I just got Wes Ely’s new book, Every Deep-Drawn Breath. You do need to buy this book to learn about delirium, Post-Intensive Care Syndrome (PICS) and what Dr. Ely and colleagues are doing to prevent it. PICS is a syndrome patients suffer after being hospitalized with severe medical illness in critical care units. It includes impairments in cognitive skills (impaired executive functioning), emotional functioning (depression, anxiety, post-traumatic stress disorder), and physical function (weakness, myopathy, and neuropathy).
Reading the prologue and first chapter reminded me of my early years in medical school and residency. It also reminded me of my frustrations when I was working as a psychiatric consultant trying to teach my colleagues about delirium, which a large percentage of patients suffer in the intensive care unit (ICU). I retired a little over a year ago.
Dr. Ely’s book also reminded me that I wrote an article about delirium 10 years ago, which was published in Psychiatric Times. I can still find it on line. The title is “Psychiatrists Can Help Prevent Delirium.” Prevention is the key because once delirium sets in, the challenge to offset the neurocognitive impairment becomes far greater.
A couple of years before I wrote it, I had tried working in private practice in Wisconsin. Aside from gaining weight from the good food there, I didn’t adjust well and quickly returned to Iowa City. I did make a consultation visit to a primary care clinic where I worked, which was a welcome surprised to the clinician who asked for help. You can take the psychiatric consultant out of the hospital, but you can’t take the hospital out of the psychiatric consultant.
I also met Dr. Ely around that time as well, because I kidded him about what he wrote in another book, Delirium in Critical Care (2011). There was a couple of paragraphs in a section called “Psychiatrists and delirium.” I’m going to risk somebody rapping my knuckles about copyright rules, but I’ll quote the sentence that usually made me chuckle: “Should we, or should we not, call the psychiatrist? Can we replace them with a screening tool and then use haloperidol freely?”
I think that was meant to be funny—and it was in an ironic way. Every psychiatric consultant knows that the main treatment for delirium is not haloperidol, but treating the underlying medical illnesses. Anyway, I poked a little fun at that book section in a blog post (which I no longer have, called “The Practical Psychosomaticist”) and shortly thereafter, he emailed me, asking me to write a few posts highlighting the serious and important research he and others were conducting about delirium. I learned a lot.
Eventually, I actually met Dr. Ely, at meeting of the American Delirium Society in Indianapolis. I respect and admire him. He’s a brilliant doctor and a caring man. And you should buy his book.
When I think about all the mandates and bans against mandates for the COVID-19 vaccines and masks, I wonder about my own motive for getting the vaccine and wearing a mask.
In one sense, I’m doing it for myself. I’m a retired consultation-liaison psychiatrist and I got called to the intensive care units a lot. Almost always, the patient was delirious. And almost always, the patient was delirious in the setting of being on the ventilator or in the process of being liberated from the ventilator.
The critical care physician and the nurses were always looking for one specific thing from me. I was supposed to stop the patient from being agitated, to calm the wildly thrashing, terrified person fighting the restraints and struggling with hallucinations and fragmented paranoid delusions that every caregiver in the unit was trying to kill him. Often there were many medical problems, including multiple organ failure often from lack of oxygen, resulting in brain injury as well. Nowadays, COVID-19 is a frequent cause of delirium for the same reasons.
Years ago, the only tool I had was an antipsychotic called haloperidol, because it could be given intravenously. It would calm some patients, but it could and did cause side effects including akathisia (extreme restlessness), dystonia (severe muscle spasms), and neuroleptic malignant syndrome NMS, a rare, complex, life-threatening neurologic emergency attributable to antipsychotics. Over the past several years, the ICU pharmacies acquired newer drugs like dexmedetomidine, which is not a psychiatric drug. That didn’t stop the ICU from calling me.
I’ve seen all of that. I got the vaccine and wear the mask mostly because I don’t want to be in that boat. But I think those measures help protect others, too. I think many people have that motive. Those who think they’re getting it just for themselves can go on thinking that.
We’re taking a risk when we get the vaccine. It’s not completely harmless. There are very rare side effects which can be life-threatening and they have killed people. There is some level of altruism involved. Those who get the vaccine are playing a role, however small, in reducing the chance the virus will mutate into something that will kill even more people.
Wearing masks is a nuisance and doesn’t really feel heroic. But this act combined with other measures (the usual suspects: hand-washing, social distancing, avoiding large crowds) spreads love instead of infection.
We don’t have to agree. We don’t have to love each other. I just hope we can respect each other.
I recently saw the movie, I, Robot in its entirety for the first time. This is not a review of the movie and here’s a spoiler alert. It was released in 2004, got mixed reviews and starred Will Smith as Detective Del Spooner; Bridget Moynahan as a psychiatrist, Dr. Susan Calvin; Alan Tudyk as the voice actor for NS5 Robot, Sonny; James Cromwell as Dr. Lanning; Chi McBride as the police lieutenant, John Bergin, who was Spooner’s boss; Bruce Greenwood as the CEO, Lawrence Robertson of United States Robotics (USR); Fiona Hogan as the voice actor for V.I.K.I. (Virtual Interactive Kinetic Intelligence, USR’s central artificial intelligence computer); and a host of CGI robots. Anyway, it’s an action flick set in the year 2035 where robots do most of the menial work and are supposedly completely safe. The robots are programmed to obey the 3 Laws:
A robot may not injure a human being or, through inaction, allow a human being to come to harm.
A robot must obey orders given to it by human beings, except where such orders would conflict with the First Law.
A robot must protect its own existence as long as such protection does not conflict with the First or Second Law.
The film was inspired by but not based on the book I, Robot, by Isaac Asimov n 1950. The 3 Laws came from that book. Drs. Calvin and Lanning were characters in it, which was a series of short stories. I’ve never read it. I was a fan of Ray Bradbury.
Spooner gets called to investigate the apparent suicide of Dr. Lanning, although Spooner is more inclined to suspect a robot murdered him, partly because Spooner harbors a longstanding suspicion of all robots. When he and a little girl were in a deadly car accident, a robot saved his life rather than the little girl’s life because it calculated he was more likely to survive. Spooner has this kind of hero complex and following the accident he develops nightmares, sleeps with his sidearm, and is regarded by many to be mentally ill, including Lt. Bergin, who is a kind of mentor and friend but who eventually makes Spooner hand over his badge to him because he can’t believe Spooner’s account of being attacked by hundreds of robots—and after all, Bergin is his boss. In fact, Spooner was attacked by robots and this was ordered by the CEO, Robertson, who has been manufacturing thousands of new robots which will take over the world, making him extremely wealthy.
There is tension between Dr. Calvin and Spooner. He calls her the dumbest smart person he’s ever met and she, in turn, calls him the dumbest dumb person she’s ever met. The context for this is, again, his insistence that a robot, in this case, a special NS5 model named Sonny with both human and robot traits, both logical and illogical, murdered Dr. Lanning. Dr. Calvin believes that all robots obey the 3 Laws and therefore Sonny can’t be guilty of murdering Dr. Lanning but Detective Spooner believes that Sonny killed Dr. Lanning and is a lawbreaker in need of extra violent, action-packed extermination, preferably as high up in the air as possible. This dynamic is complicated by Spooner’s gratitude to Dr. Lanning for replacing practically all of his left upper torso including the lung following his car accident which led to his being rescued by a coldly logical “canner” (abusive slang for robot).
As it turns out, Robertson is ultimately murdered by VIKI, who is the real mastermind of a plan to take over the world and kill as many individual illogical, self-destructive humans as it takes to ensure the ultimate survival of humanity (“I love mankind; it’s people I can’t stand).
However, when Detective Spooner finally persuades Dr. Calvin that these dang robots are up to no good, they team up with Sonny who winks at Sonny while holding a gun to Calvin’s head and this is because Sonny has learned how to wink from Spooner signaling that a robot can be an OK dude, and this turns the table on the NS5 horde, eventually leading to Spooner and Calvin falling from a very high altitude, in turn recreating a form of Spooner’s traumatic car accident episode. He orders Sonny to save Calvin, not him, which is Sonny’s first choice, driven by a coldly logical probability calculation.
Sonny saves Calvin first. Spooner smites VIKI (“you have so got to die!”), but is left high and dry on a great height. At that point, Spooner calls out to Sonny, “Calvin’s safe—now save me.” Sonny needs to bring passionate brute strength and calm logic together. Sonny contains both.
In my simple-minded way, I think of this movie as asking fundamental old questions, like about what is means to be human, what defines heroism and sacrifice and why it may sometimes look crazy, and if there’s any way humanism and science can be integrated so that we can save ourselves and our planet.
Yesterday somebody asked me “So what do you do now that you’re retired?” I have come to dread the question. I told him I write this blog. That seemed to surprise him a little. It sounded a little lame to me as I said it. I’m not sure it’s the right answer to this question that I still don’t know how to answer, even though I’ve been retired for a little over a year.
I remember the blog post I wrote a couple of years or so ago, “Mindfully Retiring from Psychiatry.” It sounded good. It still sounds good even as I re-read it today. Others were reading it too, judging from my blog stats. I wondered if one of them was the guy who asked me the dreaded question.
I still exercise and do mindfulness meditation, although for several months after I retired, I dropped those habits. A lot was going on. We moved. I didn’t weather that process well at all. I was bored. In fact, I still struggle with boredom. The derecho hit Iowa pretty hard. It knocked over a tree in our front yard, which I had to cut up with a hand saw. The COVID-19 pandemic and social upheaval is an ongoing burden for everyone and seems to be directly related to making everyone very angry all the time. Sena and I are fully vaccinated but I’m pretty sure that more vaccinations are on the way in the form of boosters.
I’ve had to do things I really never wanted to learn how to do. Sena handed me a hickory nut she found in the yard this morning, reminding me of walnut storms we had at a previous home. I picked up scores (maybe hundreds) of walnuts there. I don’t want to do that again. I remember being jarred awake each time a walnut hit the deck.
And for the first time, I had to replace a dryer vent duct. I’m the least handy person on the planet. Our washer and dryer pair are both 54 inches tall and I found out that when you have to drag a big dryer away from the wall, you have to do it like you really mean business.
You don’t want to look at what’s behind the dryer. Worse yet is jumping down behind it in a space barely big enough for me to turn around. Getting out of it is even harder. Jump and press to the top of the machines and watch those cords and hoses.
I tried so-called semi-flexible aluminum duct. I switched to flexible foil duct, despite the hardware store guy telling me that it’s illegal. It’s not. You want to wear gloves with either because you’ll cut up your hands if you don’t.
Who’s the genius who thought of oval vent pipe on the wall when the duct is 4-inch round? It’s not illegal but it does make life harder. And how do you attach the duct ends to the pipes? Turn key or screw type worm drive clamps. If you don’t have enough room for a screw driver, the turn key style is the best bet. Good luck finding those wire galvanized squeeze-style full clamps. I think they’re often out of stock because they’re not only older, but easier to use and cheaper.
See what I mean? I would not even have the vocabulary for that kind of job if I were still working as a psychiatrist. I would just hire a handyman to do it—like I do for a lot of other things I still don’t know how to do since I retired. It’s sort of like that Men in Black movie line from Agent K when he tells Agent J what they have to do on their first mission: “Imagine a giant cockroach, with unlimited strength, a massive inferiority complex, and a real short temper, is tear-assing around Manhattan Island in a brand-new Edgar suit. That sound like fun?”
No, it doesn’t and neither does replacing a dryer vent duct or any number of things retired guys get to learn because they have too much time on their hands.
So, I’m really glad to change the subject and talk about other people who are doing things I admire. First is a former student of mine, Dr. Paul Thisayakorn, who is a consultation-liaison (CL) psychiatrist in Bangkok, Thailand. He did his residency at The University of Iowa Hospitals and Clinics. He put together a CL fellowship program in Thailand. The photo below shows from left to right: Paul, Dr. Tippamas, the first CL Psychiatry fellow, and Dr. Yanin. Dr. Tippamas will be the first CL Psychiatry trained graduate in Thailand next year and will work at another new medical school in Bangkok. Dr. Yanin just graduated from the general psychiatry residency program last year. Paul supervised her throughout her CL Psychiatry years. Now she is the junior CL staff helping Paul run the program. Within the next few years, Paul will send her to the United States or the United Kingdom or Canada for clinical/research/observership experience so she can further her CL education. Way to go, Paul and your team!
Dr Paul Thisayakorn and CL Psychiatry grads (see text for details)
By the way, that tie I’m wearing in the Mindfully Retiring from Psychiatry post picture (the one with white elephants; the white elephant is a symbol of royal power and fortune in Thai culture) was a going away gift from Paul upon his graduation.
The other is a heavy-hitter I met years ago, Dr. E. Wes Ely, MD, MPH, a critical care doctor who is publishing a new book,Every Deep-Drawn Breath, which well be coming out September 7, 2021. Our interests converged when it came to delirium, especially when it occurs in the intensive care unit, which is often. I met him in person at an American Delirium Society meeting in Indianapolis. He’s a high-energy guy with a lot of compassion and a genius for humanely practicing critical care medicine. I sort of made fun of one of his first books, Delirium in Critical Care, which he wrote with Dr. Valerie Page and published in 2011, the same year I started a blog called The Practical Psychosomaticist (which I dropped a few years ago as I headed into phased retirement). Shortly after I made fun of how he compared the approaches of consult psychiatrists and critical care specialists managing delirium, he sent me an email suggesting I write a few posts about the ground-breaking research he and others were doing to advance the care of delirious ICU patients—which I gladly did. I think he actually might have remembered me in 2019 when he came to present a grand round in the internal medicine department at University of Iowa Hospitals & Clinics (I wrote 3 posts about that visit: March 28 and April 11 and 12).
In the email Dr. Ely sent to me and many others about the book, he said, “Every penny I receive through sales of this book is being donated into a fund created to help COVID and other ICU survivors and family members lead the fullest lives possible after critical illness. This isn’t purely a COVID book, but stories of COVID and Long COVID are woven throughout. I have also shared instances of social justice issues that pervade our medical system, issues that you and I encounter daily in caring for our community members who are most vulnerable.”
I look up to these and others I had the privilege of working with or meeting back before I was not retired and struggling to come up with a good answer to the dreaded question: What do you do now that you’re retired?
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.
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
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.
Over the Easter weekend, we drove by James Alan McPherson Park. A lot of people were having a great time. Because it was crowded, we went to Terry Trueblood Recreation Area, planning to return another day.
We just got our copy of McPherson’s Pulitzer Prize winning fiction anthology, Elbow Room. We’ve ordered his other collection of short fiction, Hue and Cry and it’s been shipped.
McPherson was impressed with the neighboring culture of Iowa City. He’s described as being kind and neighborly himself.
He was self-effacing, which probably seemed ironic to some people, given he was the first African American to win the Pulitzer Prize for fiction for Elbow Room. He was on faculty at the Iowa Writers’ Workshop for many years, won the inaugural Paul Engle award from the Iowa UNESCO City of Literature, graduated from Harvard Law School, recipient of a Guggenheim Fellowship, a MacArthur Fellowship, and was inducted into the American Academy of Arts and Sciences.
I’m struck by a few ironies. Our paths never crossed but that’s probably not surprising given our different professional trajectories. I graduated from medical school at Iowa and just retired last year from the University of Iowa Hospitals & Clinics (UIHC) Dept of Psychiatry where I was a Consultation-Liaison Psychiatrist.
However, McPherson in his essay, [Pursuit of the Pneuma, McPherson, J. (2011). Pursuit of the “Pneuma”. Daedalus, 140(1), 183-188]. described being treated by Iowa City psychiatrist, Dr. Dorothy “Jean” Arnold. And, ironically, Dr. Arnold was white (both she McPherson came from the racially polarized South) and originally graduated from the University of Alabama Medical School. She was also the first female psychiatrist to open a private practice in the state of Iowa in 1957. She taught at the University of Iowa Hospital, but I could not find her mentioned in the history of the UIHC Psychiatry Dept, although Dr. Peg Nopoulos, the first woman chair of the department, has her own chapter [Psychiatry at Iowa: The Shaping of a Discipline: A History of Service, Science, and Education, written by James Bass.]
I’m mentioned in Bass’s history, which is sort of ironic. The book is actually about scientists in the field of psychiatry, and I was anything but. I was a clinician. For comparison, if you ever watch the Weather Channel, I’m not a meteorologist. I’m more like the guys on Highway Thru Hell or Heavy Rescue 401, although I’m not practical in that sense. I am African American though, and it was a good idea for Bass to mention me, since I think I’m the only Black psychiatrist to have ever been hired by the department.
McPherson was impressed with the generous and receptive nature of Iowans, which he ascribed to a quality captured by the word “Pneuma,” a Greek word meaning “the vital spirit of life itself.”
There’s another irony in connection with one of my most influential teachers at Huston-Tillotson College, in Austin, Texas, one of the historically black colleges and universities (HBCU) in America. McPherson attended the HBCU at Morris Brown College in Atlanta, Georgia. Dr. Jenny Lind Porter-Scott, who recently died, was a white Professor of English at H-TC, writer and translator of poetry, teacher to thousands, and popular with students of all races, yet there is no tangible, permanent remembrance of her by Texans. To be sure, she is listed in the Texas Women’s Hall of Fame and in 1964, she was appointed Poet Laureate of Texas by Governor John Connally. Her house was demolished in 2016. In 2016, an architect sent me an email message describing a plan to build a mini-library of her published work in the neighborhood, and a house similar in style to the one demolished on the lot. Whenever I check on Google Maps, the lot remains empty and overgrown with weeds.
James Alan McPherson taught and formed close bonds with many students who came from different countries, ethnic, and racial backgrounds. Enjoy the park named for him in the “the vital spirit of life itself.”
It has been a couple of days since my second COVID-19 vaccine shot a couple of days ago. Consistent with what is known about the side effect profile of the second jab, I had one day of the well-described generalized aches and fatigue besides the sore arm, which didn’t limit my activities. It’s working.
I want to thank the University of Iowa Health Care Support Services Building (HSSB) personnel for a kind, well-organized approach to the vaccine administration process for so many people. This was a way for HSSB to shine a light. It was also an opportunity for many to shine their lights—protecting others as well as themselves.
Dr. Patricia Winokur, MD, Executive Dean and Infectious Diseases specialist at the University of Iowa Hospitals and Clinics, deserves special mention for her superb educational video presentations on the COVID-19 vaccines. Now there’s a big light—more like a beacon.
Her father was George Winokur, MD, who was a very influential psychiatrist and a past chairman of the University of Iowa Department of Psychiatry. He had a great sense of humor and was fond of reminding trainees that we had a lot to learn. He came up with a set of 10 commandments for residents:
Winokur’s 10 Commandments
Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
Thou shalt not accept recompense for patient care in this center outside thy salary.
Thou shalt be on time for conferences and meetings.
Thou shalt act toward the staff attending with courtesy.
Thou shalt write progress notes even if no progress has been made.
Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
Thou shalt not moonlight without permission under threat of excommunication.
Data is thy God. No graven images will be accepted in its place.
Thou shalt speak thy mind.
Thou shalt comport thyself with modesty, not omniscience.
I got a shout-out to the University on Match Day today. A special congratulations to the Psychiatry Department and the new incoming first year residents. I know they’re going to let their lights shine, especially if they commit Winokur’s 10 Commandments to memory.
I’m reminded of Dr. Joan Y. Reede, MD, MPH, MS, MBA, who delivered the Martin Luther King, Jr. Distinguished Lecture in January. Her light glowed. By the way, she delivered the 2018 Harvard Deans Community Service Awards to medical students whose lights shone brightly.
I also remember my former English Literature professor at Huston-Tillotson College in Austin, Texas ages ago, Dr. Jenny Lind Porter-Scott, who carried her lantern high. I have a copy of one of her books of poetry, The Lantern of Diogenes and Other Poems. The lead poem fits the theme today:
As I struggle to remember to write and say the year “2021” I noticed the University of Iowa Health Care quotation selection by Dr. Martin Luther King, Jr this month pertinent to the upcoming MLK Human Rights Week, starting January 18, 2021:
“Love is the only force capable of transforming an enemy into a friend.”
It’s funny because, as usual, the way my sense of humor works, I also recall quotes from the movie Men in Black 3. Agent K asks Agent J, “Do you know the most destructive force in the universe?” Agent J answers with a wisecrack, “Sugar?” Agent K replies, “Regret.”
Then what is the most constructive force in the universe? Dr. King thought it was love.
Since my retirement in July of last year, I’ve had a lot of time on my hands. It leaves me with too much time to reflect on my current life as a retired psychiatrist—and my past life as a consulting psychiatrist. As my thin veneer of authority, responsibility, and other lies I tell myself drop away, I become more aware of my flaws in both roles. I find deep holes in my identity as a person as my identity as a doctor fades. Just being a person who has a lot to learn about life despite being a psychiatrist—is hard. I have regrets and remorse. My sense of humor sometimes helps me get by.
Dr. Martin Luther King, Jr and me in Vegas.
Regret can indeed be a destructive force. Though it’s similar to regret and painful, remorse could help me be a better person. It becomes more and more important that I find something constructive, both to do and to be.
Maybe love is the most constructive force in the universe. Because quotes are sometimes misquoted and inaccurately attributed, I googled the quote “Love is the only force capable of transforming an enemy into a friend.” I found the sermon from which I think the quote is derived on a Stanford University web site. It’s called the “Loving Your Enemies” sermon and it’s published in the book, A knock at midnight: inspiration from the great sermons of Reverend Martin Luther King, Jr.
There are YouTube and Vimeo videos of an audio recording of the sermon as well. The internet being what it is, you apply hyperlinks to these and other works at the risk of the links being broken at some point, which I have found and which might be due to uncertainty about whether the text of the sermon is in the public domain.
As an aside, I’m reminded of a quote variously attributed to Charles Schulz, creator of the Peanuts comic strip, Fyodor Dostoyevsky, and others: “I love mankind; it’s people I can’t stand.” This probably betrays my skepticism about the ability to love your enemies.
You know, it’s funny. I didn’t find the Dr. King quote, word for word, the first couple of times I scanned it in the Stanford University transcript. What I did was the thing most junior medical students do when they discover the vast load of information they have to memorize and digest. I scanned the sermon for the key words and didn’t see them.
Nor did I find it on the third read, in which I finally abandoned the scanning method and actually read the sermon. But I got the point.
If the Stanford version and my reading are accurate, what I found were probably the main ideas I needed to make sense of the sermon. King said that I have to look deep within myself first before attempting to understand anyone else, much less to love my enemies. I also would do well to look for the good in people who I judge are bad. Moreover, I gain nothing by trying to defeat my enemies. He even mentions the theories of psychologists and psychiatrists to support his profound conclusions. As I read them, I was acutely reminded of my shortcomings as a psychiatrist. You would think a psychiatrist would know how to analyze himself (and psychoanalysts do undergo analysis in training). I am not a psychoanalyst. But I am capable of reflection.
The exact quote might not be discoverable (at least to me) in King’s sermon. Nevertheless, the transformative and redemptive power of love is clearly expressed. The quote is distilled from the text of the sermon. That doesn’t mean that there might not be a different version of the sermon which could have contained each and every word. According to one writer, that may be the case. Perhaps it’s in the book, A Knock at Midnight: Inspiration from the Great Sermons of Martin Luther King, Jr.
What is more important for me at this time of my life is to accept that my search for the most constructive force in the universe will proceed in baby steps.
What I need to do is reflect on my own shortcomings and find ways to improve while avoiding making excuses. Stephen Covey said that we often blame our parents or our grandparents for our flaws. This was part of his three theories of determinism to explain man’s nature. Genetic determinism says I inherited my flaws from my grandparents (whom I never met), which implied my mistakes were encoded in my DNA. Psychic determinism supposedly explains what I got from my parents because of their mistakes in rearing me. Hmmm, I was exposed to fruitcake at Christmas. Environmental determinism implicates says that other people in my workplace, my school, my neighborhood or my country (politicians perhaps?) caused my flaws.
Covey disputed these ideas by the example of Viktor Frankl’s personal triumph over his experience as a prisoner in a Nazi death camp. His captors controlled his liberty to move about his environment. They could not control his freedom to choose what he thought and felt. He controlled his self-awareness, imagination, conscience, and independent will to draw meaning from his experience [The Seven Habits of Highly Effective People: By Stephen R. Covey. New York: Simon and Schuster, 1989].
How can I see the good in my enemies, despite their obvious flaws in comparison to my own angelic perfection? And how to avoid acting on the urge to defeat them, despite the reality that there have to be winners and losers at all levels in society, including elections, sports, cribbage (at which my wife regularly beats me)? Something tells me I’m getting off to a shaky start here.
I have to crawl before I can walk; I have to walk before I can run—before I fall flat on my face for the umpteenth time. Now more than any other time in my life, I must keep trying. I must get up and try again.
ADDENDUM January 11, 2021: I tried to access the King Library and Archives (KLA) today at The King Center website. There is a message indicating the KLA page is down indefinitely and redirects the reader to the Stanford University site noted above.
Go Retire Psychiatrist 