Veterans Day

Take time out and thank a Veteran today.

As we remember our Veterans today, those who served, those who fought, and those who died in the service of their country, let us also remember that many of our Veterans are carrying physical and emotional scars. To that end, this bit of historical and educational information is dedicated to the walking wounded....

Today we call it Post-traumatic Stress Disorder (PTSD). It has gone by many names. In the U.S. Civil War, it was "nostalgia," "soldier's heart," and "Swiss disease." Its symptoms are not new. The ancient Egyptians, Greeks and Romans all write of severe anxiety attacks, and physical symptoms associated with battle. Herodotus, writing in the 5th century BCE, tells of somatic symptoms of blindness of a soldier who witnesses the death of a comrade. Herodotus also tells of a Spartan who was so anxious as to be nicknamed "The Trembler;" a soldier who later hanged himself, presumably in shame.

As the 19th century approached, psychology was beginning to gain acceptance in the medical community, and terms like "traumatic neurasthenia" became known in the doctor's offices. World War I gave us "shell shock," a term specifically for those with neurological/physical symptoms, but without overt physical injury. Contrary to the image created by the term, most cases were not due to any actual explosions, but just exposure to the trauma of the battlefield. This was not always diagnosis of understanding: Frederick Parsons, a commanding officer at U.S. military hospital Number 117, said "a war neurosis which persists is not a creditable disease to have ... as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies." And that "no one should be permitted to glorify himself as a case of 'shell shock.'"

By World War II, the diagnosis of "combat fatigue" was given to those with a set of symptoms most similar to our current diagnosis. The numbers from WWII are quite impressive. Of the 800,000 or so direct combat troops, greater than 35% required discharge due to psychiatric reasons. Over 1 million American Soldiers suffered some psychiatric debilitation for some period of time, and over 500,000 were discharged or hospitalized due to psychiatric reasons.

Somewhere between the Korean and Vietnam War, the term "Combat Stress Reaction" gradually made its way into the medical parlance. This description was used somewhat interchangeably with Combat Fatigue, and PTSD, although it became further defined as a more acute process, rather than a persistent and recurrent anxiety state. It was Vietnam, though, that ushered in the PTSD diagnosis. Some studies have shown estimates of 400,000+, out of 2.8 million who served, as having PTSD. PTSD was added to the DSM-III in 1980. The wars in Iraq and Afghanistan have brought a new generation of service personnel affected with PTSD.

The DSM-IV criteria for PTSD are quoted as follows:

A. Exposure to a traumatic event

B. Persistent reexperience (e.g. flashbacks, nightmares)

C. Persistent avoidance of stimuli associated with the trauma (e.g. inability to talk about things even related to the experience, avoidance of things and discussions that trigger flashbacks and re-experiencing symptoms fear of losing control)

D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilence )

E. Duration of symptoms more than 1 month

F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)

For many veterans, PTSD is only part of the picture. Depression, other psychiatric conditions, and substance abuse often present as comorbid and contributory conditions, making for a very difficult to treat cluster of symptoms. Many veterans have difficulties with getting help, in part due to their own reluctance to address the painful issue, and sometimes due to the limitations of the health care and military systems. Stigma continues to be a significant problem; many veterans that I have seen professionally often confide that it took a great deal of courage, support, (and severe symptoms), in order to get them to see a psychiatrist.

Medication and therapy are common treatments for PTSD. Our local VA (like many others) has therapy groups specifically designed for veterans with PTSD. These are mostly in the "support group" modality, and often coincide with other treatments, such as individual therapy.

From an analytic point of view, I have always thought of PTSD as being a very dichotomous state. The cognitive component of the anxiety appears to be definable in two opposite areas: "Destroy" or "Be Destroyed." Both components are often present in the veteran with PTSD. They have not only the fear of harm, but a fear of loss of control, and with that, the potential harm they present to others. This often differentiates (from a therapy standpoint) the PTSD of the veteran from other traumatic sources, such as those who have been in severe car accidents.

Families and friends are often dramatically affected by the chaos that PTSD presents. It is important to be consistent, calm, patient, and supportive of loved ones as they go through the symptoms. Encouragement to seek help, and educating veterans that they are not alone in their struggle is what usually has led most veterans on their path of recovery. Many programs for veterans support exist. Now, more than anytime in the past, the Department of Veterans Affairs has taken a proactive approach to PTSD treatment.

For the rest of us, again, if you know a Veteran, call them, see them, thank them.

Music Update

With all of this angst floating about, I have decided to have a moment or two of Zen.

First up is a trip back to childhood, a good place for Zen to take us. Gordon Lightfoot has always been a favorite, and takes me back to sitting on my father's large chair listening to oversized headphones playing Gord's lilting sound on a Roberts reel to reel.

I have stayed a solid fan throughout, having performed a few pieces at a coffeehouse or two in the folk incarnation of a band called "Evergreen." Pussywillows, Cat-tails is a fairly early Lightfoot number, from the 1968 album "Did She Mention My Name." While not his best, nor even my favorite of Lightfoot's work (perhaps Christian Island, Don Quixote, Black Day in July--ironically, the flip side of "Pussywillows" single--, or Softly would be in the running there), this song definitely sets the mood I am reaching for.

There are no single renditions that can be embedded easily, so this video has a couple of bonus songs, including The Kingston Trio's "Raspberries, Strawberries" and the lovely Marianne Faithful version of "Greensleeves." (UPDATED: The video previously posted is no longer available; I was able to find a suitable replacement. )

For those who have been following along, musically two of my passions are downtempo or "chillout" music and, of course, Norah Jones. Norah has been lending her god given talents to so many artists over the past 8 years, (Willie Nelson, Ray Charles, and Outkast sure fill out a diverse discography), some of her earliest work was with a downtempo/triphop eclectic group called Wax Poetic. Norah was a member of this band before "Come Away With Me," and had a small bit of commercial success with this song "Angels."

Thievery Corporation did a very nice remix, in which they chill it out even more (Nip/Tuck fans may remember), but I still dig the ease of the original most.

Pour a cup of Chai and light some lavender candles. Breathe. All is well.

Angst and Medical Truths #4

It was about four weeks ago when I had a realization. Not an epiphany, but a realization nonetheless. Summer has usually been fairly laid back professionally, with plenty of days to catch up on paperwork, cleaning the cobwebs out of the office, do a bit of journal reading, taking the family down to the beach, etc. Certainly there was sufficient time to take a couple of nice camp-outs with the scouts (one in Jamaica!), and get in a little basketball, reading, and movies. But, otherwise, at the office, it was just busy. September usually brings spike in traffic, as kids get back to school and people are often just a bit more stressed, and more likely to schedule appointments.

This September, however, brought a tidal wave of work to the office. New consults, increased follow-ups and many, many more phone calls have made for a fast paced past several weeks.

Don't get me wrong, there's no complaint, as it comes with the territory, and busy business is certainly better than no business. I was just curious as to what was going on.

Which brings me to Medical Truths #4 :

"When you don't know, ask."

So I did.

What I found out was that people were just more anxious out there. They weren't coming in to the office saying "I'm worried about my 401K" or "I am worried about another terrorist attack." Those were conversations I have with my friends and family; patients weren't bringing it up very often. More curiously, even with patients with severe neuropsychiatric conditions, there seems to be just a bit more frequency in the appointments, and severity in their symptoms.
The anxiety appears to be pervasive, contagious, and ill-defined.

Angst is a wonderful word which is rooted in Old English (and thus, German); it's root is similar to "anger" and a close sibling of "anxiety". Popularized mostly due to the translations of Freud's work, it encompasses neurotic fear, guilt, remorse, and anxiety. Unlike Kierkegaard (who viewed angst as a fear of death and non-being), Freud viewed angst as being without any specific identifiable object. In current parlance, we might consider Freud's definition as a cross between a generalized feeling of dread and anxiety. The term angst has also been co-opted in existential thought, and certainly branches off at times from Freud, which would make for several interesting posts in and of itself. It is these variations of definition that have removed "angst" from common psychodynamic thought, reserving it usually only for the very serious, or not-at-all serious, discussants.

It does however, using Freud's definition, explain why my phone is currently ringing.

Disco Pumps?

Appreciation to a colleague contributor (look for him here soon) for sending this one my way:

WASHINGTON (Reuters) – U.S. doctors have found the Bee Gees 1977 disco anthem "Stayin' Alive" provides an ideal beat to follow while performing chest compressions as part of CPR on a heart attack victim.

The American Heart Association calls for chest compressions to be given at a rate of 100 per minute in cardiopulmonary resuscitation (CPR). "Stayin' Alive" almost perfectly matches that, with 103 beats per minute.

CPR is a lifesaving technique involving chest compressions alone or with mouth-to-mouth rescue breathing. It is used in emergencies such as cardiac arrest in which a person's breathing or heartbeat has stopped.

CPR can triple survival rates, but some people are reluctant to do it in part because they are unsure about the proper rhythm for chest compressions. But research has shown many people do chest compressions too slowly during CPR.

In a small study headed by Dr. David Matlock of the University of Illinois College of Medicine at Peoria, listening to "Stayin' Alive" helped 15 doctors and medical students to perform chest compressions on dummies at the proper speed.

Five weeks after practicing with the music playing, they were asked to perform CPR again on dummies by keeping the song in their minds, and again they kept up a good pace.

"The theme 'Stayin' Alive' is very appropriate for the situation," Matlock said in a telephone interview on Thursday. "Everybody's heard it at some point in their life. People know the song and can keep it in their head."

Some thoughts:

1. Did they have a comparator group listening to Mel Torme?
2. Will people compress harder during the “ah, ah, ah, ah” part?
3. Will the AHA have to pay a royalty?
4. For those of you who are under 30, or are Disco-phobic, a la Dr. Johnny Fever, I’ve done some research to find alternatives in the 100-105 BPM range:

-“Werewolves of London” by Warren Zevon (keep pumping through the "Aaaarooo"s)

-“Superstition” by Stevie Wonder

-“Sittin’ on the Dock of the Bay” by Otis Redding (Think of the bass line)

-“I Walk the Line” by Johnny Cash

-“The Real Slim Shady” by Eminem (do not use E's hand gestures.)

-“I Think I love You” by the Partridge Family (also a good song for euthanasia, I imagine)

-“Sledgehammer” by Peter Gabriel (may result in broken ribs?)

-“Back to You” by John Meyer

5. CPR guidelines have changed, per the American Heart Association. No rescue breaths or mouth to mouth is recommended now, just compressions. Some other experts still recommend mouth to mouth as part of the overall CPR, although studies do seem to show a more favorable outcome for compression only training.

6. If you are not CPR trained, please become CPR trained. Find a class near you.

Grand Rounds

Grand Rounds is a weekly summary of some of the medical blogs in the blogosphere. It is hosted by a different blogger each week, and usually with a theme running throughout the post. This week, T. at Notes of an Anesthioboist brings her edition out with some nice organization and a few good movie references to boot.

Click here for Grand Rounds

"I'm your biggest fan."

From iTWire Australia: Study finds most celebrity stalkers are mentally ill

From Craegmore News: Celebrity stalkers are mentally Ill.

From The Sun: Royal stalkers are mentally Ill.

From the APA Headlines: Celebrity stalkers may have much greater incidence of serious psychotic illness

A study suggests celebrity stalkers are more mentally ill?
Wow! Thanks for the newsflash.
Let’s dig a bit deeper:

Here’s a snippet from the APA:

New Scientist (10/8, Nowak) reports that the results of a study presented at a forensic science meeting in Australia suggests that, "rather than being hapless eccentrics, the majority of stalkers suffer from serious psychotic illnesses." Study leader Paul Mullen, D.Sc., a forensic psychiatrist at Monash University and the Victorian Institute of Forensic Mental Health," said, "We didn't expect such high rates of psychosis. It was very surprising to us." For the study, researchers "scrutinized over 20,000 incidences of stalking members of the [British] royal family, such as repeated and threatening letter writing, and repeated attempted approaches and attacks, from 1988 to 2003. The data was contained in files on 8000 people kept by the Metropolitan Police." After culling the files, researchers "examined in detail the files of 250 of the remaining 5000 people judged to be true stalkers. About 80 percent had a serious psychotic illness, including schizophrenia, delusions, and hallucinations, they found." Notably, this "finding contrasts sharply with people who stalk non-famous people," of which only "a fifth...have some sort of serious or severe psychotic disorder." _________________________________________________________________________________

Interesting. The newsworthy part here is that there is a greater rate of comorbid serious mental illness in this group of celebrity stalkers, than what has shown in other studies of non-celebrity stalkers. As to the science, I do wonder if there was a bias in the definition of stalking during the screening process (weeding 8000 people down to 5000). Also, this is a retrospective study (obviously, imagine recruiting for a double blind study!) and is not given an in-study comparator. Also, is this a trend only specific to the royal family? Is there a greater level of impairment if one is hung up over Prince Charles than Eva Longoria?

That all being said, there does seem to be a logic to the trend given that it would seem more “delusional” to develop a fixation with a person one has never met. It would be interesting to see what percentage of those delusional symptoms is persecutory or grandiose. Persecutory delusions are often seen in paranoid schizophrenia, and may involve famous people. For example one might believe that George Bush is bugging his telephone and wants to send him to Guantanamo. (Um, ok, make that Martin Sheen is bugging his phone..) Likewise, it would be consistent with grandiose delusions (as often seen in bipolar disorder) to develop a sense that a famous person is one’s soul mate (as I know that Norah Jones is for me).

Uma Thurman, David Letterman, Mel Gibson, Gwyneth Paltrow, Sheryl Crow, Olivia Newton-John, Sandra Day O’Connor (by the same stalker as Olivia Newton John!), Brittney Spears, Monica Seles, and Michael Douglas, are just a sampling of those in the news who have had celebrity stalkers. The effect can be quite devastating on the individual and their family. Many stalkers have tried to reach celebrities by going to the homes of the celebrity’s parents.

The challenge is in figuring out the severity of the stalkers potential for harm. Is a stalker a potential Mark David Chapman (stalker and eventual murderer of John Lennon)? Or is he a laughable (perhaps) William Lepeska, who swam naked across Biscayne Bay to woo Anna Kournakova, who ended up swimming to the wrong house, and getting an express trip to the psych ward?

The mere presence of “serious mental illness” alone though does not give one a sufficient predictor of dangerousness. Most studies have shown consistently that persons with serious mental illness (usually defined as chronic schizophrenia, bipolar disorder, chronic psychotic depression, or schizoaffective disorder) are more likely to be victims of violence than perpetrators of it.

The movies also portray the dualism of the stalker character. In “The King of Comedy” Sandra Bernhard plays a hapless comedic (albeit darkly so) stalker to Jerry Lewis’ talk show character. Ironically, Jerry Lewis had a stalker once jailed after the stalker showed up at his house with a gun. Wesley Snipes in “The Fan” is an all business stalker--angry, delusional, and on a mission. Kind of the middle ground of the stalker continuum. “Cape Fear” (Mitchum-1962 and DeNiro-1991) has a perfect sociopathic stalker. (Notice three DeNiro movies so far?) BTW, Kathy Bates in Misery is still my favorite, and scariest, on-screen stalker.

For a good book on stalking, and how one (especially young ladies) should respond to stalking, I’d suggest Gavin De Becker’s “The Gift of Fear.”

Stalking stories? Do share. Also, anyone have Norah Jones' phone number? :)

North Carolina Prescription Drug Plan?

This picture just tickled me over at GruntDoc. Go over there and leave a caption if ya' like.

Updated: Hey! How 'bout that, my caption won the contest! Apparently, I play well to the midwest and the southern element. Perhaps I should consider a run for national office. My prize, other than bragging rights, is this nice logo--which I will post with pride.