Glitch in the Matrix or Something Else?

I saw one of the paranormal shows the other night and there were a few videos supposedly demonstrating possible proof that our reality is actually a computer simulation that sometimes gets glitchy.

One of the images was a bird stopped and motionless in mid-flight. It looked like a still photo which bounced around a little. Sure, the bird was motionless—but so was everything else.

The other two were actual videos and looked more interesting. One showed a large flock of sheep that were not moving much. There was an ear or tail flip here and there so they weren’t really motionless or “frozen.”

The other video showed a pretty interesting episode of what looked like what some would call tonic immobility in a squirrel. A person was hand-feeding the squirrel nuts and it suddenly froze for a short period of time and later just snapped out of it and acted normally. I wonder how a person got a wild squirrel to take food by hand.

Both the sheep flock and squirrel videos are available on the web. Some think the sheep become still because of a change in the weather, possibly rain. There was no explanation for the squirrel freezing.

Glitch in the matrix?

The squirrel might have been displaying tonic immobility, which can occur in certain animals. Probably the best-known example is the opossum. When it senses it’s in danger from a predator, it plays dead. There’s even a saying for this, “He’s just playing ‘possum!”

You can find the immobile squirrel story on the web by searching the term “catatonic squirrel.” In the article, the squirrel is called catatonic.

Catatonia is a complex neuropsychiatric condition in humans often marked by immobility and muteness. In a small percentage of cases, people can show purposeless agitation, or automatic, stereotyped motion.

In many cases, a small dose of benzodiazepine (usually injectable) can quickly reanimate a person who has catatonia, although the improvement is often only temporary. The usual course of treatment is to look for an underlying reversible medical or psychiatric cause and to apply effective treatment quickly, which can be life-saving.

Catatonia can lead to all kinds of complications because afflicted persons can’t eat or move. Some people who recover say that they felt extremely anxious or fearful during the catatonic episode.

Catatonia in humans is not the same thing as tonic immobility, a condition that is thought to be a survival mechanism in some prey animals in response to intense fear. If they “play dead”, a predator might not notice them or might let them go. But I can see why some people speculate there might be an evolutionary link between the two conditions.

These are interesting situations, but they aren’t evidence for a glitch in the matrix.

Overdiagnosis of Psychiatric Disorders Still Happens

I read an excellent article in Clinical Psychiatry News recently in the Hard Talk section. The title is “A prescription for de-diagnosing” by psychiatrists Nicholas Badre, MD and David Lehman, MD in the July 2022 issue (Vol 50, No. 7).

The bottom line is that too many psychiatric patients have too many psychiatric diagnoses. A lot of patients have conflicting diagnoses (both unipolar and bipolar affective disorder for example) and take many psychotropic medications which may be unnecessary and lead to side effects.

It takes time to get to know patients in order to ensure you’re not dropping diagnoses too quickly. Discussing them thoroughly in clinic or in the hospital is an excellent idea. And after getting to know patients as people, it makes sense to discuss reduction in polypharmacy, which can be quite a burden.

This reminds me of the Single Question in Delirium (SQiD), a test to diagnose delirium by simply asking a friend or family member of a patient whether their loved one seems to be more confused lately. It’s a pretty accurate test as it turns out.

This also reminds me of the difficulty in making an accurate diagnosis of bipolar disorder. I and a Chief Resident wrote an article for The Carlat Report in 2012 (TCPR, July / August 2012, Vol 10, Issue 8, “Is Bipolar Disorder Over-Diagnosed?”) which warned against overdiagnosis of bipolar disorder. Excerpts below:

Some argue that bipolar disorder is actually under-diagnosed. They have support from abundant literature showing that bipolar disorder tends to present more often with depression than mania or hypomania (Judd LL et al, Arch Gen Psychiatry 2002:59(6):530–537). As many as 10% of patients with unipolar depression ultimately are shown to have bipolar illness instead, according to some experts (Goodwin GM et al, Eur Neuropsychopharm 2008:18(7):535–549). (See this month’s Q&A with Claudia Baldassano for more on this.) In addition, a new emphasis on subthreshold mood symptoms and more rapid mood shifts has led some psychiatrists to promote the concept of a “bipolar spectrum disorder” (Youngstrom EA et al, Curr Psychiatry Rep 2010;12(6):479–489).

While it’s important to remain vigilant about a history of manic and hypomanic symptoms, we think the problem of over-diagnosis is probably greater. For instance, in a 2008 study, Zimmerman and colleagues performed a comprehensive diagnostic interview on 700 patients, nearly 21% of who self-reported a history of “bipolar disorder.” However, when using the gold-standard SCID (structured clinical interview), only 13% had the diagnosis; they also had more first-degree relatives with bipolar disorder than the others (Zimmerman M, Ruggero CJ et al, J Clin Psychiatry 2008:69(6):935–940). The authors hypothesized that over-diagnosis of bipolar disorder might be a consequence of efforts to improve recognition of it and avoid under-detection. In fact, the same authors studied 40 depressed patients previously diagnosed with bipolar disorder and found that, by the SCID, they had specific phobia, PTSD, drug abuse/dependence, or a personality disorder instead (Zimmerman M et al, Compr Psychiatry 2010;51(2):99–105).

Over-diagnosis can also occur when apparent mood episodes are defined as psychiatric when in fact, they have a different etiology altogether. Decreased need for sleep, disorganized or racing thoughts, increased activity and agitation, and delusional thinking, even when they occur together, can represent a sort of “final common pathway” for medical conditions and other syndromes. The manic phenotype can occur in patients with agitated delirium, brain tumors, corticosteroid treatment, and of course substance intoxication (Bunevicius A et al, CNS Spectr 2008;13(11):950–958; Brooks JO and Hoblyn JC, Am J Psychiatry 2005;162(11):2033–2038). These other phenotypes can be distinguished by recognition of key features such as the fluctuating nature of consciousness in delirium, neuroimaging findings, and positive urine drug screens.

Unfortunately, physicians may also be susceptible to diagnostic shortcuts. When faced with limited time for diagnostic interviews and the pressure to prescribe by patients and their families, well-meaning clinicians may give the diagnosis after a single brief interview. Not uncommonly, we find that it was diagnosed on the basis of mood fluctuation over minutes, temper tantrums, and fleeting insomnia. The rapidly expanding repertoire of medications approved for bipolar disorder, and their relative ease of use, may also contribute to over-diagnosis. Unfortunately, in some cases the treatment may be worse than the symptoms themselves (Iordache I and Low NC, J Psychiatry Neurosci 2010;35(3): E3–4).

I was accustomed to asking what I called the Single Question in Bipolar (SQiB). I frequently saw patients who said their psychiatrists had diagnosed them with bipolar disorder. I would ask them, “Can you tell me about your manic episodes?”

Often, they looked puzzled and replied, “What’s a manic episode?” I would describe the typical symptoms and they would deny ever having them.

The article by Drs. Badre and Lehman is a bit disappointing in that it doesn’t look as though we’ve improved our diagnostic acumen much in the last decade.

We need to try harder.

New 988 Suicide and Crisis Lifeline Starts Today!

The new 988 Suicide and Crisis Lifeline number is available starting today. Iowa is with the program and you can read more about it at the Iowa State University Extension and Outreach website.

You can also learn more at the 988 Lifeline web page.

Thoughts on the Song “Against the Wind”

A couple of days ago, while we were playing cribbage, Sena asked me who sang the song “Against the Wind.” I offered a name, which later turned out to be wildly wrong. It bugged her so much she got up from the cribbage game and went to the computer to look it up.

Of course, Bob Seger wrote the lyrics and sang it. She asked me what I thought it meant. I wasn’t sure at the time. I hadn’t thought about it for a really long time.

I read about it on the web. I didn’t know what the lyric “8 miles a minute” meant and found a forum message saying that it corresponds roughly to the speed of a cruising airliner which is about a “480 mph.” That’s technically more like 480 knots, which converts to about 550 mph.

Anyway, it’s really fast and might be a way of saying you’re moving through life at breakneck speed. In Seger’s case, it might have had a more concrete meaning, referring to flying all over from concert to concert.

The song was released in 1980, which was about the time we moved to Ames so I could go back to college at Iowa State University (ISU). It was a big change from working as a draftsman and land surveyor’s assistant in my hometown of Mason City.

If you extend the “against the wind” metaphor a little bit, Sena and I were both moving against the wind in terms of our place in society, income level, location and educational attainment. I thought I wanted to be an engineer at the time, mostly because I had worked for years for consulting engineers.

Backing up in time a little, I had done some undergraduate college work previously at an HBCU (historically black college/university), Huston-Tillotson College (now Huston-Tillotson University) in Austin, Texas in the mid-1970s.

That was also a kind of move against the wind. I grew up in Mason City, and often I was the only black kid in grade school. I got used to that, although the racism was more overt back then and it was difficult sometimes to bear up against that kind of wind. On the other hand, I felt like a fish out of water at H-TC. I just felt like I didn’t fit in. It was part of the reason I left Austin.

It was also challenging to fit in at ISU. I figured out quickly that I would never complete the engineering degree program. The math and hard science courses were tough from the beginning and only got harder. I realized I was going against the wind there.

So, I changed my major and settled on medical technology, which led to working in a hospital laboratory. But it took about a year to get a job after graduation. Looking back, It was a frustrating time and that really felt like pushing against a headwind. I don’t know what I would have done without Sena.

I finally got into medical school at the University of Iowa. Biostatistics and Biochemistry were brutal. I was very close to quitting before the 3rd year of clinical rotations. I doubted I was cut out to be a physician. I thought about going back to surveying. But I didn’t.

Many deadlines, commitments, and struggles leading to brief forays from academia into private practice led me to think of myself as more of a fireman or a cowboy than an academician. Yet I spent most of my career at the University of Iowa.

Now I’m retired. Sena is my shelter against the wind. I guess if you look hard enough, just about anybody can relate to Bob Seger’s song. Let the cowboys ride.

Thoughts on the GuideLink Center Incident

The attack a few days ago by what was most likely a mentally ill person on staff at the recently opened GuideLink Center in Iowa City reminded me of what may appear to be disparate views by mental health professionals on the link between mental illness and mass violence perpetrators.

The GuideLink incident involved a person who assaulted GuideLink staff and who also left bags containing incendiary devices at the center and another building in Iowa City. The person is being charged with terrorism and is currently in custody in the Johnson County Jail.

I have not seen information about any injuries sustained by the mental health center staff. There were no explosions or fires at either location where incendiary devices were left. Bomb squad experts removed the devices. It’s not clear whether the perpetrator had been a GuideLink Center client.

The GuideLink Center opened in February 2021 and by all reports is a welcome and very much needed crisis stabilization mental health resource in the community. The staff members are dedicated to their calling.

Dr. H. Steven Moffic, MD, a retired psychiatrist who writes for Psychiatric Times, readily says that the perpetrators sometimes do have mental illness that at least contributes to committing acts of mass violence. Dr. George Dawson, MD, another retired psychiatrist, seems to say that the major reason for mass shootings is the ready availability of guns, a culture of gun extremism, and mental illness accounts for a small proportion of acts of mass violence.

But neither Dr. Moffic nor Dr. Dawson say that it’s only either mental illness or guns (or other instrument of mass violence) that lead to acts of mass violence. Both are important.

I’m a third retired psychiatrist and by now some readers might be asking themselves whether they should listen to any retired psychiatrist. Experience counts.

Speaking for myself, as a general hospital psychiatric consultant I was frequently faced with violent patients in the general hospital. Often, I found it necessary to ask a judge for a court order to involuntarily hospitalize a violent and/or suicidal patient on a locked psychiatric unit by transfer from an open medical or postsurgical unit.

In order to obtain an order in the state of Iowa, I had to be able to state to the judge that the patient in question had a treatable mental disorder and was an acute threat to himself and/others. In most situations, I had an open bed on a locked psychiatric unit available ahead of time.

Even if a Code Green was necessary, I usually had an inpatient resource to which I could move the patient. A Code Green is a show of force or takedown maneuver by a specially trained team to control a violent patient while minimizing injury to everyone involved.

I don’t know if that kind of approach is even possible in a community crisis stabilization setting like the GuideLink Center. I think it’s fortunate that it partners with many other community resources including the Johnson County Sheriff’s Office.

The outcome of the incident at the GuideLink Center was that the overall safety of the staff, the patient, and the community was preserved. More resources like this are needed everywhere. They deserve all the support we can give them.

Invasion of the Pregnant Man Emojis!

I just saw a pretty funny story in the news about an old guy who was not allowed to donate blood at a Scotland blood bank because he refused to answer a new questionnaire asking whether or not he was pregnant.

I thought that was uproariously funny. Then I read the rest of the story and found another punchline: The director of the Scottish National Blood Transfusion Service defended the question on grounds of respect for inclusiveness. So, I had a good laugh about that one too.

I wonder if there could more than just a yes/no question about whether a guy is pregnant. We need space for an essay response: “No, but my 33-year-old son is living in our basement. Would you please adopt him?”

There are two other comical trends. One is providing tampon dispensers in men’s bathrooms. Another is the chuckle-provoking pregnant man emoji. What kind of email message would you use that for unless it’s a joke?

The issue is less farcical when you consider there is a rare psychiatric disorder known as delusion of pregnancy in men, otherwise known as Couvade syndrome. I never encountered it in my career as a psychiatric consultant in the general hospital.

And there is a psychiatric disorder known as pseudocyesis or delusional pregnancy as well as denial of pregnancy in women.

This reminds me of a fascinating episode from Blue Planet II in which David Attenborough filmed the transformation of a kobudai wrasse female fish into a male.

I gather some people are pretty angry about this exaggerated inclusivity trend. I’m not sure why.

We all need a good laugh whenever we can get it nowadays—as well as a fresh perspective.

Thoughts About Guns

I think there a lot better places to read about viewpoints on mass shootings than my blog. I recommend you check out Dr. George Dawson’s post “Gun Extremism Not Mental Illness,” posted on May 31, 2022, then read the editorial in Scientific American, “The Science is Clear: Gun Control Saves Lives,” posted on May 26, 2022.

I’m going to chime in mainly to show a few graphics I found which I think send a clear and simple message. Before I get to that, I just want to mention a few anecdotes to show how little hands-on experience I have with guns.

My earliest memory of any contact with firearms is in early childhood. My dad and a friend came home from a hunting trip with some rabbits for dinner for the family, which included my younger brother and my mother. I don’t know who cleaned or cooked them. I’m pretty sure my mom would not have had anything to do with them. I got my first taste and didn’t like it and said so to my dad. He introduced me to the word “gamey.” I didn’t know meat could taste gamey. The other thing I got from that meal was a mouthful of buckshot. I silently vowed I would never eat anything like it again while I lived.

My next encounter with guns was a YMCA program for kids to learn how to shoot. I might have been in my early teens, maybe even younger. We were given BB guns and instructed to do some target shooting. The paper bullseye targets were set up several yards away. I took many shots and collected my target to show the instructor.

I thought I hit it once and pointed to the hole. The instructor looked at it critically for a few seconds and then told me kindly that the hole was where the pin was stuck to fix the target to the wall. I never touched another gun.

Fast forward to when I was a third-year medical student getting through my clinical rotations at the University of Iowa. In 1991, a physics graduate student named Gang Lu shot and killed 6 people on campus including himself, wounded another rendering her paralyzed from the neck down, all apparently because he was not chosen to get an award for his dissertation. I remember feeling shocked when I read about it in the newspaper.

Now let’s move to some graphics I found at a website maintained by The University of Sydney, GunPolicydotorg, International firearm injury prevention and policy https://www.gunpolicy.org/. It makes it easy to put together comparison statistical graphics on things like gun violence. I compared the United States to New Zealand, Australia, and Canada. Click the next few links in order to get the message. In my opinion, I think the last one is a consequence of the first few.

First

Second

Third

Last

I guess now it’s up to Congress. God help us all.

Kickball Challenge in June!

The annual Kickball challenge between University of Iowa Department of Psychiatry Residents and Faculty is coming up in June. You know what that means.

Losers suspend the winners’ trophy in Jello. Somebody did that when we played Matball several years ago. If you need a recipe:

Matball was the forerunner of Kickball in the department. I think the Kickball rules are here. Federal law says you have to play in 95-degree heat with insane humidity driving the perceived temperature to slightly above that on the surface of the sun. Other rules:

If the ball melts, faculty wins.

For every point the residents score, faculty automatically score 5.

Faculty may tackle the base runner at any time.

If it rains, faculty win by 10 points.

The thing to do is to recruit Sasquatch for your side, who will always boot the ball into the next county. Bring many replacement balls. Sasquatch will bring the beef jerky.

The games are fun to watch. Residents jumping over faculty; Faculty collapsing from heat stroke.

I never played.

I’m trying to recall whether faculty ever won a game. I don’t think we ever did. I think that’s why the trophy ended up in Jello.

Short History of C-L Psychiatry Fellowship at Iowa

I read a short article, “The case for pursuing a consultation-liaison psychiatry fellowship” by Samuel P. Greenstein, MD in Current Psychiatry (Vol. 1, No. 5, May 2022). After 3 years as an attending, he found his calling as a C-L psychiatrist, especially after getting teaching awards from trainees. But when he applied to academic institutions for position as a C-L academic psychiatrist, people kept advising him to complete a fellowship training program in the subspecialty first. He gave it careful thought and did so, even he called it going “backwards” in his career.

On the other hand, he believes C-L fellowships will help meet the challenges of addressing rising health care costs and improving access to what most people see as the critically important goal of providing access to integrated mental health and medical care.

I’ve been retired from consultation-liaison psychiatry for two years now. I get an enormous sense of achievement on the rare occasions when I hear from former trainees who say things like “For me you were…one of the most outstanding attendings I had at my time at Iowa.” And “I can at least take comfort that University of Iowa is still at the forefront of psychiatry.”

Several years ago, one of the residents suggested starting a Psychosomatic Medicine Interest Group (PMIG). This was before the name of the subspecialty was formally changed to Consultation-Liaison Psychiatry in 2018. I know many of us were very pleased about that.

I sent a short survey (see the gallery below the slide show) to the faculty and residents in an effort gauge support for the idea and readiness to participate. I used a paper published at the time to guide the effort, (Puri NV, Azzam P, Gopalan P. Introducing a psychosomatic medicine interest group for psychiatry residents. Psychosomatics. 2015 May-Jun;56(3):268-73. doi: 10.1016/j.psym.2013.08.010. Epub 2013 Dec 18. PMID: 25886971.).

You’ll notice on slide 4 one faculty member’s comment, “I think it doesn’t matter whether faculty are certified in PM.” As Dr. Greenstein discovered, it probably does matter, at least if you want to be board certified.

I was initially certified by the American Board of Psychiatry & Neurology (ABPN), but I objected to the whole Maintenance of Certification (MOC) program, as did many other psychiatrists. I eventually declined to continue participating in the MOC process. However, I notice that the Delirium Clinical Module that I and a resident put together is still accessible on the ABPN website.

Although response numbers were low, there was clearly an interest in starting the interest group. There was also an incentive to reapply to the ACGME for approval of a Psychosomatic Medicine (Consultation-Liaison Psychiatry now) fellowship.

My attempt years earlier had been frustrating. While it was approved, I couldn’t attract any fellows, forcing me to withdraw it without prejudice (meaning another application for approval could be attempted). Fortunately, that situation changed later. The Psychiatry Department at The University of Iowa now has an early career C-L psychiatrist who graduated from the reinstated C-L fellowship.

As the saying goes, “What goes around comes around.” Although the origin of that saying might have originated in the 1970s, at least one person thought his grandmother had her own version in the 1950s: “You get what you give.”

NAMIWalks Today and Beyond!

We drove by Terry Trueblood Recreation Area today and were amazed by the big crowd of people. We found out about the NAMIWalks today because of the signage and people everywhere at the park.

The National Alliance on Mental Illness (NAMI) has been around since 1979, and you can read more from the top fundraiser for today’s event, Margalea Warner!

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