I found a pdf of the Owner’s Manual on line, but it had all the same flaws as the original. I couldn’t find a YouTube video about assembly. I tried installing the nuts, bearings, and little covers where I thought they should go, but often the spinners refused to spin and the connector would come loose. It would only sort of work without wiggling apart when I put the spacer/bearing piece on the threaded top section of the pole or connector first, then slipped the cover over the spacer bearing, and twisted the nut over that.

At times, I half-expected little gray aliens would manifest from the spinners (could be some kind of vortex wormhole) and laugh at me.

The product is sold under slightly different names by on-line retailers. I could not find anything about FMKDSGS at the corporate Alpine web site. The Alpine contact form spelled one retailer’s name (Menards) wrong (“Mernards”). It’s not BBB accredited but there are a couple of complaints about customer service and work environment.

I tried different ways to connect the mystery parts to the two spinners. I got pretty frustrated, which was echoed by a couple of reviews by other Amazon customers who complained about missing instructions and being forced into trial and error problem-solving. We didn’t see those reviews before buying the product.

After a lot of trial and error, I thought I made the thing work.  I still didn’t know if it was put together right, though. Both spinners spun although the front spinner often stalled. It didn’t immediately fall apart when it was stuck in the ground and took the breeze. However, we were not confident it wouldn’t collapse in the near future—so we returned it to the store.

Pink flamingos don’t look that bad.

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