September 2023 – Page 2 – Go Retire Psychiatrist

The Trouble with HOAs According to the X-Files

I just recently saw an old rerun of the X-Files episode, Arcadia. The Wikipedia spoiler link is here, but I’m going to talk about it anyway. Arcadia in Greek mythology was the home of the gods, Hermes and Pan. In the X-Files episode, though, it’s more like one of the deepest circles of Hell in Dante’s Inferno.

I think I saw this one in 1999, but I can’t be sure. I did vaguely recognize the fake names Mulder and Scully assumed when they investigated the Home Owners Association (HOA) cursed neighborhood to investigate disappearances of 3 residents. The fake names were Rob and Laura Petrie. Remember the Dick Van Dyke show about a cute, lovable, wacky married couple? You don’t? Shame on you!

The idea of the show’s nightmarish depiction of horrible HOAs was taken from the real-life experience of the guy who wrote the script. He arrived late in the evening to move in to his new house in the HOA—which fined him $1,000 for the offense of moving too late in the day. No kidding, this really happened to the poor guy.

Anyway, if you don’t mind your p’s and q’s in this neighborhood, a giant garbage goblin rises out of the yard and tears you limb from limb. Sound like fun?

Don’t put pink flamingos in your garden and definitely don’t put a basketball hoop in your driveway.

By now, those of you who have ever lived in an HOA know what this episode is driving at. We’ve lived in a couple of them and we didn’t care for the concept.

If you’ve never lived in an HOA, then you’re not just lucky. You’re probably part of a minority in this country because the HOA concept has been embraced by a growing number of Americans since the 1960s. I frequently see horrible news headlines about them in which people who don’t obey all the little rules get fined or worse. Often, the main recommendation by some experts is to take the HOA to court.

And maybe you’ll get a visit from the garbage goblin.

COVID-19 in the Rearview Mirror?

One way to think about the Covid-19 pandemic can be that it’s in our rearview mirror, which is one way of saying it’s behind us now.

On the other hand, another way to think about it is that COVID-19 is in our rearview mirror because it’s tailing us.

So, we can’t keep staring in the rearview mirror because that’s not a safe way to drive. We can look forward and drive, paying attention to the signs, which guide us on how to stay ahead of and outrun another pandemic.

One way to do that is to bookmark the CDC COVID-19 web site.

A Short Review of Dixie Paper Coffee Cups

Sena bought some Dixie coffee cups the other day. They don’t contain polystyrene foam, which is what Styrofoam cups are made of. Dixie cups are made from paper with a polyethylene coating and contain 80% cellulose fiber by weight, according to the Dixie company website. On the other hand, many recycling centers won’t take paper cups because they have a coating on the inside of the cup to hold liquids and prevent leaks. So, recycling centers won’t take Styrofoam or Dixie cups. They both have to go to the landfill.

So, are Dixie cups more environmentally friendly or not?

I’m not sure. I know they transmit the heat of hot coffee to the outside of the cup. That means I have to double cup my coffee. I stick the hot coffee cup inside of another paper cup so that I can hold it without burning my fingers.

Dixie does make a “perfect touch” insulated paper cup which is made with air bubbles. I tossed the plastic package containing the cups in the garbage and didn’t find out until later that Dixie makes insulated cups.

The reviews on the web are generally positive and I couldn’t find any stores on the web that didn’t sell non-insulated cups. I found a few reviews advising caution about the insulation not being effective and that the cups could get too hot to handle. They’re also not recyclable at every center because they contain food residue.

And we found out that the coffee temperature gets to 160-180 degrees in the Dixie cup after brewing in the Keurig machine, which makes it comparable to the double wall glass mug. The difference is that I can hold the glass mug without fear of burning my fingers.

There are times when paper cups are handy. They’re great on picnics when you don’t want to use your fancy dishes. They’re also helpful for keeping your hands warm when you’re drinking coffee or hot chocolate outside in the brisk fall weather. But I would need gloves anyway.

Phenylephrine Spelled Backwards is Enirhpelynbehp

News headlines are screaming about class action lawsuits being filed against drug companies selling the oral form of a nasal decongestant that the FDA says doesn’t work. It’s called phenylephrine. Phenylephrine has been around since the early 1970s and it’s a common ingredient in over-the-counter (OTC) cold remedies found in grocery stores in the medicine aisle.

The FDA advisory committee met on September 11-12, 2023 about phenylephrine-containing oral products and there is a clarification of the FDA committee’s decision to identify them as ineffective that was posted on September 14, 2023.

A common OTC containing the agent is Sudafed PE. The Equate version of it is Suphedrine PE, which is cheaper. The name capitalizes on its similarity to the name Sudafed, which is pseudoephedrine—which is an effective oral agent for relieving nasal congestion. The problem with it is that it’s been behind-the-counter since 2006 because it can be used in the manufacture of methamphetamine.

Sena bought a box of Suphedrine PE the other day because she caught a head cold. She thinks it’s helplful.

I took a quick look at a few of the presentations of the FDA Advisory Committee meeting. Mainly I just noted the last slide of the FDA presentation, which said that recent studies showed phenylephrine 10 mg was not significantly different from placebo.

Another presentation showed that a large consumer survey indicated that Americans rely on phenylephrine and thought it was an effective nasal decongestant.

This reminded me of Serutan, which is just Nature’s spelled backwards. Serutan was not a placebo; it was a fiber-based laxative, but a lot of people made fun of it. But that, in turn, reminded me of Geritol, which was sold as a tonic a long time ago and which, for a while, was thought by many people to help women get pregnant. Who knows? Maybe some people still believe that, although even the manufacturer disputes the claim.

On the other hand, this in turn reminded me of a medication called Obecalp. You can find many web entries about Obecalp, which is just “placebo” spelled backwards. Some physicians may still be prescribing Obecalp (placebos don’t always have to be pills). In general, the opinion about the ethics of the practice is expressed in a recent paper (Linde K, Atmann O, Meissner K, Schneider A, Meister R, Kriston L, Werner C. How often do general practitioners use placebos and non-specific interventions? Systematic review and meta-analysis of surveys. PLoS One. 2018 Aug 24;13(8):e0202211. doi: 10.1371/journal.pone.0202211. PMID: 30142199; PMCID: PMC6108457.):

“Although the use of placebo interventions outside clinical trials without full informed consent is generally considered unethical [1–3], surveys in various countries show that many physicians prescribe “placebos” in routine clinical practice [4–7].”

There’s actually a fairly large body of research about placebo effects. One really long paper has interesting conclusions and key points (Wager TD, Atlas LY. The neuroscience of placebo effects: connecting context, learning and health. Nat Rev Neurosci. 2015 Jul;16(7):403-18. doi: 10.1038/nrn3976. PMID: 26087681; PMCID: PMC6013051.):

Conclusions:

A substantial part of the therapeutic benefit patients experience when undergoing medical treatment is caused by their brain’s response to the treatment context. Laboratory investigations of placebo effects provide a way of examining the brain mechanisms underlying these effects. Consistent findings across studies include reduced activity in brain areas associated with pain and negative emotion, and increased activity in fronto–striatal–brainstem circuits. In most cases, the creation of robust placebo effects across disorders and outcomes seems to require appropriate conceptual beliefs — maintained in prefrontal cortical networks — that are supported by experience-dependent learning in striatal and brainstem circuits. However, the critical ingredients for eliciting placebo effects, at both the psychological and brain level, are just beginning to be understood. These ingredients may differ substantially depending on whether the outcomes are symptoms, behaviours or changes in physiology. A better understanding of the neuroscience of placebo could yield rich benefits for both neuroscience and human health.

Key Points:

Placebo effects are effects of the context surrounding medical treatment. They can have meaningfully large impacts on clinical, physiological and brain outcomes.
Effects of placebo treatments are consistent across studies from different laboratories. These effects include reduced activity in brain areas associated with pain and negative emotion, and increased activity in the lateral and medial prefrontal cortex, ventral striatum and brainstem.
Placebo effects in pain, Parkinson disease, depression and emotion are enabled by engagement of common prefrontal–subcortical motivational systems, but the similarity across domains in the way these systems are engaged has not been directly tested.
Meaningfully large placebo effects are likely to require a mixture of both conceptual belief in the placebo and prior experiences of treatment benefit, which engage brain learning processes.
In some cases, placebo effects are self-reinforcing, suggesting that they change symptoms in a way that precludes extinction. The mechanisms that drive these effects remain to be uncovered, but doing so could have profound translational implications.

I will probably catch Sena’s head cold. By the way, Phenylephrine spelled backwards is enirhpelynehp.

The Cat is Literally Littering the Litterbox with Her Litter

Is it OK to say that using the word “literally” for emphasis bugs me—a little? I don’t get enraged and break furniture when I hear it, but it does sound wrong. I get over it in a couple of days, literally without taking any hard drugs.

The problem is that some dictionaries say we can use “literally” as an intensifier, like “really” or even “virtually”. I won’t mention which dictionaries (MERRIAM-WEBSTER CAN YOU BELIEVE IT? GOOD GAAWD ALMIGHTEEE!).

But the on-line version of Merriam-Webster almost apologizes for the extension of the use of “literally” (they call it Sense 2): “Sense 2 is common and not at all new but has been frequently criticized as an illogical misuse. It is pure hyperbole intended to gain emphasis, but it often appears in contexts where no additional emphasis is necessary.”

It then goes on at length with examples of the so-called misuse, almost as if to justify the practice.

I admit I’m literally no angel when it comes to writing. I break all kinds of rules. I used to write “begs the question” when I actually meant “raises the question.” The whole begging the question thing actually got started with Aristotle and his thoughts on circular reasoning. He was always causing problems like that.

Anyway, people get on rants about using the word “literally” in the original sense (exact equivalence) as opposed to using in the idiotic and totally wrong way of expressing emphasis.

Throw down dude, you literally can’t use the word “literally” that way!

You can find articles on the web which literally make fun of those who use the word “literally” as though they had cat litter for brains. Some experts think they’ve trounced the “literally” lovers by saying that the use of the word for emphasis has been around since the 17^th century.

Some might reply “That may be true, but you are literally barking mad!”

I literally cringe whenever I hear the word “literally” because I know it’s not going to be used in the way I expect. No kidding, if you were in the room with me whenever that word is used as an intensifier by someone, you would literally see me cringing.

I am literally done with this subject for now.

Striking a Blow for Science with the Coffee Temperature Experiment!

We got our new thermometer the other day and did a coffee cup temperature test. It’s certified by the National Sanitation Foundation (NSF), but we’re not sure where it was manufactured. The instruction sheet looks like it was translated into English.

First, we measured the temperature of coffee in different cups. We measured the temperature of coffee in a double wall glass mug and compared it with the temperature of coffee in a stoneware mug. Stoneware is a type of ceramic.

Right after brewing, the coffee in the double wall glass mug was around 180 degrees. In the stoneware mug, the coffee temperature was around 160 degrees. After 5 minutes the temperature dropped by about 20 degrees in both mugs. Not a big surprise to learn that the double wall glass mug kept coffee hotter.

In fact, I previously noticed when I drank coffee from the stoneware mug last week, it was less hot right after brewing.

Sena wanted to test the Keurig machine to see if the preference setting for making coffee hotter actually worked. In fact, there was no difference in the coffee temperature in either the glass or the stoneware mug after setting the temperature higher.

We then tested the claim of the makers of our old Black & Decker coffee maker that preheating the carafe with hot water actually kept coffee hotter. We were a little surprised that it seemed to work for the stoneware mug, but not for the double wall glass mug.

Just in the interest of full disclosure, we used plain water for the last two experiments. We didn’t think getting buzzed out on coffee was a worthwhile sacrifice in the name of science.

So, the takeaways from this experiment:

The preference setting for temperature adjustment on the Keurig may not be all it’s cracked up to be.
The stoneware mug didn’t keep coffee as hot as the double wall glass mug in either the Keurig or the Black & Decker model.
The stoneware mug seemed to stay hotter when we pre-warmed the carafe on the Black & Decker coffee maker by filling it with hot water before brewing. Be sure you empty out the hot water first.

If you don’t mind sacrificing hot temperature for looks, then go with stoneware mugs. I guess some male reviewers said things like, “Now there’s a man’s coffee mug! I guess maybe that’s because they’re broader than they are tall—I mean the mugs, not the men (although I don’t know if they sent photos of themselves).

By the way, extraterrestrials are not intimidated by a thermometer.

Stop Me If You Heard This One Before

I saw one of my favorite X-Files episodes the other night. It’s titled “Monday.” Mulder goes through the day repetitively doing the same things, including fumbling his chance to thwart a bank robber who blows up the bank and everyone in it, including Mulder. See the Wikipedia for a full spoiler alert but I’m going to spill the beans here anyway.

A lot of people think the idea was stolen from the movie “Groundhog Day,” which I’ve never seen. Actually, it was stolen from a Twilight Zone episode called “Shadow Play,” which I have seen.

“Monday” got good reviews overall, which is saying a lot. I never got the part about how a bank robber (Bernard) who can only land a job mopping floors would be smart enough to build a bomb jacket.

That said, the scenes are mostly everybody going through the day doing the same things over and over. Mulder and Scully both meet Bernard and his girlfriend Pam, who was always waiting outside in the getaway car and is the only one who remembers what has happened each and every time, which is about 50. Pam thinks Mulder is the key to disrupting the endless cycle. She has been trying to get Mulder to change what he does every time he walks in the bank just to cash a check and interrupts Bernard in the process of robbing the bank.

Mulder never gets it right away, but does wonder aloud that he’s getting a sense of déjà vu. Déjà vu is the sense that an experience is something you had before but could not have. The medial temporal cortex triggers the false memory and, normally, the frontal lobe says, “No, this is not a memory.”

Eventually, Mulder gets the idea of repeating to himself over and over that Bernard has a bomb and changes his approach by giving his gun to Bernard and telling him he knows he has a bomb. This approach is based on the assumption Bernard will walk out without setting off the bomb because Mulder will let him go without trying to arrest him.

Then, Scully brings Pam into the bank, and Bernard almost surrenders to Mulder, until he hears police sirens—and tries to shoot Mulder but instead kills Pam because she steps into the path of the bullet. He gives up and doesn’t set off the bomb. Pam changed the ending and notices just before she dies that it never happened in any of the previous enactments.

There’s the brain-based definition of déjà vu and then there’s a more mundane definition, both of which are in the Merriam-Webster dictionary on the web. The mundane definition is “something overly or unpleasantly familiar,” mainly about situations that happen repeatedly (“here we go again”).

We all recognize the second definition. We sometimes say or do something which we would not if we just recognized that it’ll trigger a pattern of events we would like to avoid. Something has to change in order to interrupt the pattern.

Psychiatrists and psychotherapists are usually experts in helping people change repetitive, maladaptive patterns of thought and behavior.

Medications can be helpful, for example in the repetitious thoughts and behaviors of obsessive-compulsive disorder (OCD). Some cases of that may respond better to a combination of psychotherapy and medication.

One of the challenges is that there are not enough helpers to help those who need it. Another challenge is that the ones who need help often don’t recognize they need it. That’s called lack of insight.

The cycle of lack of insight and unpleasantly familiar, repetitive patterns sometimes resulting in explosive consequences is ubiquitous in our society.

Can somebody please bring Pam into the consulting room?

How to Find Covid-19 Vaccine Availability By County

I’m finding out that maybe the best way to learn what the local public health issues are concerning Covid-19 infections as well as vaccine availability are through the county public health agency in my area.

According to the Johnson County Public Health department, hospital admission rates in Johnson County currently low. I can search the map and see that admissions are rising in certain areas of Iowa.

I also learned that the new Covid-19 vaccine will more likely be available closer to the end of the month or early next month rather than in a few days as suggested by presenters at the CDC meeting on September 12, 2023.

The county public health agencies may not have the most current information. Johnson County’s last update as of yesterday was September 1, 2023.

You can also check local pharmacies for availability of the Covid-19 vaccine.

This is National Suicide Prevention Week

Thanks to Dr. H. Steven Moffic for his Psychiatric Times article, “A Psychological Autopsy on My Only Patient Who Died by Suicide.” In it he describes his own experience with a patient who committed suicide. He also reminded us that this is National Suicide Preven t ion Week. It’s also National Suicide Prevention Month.

The quote I’m familiar with about psychiatrists and patients who die by suicide Moffit is by forensic psychiatrist, Robert Simon:

“There are two kinds of psychiatrists—those who have had a patient die by suicide and those who will.”

I have been through that experience. It led me to focus on my role as an educator to psychiatry residents and other trainees to learn as much as I could about the process of suicide risk assessment.

On the other hand, my first experience with someone who died by suicide happened long before I became a psychiatrist. It was in the early 1970s and I was working for a consulting engineer company. I was just a kid, learning on the job to be a drafter and surveyor’s assistant.

One of my teachers was a man I would come to respect a great deal. Lyle was a land survey crew chief and part time photographer. He was gruff, but kind and had a great sense of humor. We all liked him.

He was so tough that, while perched high in a tree and trimming a large branch to enable a line of sight for the instrument man running a theodolite (used to measure vertical and horizontal angles)—he accidentally cut a significant gash in his hand. We on the ground were aghast because blood was dripping from his hand.

He just laughed and said, “I don’t sweat the small stuff.”

One day, he told me and another survey crew member that his girlfriend left him, saying she was tired of picking up after him. He was crying. We felt sorry for him and didn’t know what to say. We never saw him cry before. This image was strikingly different from the tough guy persona he usually had.

As I look back on it, I wondered why he didn’t think the breakup was just more “small stuff.”

The next day, one of the leaders of the company made a short announcement, saying that Lyle had “passed away,” the night before, by suicide. A little later, the rest of the story gradually emerged. Lyle had shot himself in the chest. One of the guys said that it took a long time for him to die, that somebody found him early the next morning, and all Lyle could say was “It hurts.” At first, I thought he meant physical pain. Later, I wondered if he meant physical and emotional pain.

About a week later, one of the survey crew members was planning to pick me up and drive us to Lyle’s funeral. He never showed up.

Of course, I could not have foreseen Lyle’s suicide based on his being so upset about a breakup with his girlfriend. I was just a kid.

When I became a psychiatrist, I saw this quite a lot. I learned, a few times the hard way, how to make the best judgments I could about what might happen to a patient describing physical and emotional pain.