What fear looks like part 3

Another in a series of posts featuring images that somehow depict panic and anxiety. These are photos that can set my heart to racing before I've consciously realized what I'm looking at. Seriously.*








See any common themes?

* From an an article about neuroscientist Joseph LeDoux:

"Over the last decade or so, LeDoux and others have worked out this circuitry in lab rats step by step, each accreted detail sending a small ripple through the world of human psychology. His laboratory has been able to show that as soon as conditioned animals hear the tone that precedes a shock, the auditory information travels to a way station in the brain known as the sensory thalmus, an essential stop for any incoming information about the world, and then immediately continues on to the amygdala. In rats, a fear-inducing sound goes from the ear to the amygdala in 12 milliseconds - that is, 12 one-thousands of a second. Moreover, LeDoux says, cells in this corner of the amygdala, known as the lateral nucleus,"learn" and memorize the fearful stimulus with incredible rapidity and tenacity. The research suggests that all it takes is one terrifying experience to form a lifelong emotional memory, one that is extremely difficult to erase.

"While LeDoux's lab has concentrated on this downstairs circuit, the laboratory of Michael Davis, now at Emory University in Atlanta after 29 years at Yale, has sketched out what might be considered the high road in the processing of fear, one that may more closely mirror the routine processing of fearful information in humans. It passes from the sensory organs, like eyes and ears, and lingers in the cortex, where conscious memories are formed, before threading down to the amygdala. Davis has also tentatively identified a separate destination, called the bed nucleus of the stria terminalis, which is heavily connected to the amygdala and seems to control chronic states of fear like anxiety and worry.

"This may sound like a lot of dense neural cartography, but the significance for psychiatry, if the same dual circuitry pertains to humans, would be profound. It suggests that because there are two different neural routes to the amygdala, two different kinds of fear-related memory can form. Indeed, one of the provocative things about LeDoux's circuit is where it doesn't go. It doesn't go to the thinking part of the brain first. And what that implies - certainly in rats, and almost certainly in humans ... is that we experience, learn and unconsciously commit to emotional memory many fearful situations, without ever being aware of what has triggered the racing heart and quick pulse.

"One hallmark of a panic attack, for example, is that its victim cannot understand what has triggered such a powerful reaction. The implication of fear-conditioning experiments in animals is that we have a separate memory of a fearful stimulus, be it a bear or a dinner party, lodged in the amygdala, probably informed by things we have heard or seen but do not consciously remember. So it's as if we walk through the world half-blind, bumping into archival stimuli, things we never knew scared us, things that we can't consciously remember but that nevertheless set in motion inexplicable and disturbing sensations of dread. Freudian analysts who have followed the work of LeDoux and others have been quick to point out that neuroscience's version of unconscious fear, in the words of Dr. Jean Roiphe, a Manhattan analyst, "strongly corresponds with the Freudian notion that it's indelible and never goes away."

(Italics are mine.)

WHAT FEAR LOOKS LIKE, PART 1

WHAT FEAR LOOKS LIKE, PART 2

Hey Slapass What Are You Supposed to Be Doing Right Now Taint This

Hey fathead!

What are you doing here, anyway? Are you malingering, procrastinating, wasting your precious gifts, face deep in a laptop when you could be face deep in the lap of a fine young man or woman, ignoring your garden, ignoring your children, ignoring that strange man at the front door with the funny tic in his eye and the metallic smile, wishing you were somewhere else, wishing you could run off and join the circus, wishing that the world would stop and grant you a few more hours, biding your time until the muse comes up and bites you on the perineum, wasting your time until the oceans rise and wash over you and your uncompleted manuscripts?

Go on, get outta here! If I catch you on Twitter later this evening, there will be hell to pay, I assure you.

Are you still here? Do I have to take the switch to you?

Go away. Your naughtiness will be recorded in the annals for all to read and you will be mocked and people will throw potatoes at your head. And maybe bricks and nails.

I'm getting really angry now.

Go and make beautiful art, muttonheaded buffoon! The world is mooning over you, prematurely. The celebrity rags have already prepared their articles.

I am going to get on a plane now and whup the daylights out of your porkchop ass. Get ready, dinkums. When I arrive, I expect to see a first draft. Or hear your fine composition on the peee-a-no. Or taste your cake baked in the shape of the state of Texas. Or see the tree that you have carved into a fine replica of Abraham Lincoln. Or pet the little knitted Zombunny that you have stitched in your spare time.

Go now and do what you are meant to do.    

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Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing

My malpractice carrier, which is physician owned and operated, recommends taking one of their seminars or online courses on different aspects of medical malpractice every year, and gives those policy owners who do a 10% discount on their yearly premium. 

The course I took this year was on misdiagnosis.

The course was not really geared to psychiatrists at all, but it seemed to me that the general advice still applies to them. However,  in my experience the advice is not clearly being followed by a lot of my colleagues these days. If these recommendations are indeed valid, and I certainly agree that they are, a lot of psychiatrists are getting away with gross negligence. 

Statistics show, by the way, that doctors are actually far more likely to get sued for something they did not do wrong than they are to get sued for actual malpractice. Isn’t that bizarre?

Some of the advice in the malpractice course concerns two major criticisms of my colleagues that I have written about extensively on this blog and in my last book: relying on symptom checklists, and relying on a diagnoses made by a prior clinician. Truly frightening.

So, as a public service, here’s some information from the course that psychiatric patients might find useful if they are considering suing a psychiatrist for malpractice. From MedRisk (Medical Risk Management, Inc.).

Misdiagnoses were more likely to be considered negligent in malpractice suits. Misdiagnoses were more than three times more likely to result in serious patient injury than medication errors.

2.      Multiple case law decisions have consistently held that the patient has no duty to volunteer information the physician does not ask about, and the patient’s only duty is to answer the physician’s questions honestly. (A smoker actually has no duty to tell his cardiologist about the smoking if the cardiologist does not ask!)

3.      Review any written history questionnaires with the patient to make sure the information is accurate. Patients who are sick or in pain can’t be relied on to even read the questions carefully, let alone provide thoughtful answers. Many patients will simply respond with a “No” to all prior diseases without reading the list and some patients, as discussed below, may not even be able to read or understand the questions. For example, the patient with a known history of high blood pressure may answer “No” when asked if he has ever been diagnosed with hypertension simply because he doesn’t know that they are the same thing. So make sure that your questionnaires are worded as simply as possible. Even then, review the responses verbally with the patient and make sure that you really do have a useful medical history. 

      

      Most healthcare instructional materials provided to patients are written on a 10th grade reading level or higher. Yet the reading level of the average patient is 4.6 grade levels below the last year of school completed, which means that a typical high school graduate reads at around an 8th-grade level. Further, the average Medicaid recipient reads at less than a 6th grade level, with more than one-third reading below the 4th grade level.

4.      Hear the patient outwhile taking the history and do not interrupt. Physicians are often overworked, overbooked, and scrambling to stay on schedule. This can leave them anxious to get to the point of a patient visit. One study found that physicians on average interrupted patients only 18 seconds into the explanation of the reason for the visit. This is significant because patients typically have a list of several complaints or observations they would like to discuss, yet rarely get beyond the first or second before being interrupted. Cutting the patient off before you’ve heard him out is called “premature closure,” and the main problem with this approach is that it assumes that the presenting complaint carries the most medical significance.

This is often not the case because the patient experiencing multiple symptoms may not know which are the most important, nor which may be related to the same underlying cause. For example, the patient who reports transient blurriness in her right eye may not realize that the simultaneous tingling sensation she feels in her right arm and leg are related. Premature closure typically involves a patient with a serious but uncommon diagnosis who presents with symptoms suggestive of a less serious and more common diagnosis.  

Contributing to premature closure is a general human tendency to hear what we expect to hear, and mentally filter out as extraneous any details that we don’t expect. Fortunately, the main assumption underlying premature closure—that patients will talk endlessly if allowed—appears to be incorrect. Several studies have found that patients who are allowed to list all their concerns without interruption rarely speak for more than two minutes. Allowing the patient those two minutes not only prevents premature closure, but can actually save you time by allowing you to focus on the most important symptoms first. It also avoids those “Oh, by the way…” conversations in which the patient brings up a new problem just as you’re headed for the door.

And finally:

5.      Every doctor owes a duty of making an independent assessment of the patient, utilizing the full range of his or her clinical skills, regardless of whether you’re a primary care provider or a sub-specialty consultant. If you’re an FP [family practitioner] and receive a specialty ob-gyn report informing you that a 60-year-old woman who had a hysterectomy 15 years ago is pregnant, you’d obviously recognize that you’d received the wrong patient’s report or that some other mix-up had occurred. Yet far less blatant errors occur all the time in the exchange of patient information, and you should always be mindful of that possibility any time the specialist’s opinion doesn’t fit your clinical finding or the patient fails to respond to treatment as expected.

Clearly, the same can be said for not entirely relying on the diagnosis of some other practitioner even  in the same specialty, who may or may not have done a good diagnostic workup, but instead doing one’s own independent assessment. If a  psychiatrist prescribes something to you after initally talking to you for just fifteen or twenty minutes, find another doctor.

The Manny Diaries Part Five What a World

The Manny was in the house.

For a couple of hours, we heard nothing. He was up there, sleeping it off. I wondered when I would see him.

Our upstairs bathroom has two doors. I had entered through door #1, while door #2 remained closed. I was putting my contact lenses into my eyes, when he lurched in through door #2, looking like he'd been deposited there by a tornado belching up its unwanted offerings. He was wearing a snappy new pair of pajama pants but otherwise looked unwashed and miserable. His eyes looked like fried eggs sprayed with shellac.

"Why, hullo," I said. He promptly screamed like a little girl who has seen a spider.

"I'm sorry I'm sorry I'm sorry," he mumbled, and then he repeated one of his favorite maxims: "People scare me."

He used to say this a lot when he first moved in with us. You'd surprise him at a bend in the stairway and he'd shriek and flutter back against the peeling walls, whispering People scare me. We have two stairways in our house, front and back, and so he'd take to creeping down one when he knew the other was occupied, just to avoid unforeseen meetings. No matter how innocuous your behavior, if he ambled into the kitchen and saw you there frying up an egg he'd gasp and flail backward as if spying a predator with a baseball bat.

"What, you didn't expect to see me?"

"It's just that...people scare me."

He told me once why it was. He did it to stop himself from immediately beating the tar out of whomever innocent had startled him. His natural reflex was to launch himself into kill mode, and to arrest this impulse he had developed a highly-tuned startle reflex, so that the first impulse became "scream like a tiny girl in panties" while "destroy the enemy" moved into second place. While in Vietnam, he had been taken prisoner for several weeks. They had sliced both his Achilles tendons so that he couldn't run away, and then they punched and kicked him until he spat blood.

But on this morning in the bathroom, I didn't know that story yet. I turned to him and said, "So, I hear you were in the hospital?"

He shook his head vigorously. "No way, no way.  Hospital? Pffah! I missed my flight, man. It's my friend. The friend I was staying with. She got me all upset. She pushes my buttons, man, she pushes my buttons!" And he jabbed at the air vigorously.

"So you weren't drunk and strapped down by EMTs and carted off to Bellevue?"

"Crazy talk," he said. "Lies!"

"What about your tooth?" I said.

He said: "I am dead inside. I am just dead inside. My toof hurts."

I prodded at my contact lens until it made purchase with my eyeball.

"What will you do about your tooth?" I asked.

"That bitch ruined it all!" he said, running his hands through his now-short hair. "She was out to get me, let me tell you. She set me up. She ruined me. She ruined my life. Lies. I mean, she called an ambulance on me. Who would do that? WHO would do that?"

"Maybe she was trying to help?"

"Help? She was trying to ruin my life. She was trying to see me destroyed. This is what happens when you trust people, Miss Jennifer. This is what happens when you are a nice person. Oagh, my toof!" 

I couldn't look at him anymore, so I backed away and darted downstairs. I heard him shuffling and mumbling about upstairs. Then I heard him plodding back to the attic. My husband sent him an email. It told him that we knew the true story and, while we loved him, he must not drink one more drop of alcohol. If so, he would be out. Last chance. And he didn't come out of the attic—not at all—for two more days. I swear I didn't hear him come out to urinate, or anything. He didn't eat a scrap.

I asked a friend for some advice and she said: "He's up there detoxing. Your home has now become a halfway house, a rehab facility. With three kids under the age of 10 under the roof. I guarantee that you are not prepared to handle this. This man needs medical supervision. You should get him to a hospital."

I looked upwards, to the attic, and thought of the ominous and terrible task of extracting the Manny and delivering him to a nearby hospital, with no medical insurance. I thought of the only possible recourse if he should come barging down in a drunken apoplexy, which was calling the police. That would truly "ruin his life." I thought about the fact that it was only 6 degrees outside. Drunks die in the snow.

I thought about the fact that once, when Manny was a very young boy, he had seen an old man stumble off some apartment steps in the cold. The old man had fallen and his teeth had been knocked out—bang!—on the concrete, and he had died right there at Manny's feet. And Manny had wanted to tell someone, anyone, but his adoptive parents (distant relatives of some sort, as his biological parents had been murdered by Stalin) didn't love him and didn't care about anything he had to say or think.

He said to me, "What a world. What a world! I watched that old man die, and no one cared."

I looked up toward the attic and simply waited.

Oh, what a world! What a world!