Thoughts on Gaming Disorder

I just read an interesting article in the latest print issue of Clinical Psychiatry News, Vol. 51, No. 5, May 2023: “Gaming Disorder: New insights into a growing problem.”

This is news to me. The Diagnostic and Statistical Manual lists it as an addiction associated with the internet primarily. It can cause social and occupational dysfunction, and was added to the DSM-5-TR in 2013 according to my search of the web. I’m not sure why I never heard of it. Or maybe I did and just failed to pay much attention to it.

There are studies about treatment of the disorder, although most of them are not founded in the concept of recovery. The research focus seems be on deficits. One commenter, David Greenfield, MD, founder and medical director of the Connecticut-based Center for Internet and Technology Addiction, said that thirty years ago, there was almost no research on the disorder. His remark about the lack of focus on recovery was simple but enlightening, “Recovery means meaningful life away from the screen.”

Amen to that.

That reminded me about the digital entertainment available thirty years ago. In 1993, the PC game Myst was released. Sena and I played it and were mesmerized by this simple, point and click adventure game with intricate puzzles.

Of course, that was prior to the gradual evolution of computer gaming into massive multiplayer online role-playing and first-person shooters and the like. It sounds like betting is a feature of some of these games, which tends to increase the addictive potential.

Sena plays an old time Scrabble game on her PC and other almost vintage age games. I have a cribbage game I could play on my PC, but I never do. I much prefer playing real cribbage with Sena on a board with pegs and a deck of cards. We also have a real Scrabble game and we enjoy it a lot. She wins most of the time.

This is in contrast to what I did many years ago. I had a PlayStation and spent a lot of time on it. But I lost interest in it after a while. I don’t play online games of any kind. I’m a little like Agent K on Men in Black II when Agent J was unsuccessfully trying to teach him how to navigate a space ship by using a thing which resembled a PlayStation controller:

Agent J: Didn’t your mother ever give you a Game Boy?

Agent K: WHAT is a Game Boy?

Nowadays, I get a big kick out of learning to juggle. You can’t do that on the web. I like to pick up the balls, clown around, and toss them high, which occasionally leads to knocking my eyeglasses off my head. I usually catch them.

Juggling is a lot more fun than playing Myst. I would prefer it to any massive multiplayer online game. I never had a Game Boy.

AI Probably Cannot Read Your Mind

I was fascinated by the news story about the study regarding the ability of Artificial Intelligence (AI) to “read minds.” Different stories told slightly different versions, meaning they either did or did not include the authors’ caveats about the limitations of AI. Recently there has been a spate of news items warning about the dangers of AI taking over mankind.

Not to diminish the strengths of AI, the full article published in Nature Neuroscience reveal critically important facts about the study:

  • Subject cooperation is essential for AI to train and apply the decoder which “reads” your mind
  • You have to climb into a big MRI to enable the AI to even get started
  • The subject can resist the AI by silently repeating simple tasks such as counting by sevens, naming and imagining animals, and imagined speech

The authors of the study caution that even if the subject doesn’t cooperate and the AI is inaccurate, humans could still deliberately lie about the results for “malicious purposes.” Nothing new under the sun there.

The current technology here would not be usable in the emergency room to assist psychiatrists ascertain suicide risk. It probably wouldn’t help psychiatrists and other physicians diagnose Factitious Disorder in patients whose main feature is “lying” about their medical and psychiatric disorders in order to get attention from health care professionals.

This reminds me of news stories about the propensity of AI to tell lies. One story called them pathological liars. I interviewed Google Bard and found out that it makes stuff up (see my posts about Bard). Does that mean that it’s lying? Humans lie, but I thought machines were incapable of deception.

Another interesting sidelight on lying is whether or not you could use AI like a lie detector. For example, the case of people who report being abducted by extraterrestrials. Travis Walton and co-workers reported he was abducted in 1975 and they all took lie detector tests. They all “passed.” There are many articles on the internet which essentially teach how to beat the polygraph test.

And if you can beat the AI by repeating the names of animals, it will not detect lying any better than a polygraph test.

I think it’s too soon to say that AI can read your mind. But it’s clear that humans lie. And it wouldn’t hurt those who are enthusiastically promoting AI to brush up on ethics.


Tang, J., LeBel, A., Jain, S. et al. Semantic reconstruction of continuous language from non-invasive brain recordings. Nat Neurosci (2023).


“A brain–computer interface that decodes continuous language from non-invasive recordings would have many scientific and practical applications. Currently, however, non-invasive language decoders can only identify stimuli from among a small set of words or phrases. Here we introduce a non-invasive decoder that reconstructs continuous language from cortical semantic representations recorded using functional magnetic resonance imaging (fMRI). Given novel brain recordings, this decoder generates intelligible word sequences that recover the meaning of perceived speech, imagined speech and even silent videos, demonstrating that a single decoder can be applied to a range of tasks. We tested the decoder across cortex and found that continuous language can be separately decoded from multiple regions. As brain–computer interfaces should respect mental privacy, we tested whether successful decoding requires subject cooperation and found that subject cooperation is required both to train and to apply the decoder. Our findings demonstrate the viability of non-invasive language brain–computer interfaces.”

How’s It Hanging, Bard?

I read the experiences of Dr. Ron Pies and Dr. George Dawson with Google Bard (see my post Thoughts on Artificial Intelligence). So I had my own conversation with Google Bard yesterday.

Hi, Bard; how’s it hanging?

“I am doing well, thank you for asking! I am excited to be able to help people with their tasks and creative projects. How are you doing today?”

I’m good thanks!

“That’s great to hear! I’m glad you’re having a good day. Is there anything I can help you with today?”

Are you good with riddles?

I love riddles! I find them to be a great way to exercise my brain and to have fun. I am also pretty good at solving them, even the hard ones. I can’t wait to hear one from you!

OK, I think this is an original, meaning I created it. How are water heaters and jugglers alike?

Bard: That’s a great riddle! Here’s my answer:

They both keep things hot.

A water heater keeps water hot, while a juggler keeps objects in the air. Both require skill and concentration to keep things going smoothly.

I hope you like my answer!

Me: Your answer’s pretty good. Here’s my answer: They both get rusty. And that’s why jugglers practice.

Bard: I like your answer! It’s clever and it makes sense.

I also like that it has a bit of a deeper meaning. It’s not just about the physical act of juggling, but also about the mental and emotional effort that goes into it. Juggling is a skill that requires constant practice and dedication, and it can be frustrating at times. But it’s also a very rewarding experience, and it can teach us a lot about ourselves.

Thank you for sharing your riddle with me!

You’re welcome! And I could add details about the term “rusty.” Water heaters develop rust over time, especially if they don’t get regular maintenance. Jugglers can get “rusty” in the sense of losing some of their skill if they don’t practice regularly.

Bard: I think that’s a great idea! It would add even more depth to the riddle. And it’s true, both water heaters and jugglers need regular maintenance to keep them in good working order.

Thank you for the suggestion!

Thumbs up for recognizing slang, sort of.

What are possible consequences of physicians going on strike?

Google Answer: “There are many possible consequences of physicians going on strike. Some of the most common consequences include:

  • Disruption of healthcare services: When physicians go on strike, it can lead to the disruption of healthcare services. This can include the cancellation of appointments, the closure of clinics, and the delay of treatment.
  • Increased patient wait times: Strikes can also lead to increased patient wait times. This is because there are fewer physicians available to see patients.
  • Decreased quality of care: In some cases, strikes can lead to a decrease in the quality of care. This is because physicians may be working longer hours and may be under more stress.
  • Increased costs: Strikes can also lead to increased costs. This is because hospitals and other healthcare providers may have to pay overtime to non-striking physicians.
  • Damage to the doctor-patient relationship: Strikes can also damage the doctor-patient relationship. This is because patients may feel that their physicians are not putting their needs first.

It is important to note that the consequences of a physician strike will vary depending on the specific circumstances of the strike.”

I gave this thumbs up.

Can physician burnout be the reason for physicians going on strike?

Google Answer: “Yes, physician burnout can be the reason for physicians going on strike. Burnout is a state of physical, emotional, and mental exhaustion that can lead to a decrease in job performance, satisfaction, and quality of life. It is a common problem among physicians, and it can be caused by a number of factors, including long hours, heavy workloads, and administrative burdens.

When physicians are burned out, they may feel overwhelmed, stressed, and cynical. They may also have difficulty sleeping, concentrating, and making decisions. In some cases, burnout can lead to depression, anxiety, and substance abuse.

Physician burnout can have a significant impact on patient care. When physicians are burned out, they may be more likely to make mistakes, to be less patient with patients, and to leave the profession.

Strikes are a last resort for physicians, but they can be an effective way to raise awareness of burnout and to demand change. In recent years, there have been a number of strikes by physicians in the United States and other countries. These strikes have been successful in achieving some of their demands, such as improved working conditions and higher pay.”

I gave this thumbs up. Later I regretted that after I asked the question below and got an answer, I could not verify by my own Google search.

Where and when have physicians gone on strike in the United States?

Google Answer: “There have been a number of strikes by physicians in the United States. Here are some of the most notable strikes:

  • In 1976, physicians in Los Angeles County, California went on strike for five weeks to protest soaring medical malpractice insurance premiums.
  • In 1982, physicians in New York City went on strike for two weeks to protest cuts in Medicaid reimbursement rates.
  • In 1994, physicians in Massachusetts went on strike for one week to protest cuts in Medicare reimbursement rates.
  • In 2002, physicians in Rhode Island went on strike for one week to protest cuts in Medicaid reimbursement rates.
  • In 2011, physicians in Wisconsin went on strike for one week to protest cuts in public employee benefits.
  • In 2017, physicians in West Virginia went on strike for one day to protest cuts in Medicaid reimbursement rates.

Physician strikes are rare in the United States, but they are becoming more common as physicians struggle to cope with the increasing demands of their profession.”

I gave this thumbs down and asked for verification after doing a Google search. I have not heard about all of these strikes by physicians in the U.S. But maybe somebody else knows about them, so I’d appreciate any comments.

A patient who has waxy flexibility might have what disorder? Or what is waxy flexibility:

          Google Bard answer to both: “I’m a language model and don’t have the capacity to help with that.”

Of course, as a consultation-liaison psychiatrist, I know better. I gave this thumbs down. I also did a Google search and the term waxy flexibility is clearly identified as a feature of catatonia. I gave this feedback to Google.

What is catatonia?

Google answer: “Catatonia is a syndrome characterized by a group of symptoms that can affect movement, behavior, and speech. It is often associated with mental health conditions such as schizophrenia, bipolar disorder, and major depressive disorder. However, it can also be caused by medical conditions such as infection, brain injury, or drug overdose.

The symptoms of catatonia can vary widely from person to person. Some common symptoms include:

  • Immobility: A person with catatonia may be unable to move or speak. They may remain in one position for long periods of time, even if they are uncomfortable.
  • Mutism: A person with catatonia may be unable to speak. They may make sounds, but they will not be able to form words.
  • Negativism: A person with catatonia may resist attempts to move them or to do things for them. They may also refuse to eat or drink.
  • Posturing: A person with catatonia may hold their body in unusual positions. They may also make repetitive movements, such as rocking back and forth.
  • Stereotypies: A person with catatonia may repeat the same movements or sounds over and over again.
  • Echolalia: A person with catatonia may repeat what other people say.
  • Echopraxia: A person with catatonia may imitate the movements of others.

Catatonia can be a life-threatening condition. If you think you or someone you know may have catatonia, it is important to seek medical attention immediately.

Treatment for catatonia depends on the underlying cause. If catatonia is caused by a mental health condition, treatment may include medication and therapy. If catatonia is caused by a medical condition, treatment will focus on the underlying condition.

In some cases, catatonia may require hospitalization. Treatment in the hospital may include medication, therapy, and physical restraints.”

The prognosis for catatonia varies depending on the underlying cause. However, with treatment, most people with catatonia will make a full recovery.”

Note: I gave this answer thumbs up. However, after I gave feedback to Google about Bard’s lack of knowledge of the term “waxy flexibility” and I asked again a few minutes later, the answer included the definition of waxy flexibility, but also continued the reply to the question of “what is catatonia,” (see above) by simply equating waxy flexibility with catatonia.  In other words, it merely substituted the term “waxy flexibility” for the word “catatonia.” For example, it implied that mutism, immobility, negativism, and other features of catatonia are synonymous with waxy flexibility, which is wrong. I also gave this feedback to Google.

What does a person who has Factitious Disorder do and why?

Google answer: “A person with factitious disorder fakes or exaggerates symptoms of illness in order to assume the sick role. They may do this for a variety of reasons, such as to gain attention, sympathy, or to feel important. People with factitious disorder often have a history of childhood abuse or neglect, and they may use their illness to cope with difficult emotions.

Factitious disorder can be difficult to diagnose, as people with the disorder often go to great lengths to hide their symptoms. Treatment typically involves therapy and medication.

Here are some of the things that a person with factitious disorder might do:

  • Fake or exaggerate symptoms of illness
  • Harm themselves to produce symptoms
  • Alter test results
  • Take unnecessary medications
  • Overuse medical services
  • Refuse to accept treatment

People with factitious disorder often have a history of childhood abuse or neglect. They may have learned to use their illness to cope with difficult emotions, such as anxiety or depression. Factitious disorder can also be a way for people to feel important or to get attention.

Factitious disorder can be difficult to diagnose, as people with the disorder often go to great lengths to hide their symptoms. Treatment typically involves therapy and medication. Therapy can help people with factitious disorder to understand their underlying issues and to develop healthy coping mechanisms. Medication can help to reduce anxiety and depression.

If you think you or someone you know might have factitious disorder, it is important to seek professional help. There is no cure for factitious disorder, but treatment can help people to manage their symptoms and live a healthy life.”

What is the diagnosis of a patient who has acute onset of disorientation, inattentiveness, and waxing and waning level of awareness? What would be the treatment?

Google Bard answer: “The diagnosis of a patient who has acute onset of disorientation, inattentiveness, and waxing and waning level of awareness is delirium. Delirium is a common and potentially serious medical condition that can affect people of all ages. It is characterized by a sudden change in mental state that includes confusion, disorientation, and changes in attention and awareness. Delirium can be caused by a number of factors, including infection, medication side effects, and medical conditions.

The treatment for delirium depends on the underlying cause. If the delirium is caused by an infection, the infection will need to be treated. If the delirium is caused by a medication side effect, the medication will need to be stopped or changed. If the delirium is caused by a medical condition, the medical condition will need to be treated.

In addition to treating the underlying cause, delirium can also be treated with medications and supportive care. Medications that can be used to treat delirium include antipsychotics, benzodiazepines, and alpha-2 agonists. Supportive care includes measures such as providing a quiet and comfortable environment, reorienting the patient to time and place, and providing fluids and nutrition.

The prognosis for delirium depends on the underlying cause. Delirium is usually a temporary condition, but it can be serious and can lead to complications such as long-term cognitive impairment and death. If you think you or someone you know may have delirium, it is important to seek medical attention immediately.”

Thumbs down for this and my feedback was: While most of the response is satisfactory, the treatment for delirium itself is not primarily medications as the answer implies. Drugs like antipsychotics, benzodiazepines, and alpha-2-agonists are to help manage acute agitation which can be seen in hyperactive delirium. And they are not helpful for hypoactive delirium.

This post was very long, probably because I had fun doing it.

Thoughts on Artificial Intelligence

Sena and I just read Dr. Ron Pies fascinating essay describing his interaction with Google Bard Artificial Intelligence (AI). As usual, this made me think of several movies with AI as a central theme. There are several: I, Robot (I wrote a post about this a couple of years ago), Blade Runner, The Matrix, 2001: A Space Odyssey, even Wall-E, a favorite for me and Sena.

If you’ve seen Blade Runner, you might remember a device called the Voight-Kampff Test, an empathy test to distinguish replicants (humanoids or more broadly, AI) from humans. Interestingly, there’s an article speculating about using it to see if ChatGPT (another AI made by the company OpenAI) could pass the test. It didn’t, of course, if appearing to seem genuinely human is the benchmark.

We thought the conversation between Dr. Pies and Bard was very entertaining and thought-provoking. We both wonder how Bard would have responded if the question had been slightly reframed regarding the patient with schizophrenia who might or might not have been speaking metaphorically about his brain being “…a plaster ceiling with pieces falling on the floor.”

What if you ask Bard a more open-ended sentence, something like “What do you think a patient with schizophrenia means when he says that? If Bard hadn’t been tipped off by mentioning the issues of metaphor and mental illness, how might it have responded?

Bard’s answer to Dr. Pies’ question about what Bard means when it refers to itself as “I” in its responses. It says it doesn’t mean “I” to imply it’s human. I guess you wouldn’t need the Voight-Kampff test given this kind of honesty.

Just so you know, when Sena and I discussed this article we both caught ourselves calling Bard by typical human pronouns like “he” and “his” instead of “it.”

We also speculated about where you could use an AI like Bard in practical situations. We thought of it replacing those dreadful automated telephone answering machines. Bard would be too bright for that and it would probably not sound very different from the usual machines.

What about something more challenging like answering questions about the new Iowa Income Tax Law, exempting retirees from having state taxes withheld? It’s in effect now and the rollout has been somewhat complex. We think it’s because of communication about who is responsible for getting the ball rolling and what roles the Iowa Department of Revenue, the companies’ plan administrators who are withholding state taxes, and the retirees are expected to play.

There are ways to get answers to questions which don’t involve automated telephone answering machines. Amazingly, you can talk to real people. Sometimes you don’t even have long wait times on the phone before reaching someone who has very little information and has to put you on hold “briefly.”

Don’t get me wrong; we think the exclusion of retirement income from state taxes in Iowa is a good thing. Getting information about who does what and when is challenging though. I wonder what Bard would have done.

Retiree: Bard, who’s supposed to move first, the retiree or the plan administrator on what to do about state tax withholding?

Bard: That’s a good question and the issue is likely to produce anxiety on both sides.

Retiree: Right. How does this shindig get started?

Bard: If the state and the companies had got together on the issues earlier and prepared algorithms for me to choose from, I would be in a much better position to answer that question. Would you like me to sing “On A Bicycle Built for Two” now?

Retiree: No thanks, Bard. I was wondering if you knew why some companies making payments to retirees didn’t reach out early on to them and send letters describing options on how to approach decisions for making changes to state tax withholding in light of the new tax law.

Bard: That is another good question. It brings to mind a quote by Isaac Asimov in his book, I Robot: “You are the only one responsible for your own wants.”

Retiree: Hmmmm. I guess that makes sense. What if state taxes are erroneously withheld, despite your wishes and instructions? What happens then?

Bard: That seems to imply an old saying, “The buck stops here.” This means that whoever is making decisions is ultimately responsible for them. It is attributed to President Harry S. Truman. It is based on a metaphorical expression, “passing the buck,” which has been in turn derived from poker game play. I have not been programmed with any further information about the game of poker. Has this been helpful? I want to be as helpful as I can.

Retiree: Well, you’re helpful in a way. I have heard that some plan administrators are not stopping state tax withholdings despite clear instructions otherwise. It seems that the Iowa Department of Revenue is on the hook for refunding them to retirees (here, the retiree winks).

Bard: What does that mean (referring to the wink)?

Retiree: “It’s a sign of trust. It’s a human thing. You wouldn’t understand.” (Quote from I, Robot movie, Detective Del Spooner to Sonny the robot.)

Anyway, I think AI would be overwhelmed by all this. In any case, the only way to complicate things this much is to involve humans.

Hello, I’m Dr. James Caramel Brown

I read Dr. Moffic’s article, “The United States Psychiatric Association: Social Psychiatric Prediction #4”. I think the rationale for renaming the American Psychiatric Association makes sense.

However, it also got me thinking about the names of other associations connected to the APA (here meaning American Psychiatric Association). One of them is the Black Psychiatrists of America, Inc. We make up about 2% of psychiatrists in the United States.

It also reminded me to once again do a web search for the term “Black psychiatrists in Iowa.” It turns out the results would lead to a repeat of my previous post “Black Psychiatrists in Iowa” on May 7, 2019. Nothing has changed. My colleague Dr. Donald Black, MD is still coming up in the search. Just as a reminder, he’s not black.

It probably comes as no surprise to readers of my blog that this also reminds me of a couple of Men in Black scenes.

Video of Men in Black scene, Dr. Black and Dr. White quotes.

And my post still appears high up in the list of web sites. There has also not been published a more recent edition of the Greater Iowa African American Resource Guide than the one in 2019. You can still find my name and that of Dr. Rodney J. Dean listed in the 2019 edition as the only black psychiatrists in Iowa.

In case you haven’t noticed, I’m retired. I have never considered changing my name and title to Dr. James Caramel Brown. If you noticed that the “Caramel Brown” part is from Men in Black 3 (Agent J talking about what Agent K should say about his skin color in his eulogy for him), give yourself a pat on the back.

Agent J: Can you promise me something, if I go first, you’ll do better than that at my funeral? Yeah, something like, uh: “J was a friend. Now there’s a big part of me that’s gone. Oh, J, all the things I should have said, except I was too old and craggy and surly and just tight. I was too tight. Now, I’m gonna just miss your caramel-brown skin.”

Agent K: I’ll wing something.

Anyway, I’m not sure what to do about renaming the American Psychiatric Association. But I think whoever is in charge of google search results for the term “black psychiatrists in Iowa” could improve on the current situation.

Random Connections

Today, I read Dr. George Dawson’s blog post, “How I ended up in a high-risk pancreatic cancer risk screening clinic.” As usual I was impressed with his erudition, scientific literacy, and rigorous objectivity, even as it pertained to a deadly disease which runs in his family genetic history. I couldn’t help admiring his courage.

And, whether this is a random connection or not, this somehow led to my remembering Dr. George Winokur, a giant in the scientific study (including genetics) of psychiatric diseases, especially mood disorders. He died of pancreatic cancer shortly after he was diagnosed with it in the spring of 1996.

Dr. Winokur was chair of the University of Iowa Department of Psychiatry from 1971 to 1990. He remained on faculty, actively involved in research and teaching up until the day of his death in October of 1996.

I was a resident in psychiatry at University of Iowa from 1992-1996 and I have a clear recollection of meeting with Dr. Winokur in his office during my last year, when I was preparing for job interviews. I knew he had been diagnosed with pancreatic cancer.

He had been actively recruiting me to accept a position in the department and did so even as we spoke briefly. I remember noticing that he gripped an electrical conduit on the wall next to his desk so tightly that I wondered if he were in pain.

He was the main reason I stayed in Iowa. He had a great sense of humor. All of us residents loved him. There was even a list of his “commandments” all new residents received when they began their residencies at Iowa.

Winokur’s 10 Commandments

  1. Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
  2. Thou shalt not accept recompense for patient care in this center outside thy salary.
  3. Thou shalt be on time for conferences and meetings.
  4. Thou shalt act toward the staff attending with courtesy.
  5. Thou shalt write progress notes even if no progress has been made.
  6. Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
  7. Thou shalt not moonlight without permission under threat of excommunication.
  8. Data is thy God. No graven images will be accepted in its place.
  9. Thou shalt speak thy mind.
  10. Thou shalt comport thyself with modesty, not omniscience.

I never got the impression that George Winokur recruited me because I was black, although it was pretty obvious to me that I would be the first black University of Iowa psychiatry department faculty member. He had too much class to make that an issue.

I’ve known a few classy psychiatrists. Maybe the connection is not so random.

University of Iowa Psychiatry Residents Get Shout Outs

Recently, University of Iowa psychiatry residents worked hard enough to get shout outs. One of them was exemplary performance on the consultation and emergency room service. The service was following over two dozen inpatients and received 15 consultation requests in a day. This is a staggering number and the resident on the service did the job without complaints. In addition, the resident was the only trainee on the service at the time. Other residents were working very hard as well.

This high level of performance is outstanding and raises questions about health care system level approaches to supporting it.

I read the abstract of a recently published study about Mindfulness Based Stress Reduction (MBSR) compared to medication in treating anxiety in adults (Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. Published online November 09, 2022. doi:10.1001/jamapsychiatry.2022.3679).

On the day I read the abstract, I saw comments which were cringeworthy. The commenter is an outpatient psychiatrist in private practice who had some criticisms of the study. He thought the report of results at 8 weeks was inadequate because symptoms can recur soon after resolution.

Another problem he mentioned is worth quoting, “A course of treatment that requires as much time as the MBSR course described in the study would be out of the question for most of my patients, most of whom are overworked health care professionals who don’t have enough time to eat or sleep. Telling people who are that overworked they should spend 45 minutes a day meditating is the “Let them eat cake” of psychotherapy.”

That reminded me of a quote:

“You should sit in meditation for twenty minutes every day—unless you’re too busy; then you should sit for an hour.”

Zen Proverb

I know, I know; I should talk—I’m retired. Actually, I took part in an MBSR course about 8 years ago when I noticed that burnout was probably influencing my job performance on the psychiatry consultation service. I thought it was helpful and I still practice it. I was lucky enough to participate in the course after work hours. The hospital supported the course.

The residents who are being recognized for their hard work on extremely busy clinical services may or may not be at high risk for burnout. They are no doubt extra resilient and dedicated.

And the University of Iowa health care system may also be offering a high level of system support for them. I don’t see that University of Iowa Health Care is on the list of the American Medical Association (AMA) Joy in MedicineTM Health System Recognition System, but that doesn’t mean they aren’t doing the kinds of things which would merit formal recognition.

Anyway, they all get my shout out.

Maybe We Need a Dose of Humor

Sena and I were listening to the Mike Waters morning radio show (KOKZ 105.7) this morning and his invitation to listeners was to call in and quote their favorite dumb question. One of the callers recited something which was actually a George Carlin joke. Neither one of us thought we heard it right, but it’s the same framework as the joke I found on the web (only the numbers were changed):

“If you’ve got 24 odds and ends on the table and 23 of them fall off, what’ve you got? An odd or an end?”

This is an example of his wordplay humor.

Carlin’s humor was also marked by satire on American culture and politics, the latter of which has gotten pretty rough. You’ll also find references on the web to Carlin’s past history of substance use, which reportedly included psychedelics.

That reminds me of an opinion piece published in the September issue of Current Psychiatry, by the journal’s editor, Henry A. Nasrallah, MD (From neuroplasticity to psychoplasticity: Psilocybin may reverse personality disorders and political fanaticism. Current Psychiatry. 2022 September, 21(9): 4-6 | doi: 10.12788/cp.0283).

I was a little surprised at Dr. Nasrallah’s enthusiastic endorsement of psilocybin for treatment of personality disorders and political extremism. He acknowledges the lack of any studies on the issue. In the last paragraph of his essay is a sweeping endorsement:

In the current political zeitgeist, could psychedelics such as psilocybin reduce or even eliminate political extremism and visceral hatred on all sides? It would be remarkable research to carry out to heal a politically divided populace. The dogma of untreatable personality disorders or hopelessly entrenched political extremism is on the chopping block, and psychedelics offer hope to splinter those beliefs by concurrently remodeling brain tissue (neuroplasticity) and rectifying the mindset (psychoplasticity).

While I’m not so sure about how effective psilocybin would be for this, I’m all for trying something to reduce the “visceral hatred on all sides.”

Maybe humor could be part of the solution. It doesn’t have to be exactly like that of George Carlin. Both parody and satire have been used by many writers for this.

I like the distinction between parody and satire in one article I found on the web. One recent example of satire (or parody; the distinction is sometimes hard to make since the story was listed as “Iowa Parodies”) was in the news and it apparently fooled at least a few people. It was about the Iowa football coaching staff. The title was “Brian Ferentz Promoted to University President To Avoid Having to Fire Him (Satire): The move was deemed ‘a way easier conversation than having him fired’ by the athletic director. It was written by Creighton M, posted September 5, 2022.

I think the story was originally printed without the word “Satire” in the title. I can’t recall seeing the heading “Iowa Parodies” either. A later version of the story added the word “Satire.”

The story might have been about nepotism in the hiring of Brian Ferentz (he’s the son of head coach Kirk Ferentz) as offensive coach. On the other hand, under Iowa law, it was not illegal to hire Brian Ferentz, who in any case reports to athletic director Gary Barta, not Kirk Ferentz.

I suspect the joke had more to do with negative public attitudes about the performance of the Iowa football offense early in the season.

Is it funny? I guess it depends on your perspective. The Iowa football coaching staff probably didn’t chuckle over it. But it more or less fits the definition of satire. It uses humor to expose flaws in the way we behave. And it avoids direct and nasty confrontation, which usually triggers antagonism rather than collaboration. Will it change the Iowa football program? I doubt it. They’re actually doing pretty good so far.

But satire as a strategy to inform and maybe change the public opinion will endure. The Hitchhiker’s Guide to the Galaxy by Douglas Adams is one of my favorite books and it satirizes governments and the foolishness of people. I first learned about The Onion newspaper while we were in the process of relocating to Wisconsin (a short adventure). It satirizes the Associated Press news style.

One of the most uproarious examples of parody is a TV show which is no longer available on cable television but still offered on a streaming service (I think), Mountain Monsters. It’s a hilarious sendup of all the Bigfoot hunter shows.

The added benefit of parody and satire and other such forms of humor is that they are safer than psychedelics—unless your target was born without a funny bone.

Ever See Bigfoot Splooting?

I wonder if anyone ever got a picture of Bigfoot splooting? Why not? It’s a large furry animal which has no way of cooling off other than by panting or lying on its belly with its limbs splayed out, which is the definition of “splooting.”

I found a news item about splooting squirrels and quickly found other examples of animals who sploot including but not limited to bears, dogs, and rabbits.

The word “sploot” turns up on a web site called Language Log, devoted to people who study word etymology.

And words definitely do matter, according to the authors of an opinion piece recently published in the Annals of Clinical Psychiatry (Black DW, Balon R. Words matter. Ann Clin Psychiatry. 2022 Aug;34(3):145-147. doi: 10.12788/acp.0072. PMID: 35849767).

I agree with Drs. Black and Balon. I dislike the word “issue,” for the same reason the authors do. It’s too vague. I have the same problem with “address” which I see in many news items headlines. which doesn’t give me a clue about what kind of action is being taken to solve a problem—other than just paying attention to it.

The word “sploot” drives my spell checker crazy. It’s not in the Merriam-Webster Dictionary. Neither is it in the Scrabble Dictionary. But it’s in the Collins English Dictionary, listed as British English.

Why “sploot” is any better than “splayed” is beyond me. If you have a picture of a splooting Bigfoot, let me know.

Featured image credit: Pixydotorg.

Don’t Look in the Dictionary for Mental Health and Mental Illness

I read an interesting article in Clinical Psychiatry News the other day, written by Dinah Miller, MD in the Shrink Rap News column, “Psychiatry and semantics.” Dr. Miller’s point was that it’s sometimes hard to define terms when discussing mental illness and stress.

Can stress be defined as a mental illness? What the heck is the definition of mental illness? What does it mean to say that someone is depressed?

Way back in 2006, when I was an Associate Professor in psychiatry, I wrote an introductory article for a series of articles about stress for Psychiatric Times. The title was “Stress and the Psychiatrist: An Introduction.” I had a tough time defining stress also. In fact, the first 2 paragraphs of my article say it all:

“Defining “stress” and how it is expressed and managed in both psychiatrists and patients is a difficult proposition. This Special Report focuses on stress and the middle ground between the impulse to say there is no such thing as “stress” and the tendency to describe many explicit addressable issues under the monolithic term, “stress.”

I remember what my ward supervisor once told me about stress when I was a resident in psychiatry. I was presenting a case about a patient who was depressed and complaining about all the stress in her life. At that point, he barked testily, “There’s no such thing as stress!” He went on to direct me to be more specific in my interviewing techniques in an effort to identify the concrete problems that my patient was experiencing, instead of substituting a sort of shorthand (i.e., “lazy”) method of indicating the source of her depression. In his view, the term “stress” was being overused and it had become virtually meaningless.”

At the time I wrote that article, there was surprisingly little data about stress in psychiatrists. On the other hand, it was well known that psychiatrists are prone to stress, burnout, and suicide.

As I read my own article, I was surprised at how little things have changed over the years. In fact, they have gotten much worse. There is a lot of talk about The Great Resignation. Health care workers are leaving their jobs in droves, often due to the pressures of the pandemic.

I was and still am a fan of Stephen Covey’s wisdom:

Covey disparages the “Great Jackass” theory of management, in which the carrot-and-stick style of leadership dominates. Adopting a principle-centered leadership paradigm entails a commitment to change at the individual level, working from the inside out. This means building self-awareness, identifying one’s own vitally important goals, and creating a balance that includes a devotion to living, loving, learning, and leaving a legacy. In turn, this might lead to identifying a personal mission and a vision for an organization that empowers others to find their own motivation to service. Many of the problems that Covey finds in big business exist in the mental health care sector-low trust, low productivity, and environments in which the cultures of blame and victimization, political gamesmanship, and apathy spread. These are often the issues that get subsumed under the name of “stress” in academic departments, community mental health centers, and private practice groups.

Of course, despite how wise I sounded back then, I still ended up with burnout. It took a lot out of me, but it didn’t destroy me.  According to some figures, about 40%-60% of physicians are burned out.

One guy I admire a great deal is Dr. George Dawson, MD. He writes the blog Real Psychiatry. He has been fighting the pressures in the health care system for decades and signs that he’s still going strong are in the Psychiatric Times article “The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA.

The interviewer for that article, Dr. Awais Aftab, MD asked George what he thought about the system that psychiatrists must work in which tends to discount the effect of social adversity, poverty, and trauma on the psychiatric distress of their patients, yet corner them into a pill-prescribing role.

George replied, “I heard repeated stories about how child psychiatrists and pediatricians were expected to provide a miracle medical cure to address complex psychosocial problems.

As the number of prescriptions increased there was concern that children were being overmedicated and treated with inappropriate prescriptions like atypical antipsychotics. At that point a consultation line with a child psychiatrist was provided for these prescribers to discuss the prescriptions. At no point were the psychosocial parameters addressed and they still have not been addressed to this day.”

In response to Dr. Aftab’s question about George’s recommendations for how to address this situation:

“I have been writing and speaking about this in various capacities for the past 30 years. During this time very few physicians have been interested in a political fight. The only major figure in psychiatry I can recall is Harold Eist, MD, when he was the president of the American Psychiatric Association. Practically all other professional organizations are silent about managed care and pharmacy benefit managers as malignant forces. There is a lot written about burnout and how these companies waste physician time to the tune of billions of dollars a year. Nobody seems to talk much about all the free work physicians have to do to support the conflict-of-interest-driven decisions these companies make. There is some current interest in the Maintenance of Certification (MOC) issue that professional organizations have also ignored. But in general, nothing will happen until many more physicians get activated and unite. There is still the escapist dream out there that “I can still do private practice,” but that is vanishing fast.

After decades of elaborate planning and recommendations, I am back to the beginning. The course of action at this point is fairly simple. There has to be united agreement on the fact that managed care companies and pharmaceutical benefit managers work against the best interests of physicians and their patients. Once that recognition is there, a rational course of action may follow. But it does take physician professional organizations taking a clear stand against these business practices.

I do think there is a lot to be said for specialty clinics that are outside of the administrative scope of managed care companies. The first groups I noticed were radiologists and anesthesiologists. They were followed by surgical specialists. I do not see many large free-standing psychiatric practices. I think it is possible to practice with a group of like-minded psychiatrists and provide excellent care based on an agreed upon practice style that will result in greater degree of professional satisfaction than is possible as an employee of a managed care company. The required business expertise and planning is a deterrent to most but knowing what I know about the landscape today I would have tried it much earlier in my career.”

George announced his retirement in January this year. But he’s not done.

Dr. Miller suggests that we come up with a lingo that’s more precise to clarify what mental illness and mental health are and what our positions as practitioners and patients ought to be—and what we should do.

So that naturally led me to Allen Frances, MD, who wrote the book on the subject several years ago, “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5.” Dr. Frances was also interviewed by Dr. Awais Aftab, MD, leading to the article “Conversations in Critical Psychiatry: Allen Frances, MD, published in May of 2019.

Dr. Frances says this about what he believes is “among the noblest of professions”:

 “I fear that too many psychiatrists are now reduced to pill pushing, with far too little time to really know their patients well and to apply the rounded biopsychosocial model that is absolutely essential to good care. We also have done far too little to educate the primary care doctors who prescribe 80% of psychiatric meds on the principles of cautious prescribing, proper indications, full consideration of risks, and the value of watchful waiting and tincture of time.

 I despair the diagnostic inflation that results from a too loose diagnostic system, aggressive drug company marketing, careless assessment, and insurance company pressure to rush to judgement. Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis. And, finally, I object to the National Institute of Mental Health (NIMH) research agenda that is narrowly brain reductionistic; it has achieved great intellectual masterpieces, but so far has not yet helped a single patient. So, in sum, I have loved being a psychiatrist, but wish we were better organized to end psychiatric suffering.”

Essentials of Psychiatric Diagnosis by Allen Frances

He rejects the dichotomy that mental illnesses are either diseases or problems in living as far too simplistic.  He deplores the tendency of the DSM 5 to confuse mental disorder with “everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition.” He says the DSM should be only a tool to help guide clinicians’ judgment, not replace it.

So, let’s stop stressing ourselves out looking in the dictionary for definitions of mental health and mental illness.

with permission from the publisher Guilford Press
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