Category: Covid-19

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.

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.

Catatonia: Another Reason to Get the COVID-19 Vaccine

My wife and I have been immunized against COVID-19 and we recognize that people can be hesitant about getting vaccinated. However, I’m remembering my last few months prior to my retirement a year ago working as a general hospital psychiatric consultant and I saw one or two cases of catatonia in the context of COVID-19 infections.

Catatonia is a complex, potentially lethal neuropsychiatric complication of many medical disorders including COVID-19. It can make a person mute and immobile, often making health care professionals mistake it for primary psychiatric illness (for example, catatonic schizophrenia). You can access a fascinating educational module on the National Neuroscience Curriculum Initiative (NNCI) website about catatonia and how it can be associated with COVID-19.

Catatonia can kill people, rendering them unable to move or eat, leading to blood clots and dehydration among a host of other complications. You’ve seen the news stories about blood clots being an extremely rare but deadly side effect of the Johnson & Johnson COVID-19 vaccine. The risk for blood clots is actually higher from COVID-19 infection itself compared with the very low risk from the vaccine.

I made a YouTube video about catatonia and other neuropsychiatric emergencies and that presentation continues to be viewed fairly often. You’ll want to crank up the volume.

I wrote a blog post about catatonia in the setting of delirium a couple of years ago and the information in it is still relevant below.

Catatonic patients may have a fever and muscular rigidity that leads to the release of an enzyme associated with muscle tissue breakdown called creatine kinase (CK). The level of CK can be elevated and detectable on a lab test.

Many patients will have a fast heart rate and fluctuating blood pressure. They may sweat profusely which can lead to a sort of greasy facial appearance. They may have a reduced eye blink rate or seem not to blink at all. They may display facial grimacing.

The patient may exhibit the “psychological pillow” (some call this the “pillow sign”). While lying in bed, the patient holds his head off the pillow with the neck flexed at what looks like an extremely uncomfortable angle. The position, like other odd, awkward postures can be held for hours.

Catatonia can be caused by both psychiatric and medical disorders. It tends to be more common in bipolar disorder than in schizophrenia even though catatonia has historically been associated with schizophrenia as a subtype. You can also see it in encephalitis, liver failure, and in some forms of epilepsy and other medical conditions—to which we can now add COVID-19 infection.

The patient may perseverate or repeat certain words no matter what questions you ask. He may simply echo what you say to him and that’s called “echolalia”.

Although catatonic stupor is what you usually see, less commonly you can see catatonic excitement, which is constant or intermittent purposeless motor activity.

The usual way to assess catatonic stupor in order to distinguish it from hypoactive delirium is to administer Lorazepam intravenously, usually 1 to 2 milligrams. A positive test for catatonic stupor is a quick and sometimes miraculous awakening as the patient returns to more normal animation. The reaction is usually not sustained and the treatment of choice is electroconvulsive therapy (ECT), which can be life-saving because the consequence of untreated catatonia can be death due to such causes as dehydration and pulmonary emboli.

Another less invasive test that doesn’t use medicine is the “telephone effect” described in the 1980s by a neurologist, C. Miller Fisher. It was used to temporarily reverse abulia or akinetic mutism, which in a subset of cases of stupor are probably the neurologist’s terms for catatonia. Sometimes the mute patient suffering from abulia can be tricked into talking by calling him on the telephone. It’s pretty impressive when a patient who is mute in person answers questions by simply calling him up on the telephone just outside his hospital room. 

So that, in my opinion, is yet another reason to get the COVID-19 vaccine.

FDA and CDC Lift Pause on J&J COVID-19 Vaccine

After a safety review today, the FDA and CDC lifted the pause on the Johnson & Johnson COVID-19 vaccine. See the full announcement on the FDA website.

Virtual Information Sessions On Covid-19 Vaccines Update

Just some quick thoughts on the Virtual Information Session on COVID-19 Vaccines, Session 2 on 4/19/2021. This was another enlightening presentation. I just noticed that you’ll have to scrub forward to about 10 minutes and 30 seconds to start playback on the YouTube recording. This gap might be edited out in the near future.

It’s worth noting that the risk for getting blood clots from COVID-19 infection is greater than the risk for getting them from the vaccines, according to Dr. Pat Winokur, University of Iowa and Dr. Caitlin Pedati, IDPH. There were other educational answers to very good questions from the audience.

Don’t forget the third session on Saturday, 4/24/2021 at 10:00 a.m. in Spanish only for the YouTube event while the WebEx event will be a bilingual event. See this link for full details.