Sex, Drugs, and Twitter

The title is egregiously titillating, yes, although maybe the three may actually encompass human nature pretty well. Time today only for piggy-backing on Psychology Today, which has several interesting posts.

1. After I touched on the ambiguity of marijuana a few days ago, I see that Stanton Peele discusses the prospects of legalizing that drug (at least), in contrast to President Obama's dismissal of the idea. I am not voicing an opinion, just providing a link; and to state the obvious, legalization is no guarantee of benignity (see alcohol, cigarettes).

2. Satoshi Kanazawa presents evidence, furthering the sum total of unfairness in the world, that contrary perhaps to dumb-blonde stereotypes, there is a modest but real positive correlation between attractiveness and intelligence in both men and women. Superficiality as profundity.

3. Moses Ma considers the psychology of Twitter (basically, we evolved over eons in groups of 30 to 70 relatively close peers, and we're continually trying to recreate that in our socially deprived culture, but one can have too much of a good thing and become, if successful, a celebrity, and if unsuccessful, a narcissist). Actually I may give in to Twitter, as part of my slow descent into decadent digital distraction, and as a 140-character pithiness challenge. Blogs encourage prolixity. Bad.

Findings

(Franz Marc, "Tyrol")

Who am I

To stand and wonder, to wait

While the wheels of fate

Slowly grind my life away.

Who am I?

Country Joe and the Fish

(Thanks to Charles Anderson for reference).

I was reading Robert Lowell again this weekend. Overall he is not one of my favorites, but every now and then a few lines of his haunt me--for instance, the final section of "Hawthorne." This for me encapsulates the Romantic's dilemma--where is spiritual significance to be found? Science gives us facts; the universe is awash with truths, but there is truth and then there is Truth. Science cannot ultimately guide us to the latter--we must rely on contingency, consensus, debate, narrative, but without appealing to ghost stories...

Hawthorne

Follow its lazy main street lounging

from the alms house to Gallows Hill

along a flat, unvaried surface

covered with wooden houses

aged by yellow drain

like the unhealthy hair of an old dog.

You'll walk to no purpose

in Hawthorne's Salem.

I cannot resilver the smudged plate.

I drop to Hawthorne, the customs officer,

measuring coal and mostly trying to keep warm--

to the stunted black schooner,

the dismal South-end dock,

the wharf-piles with their fungus of ice.

On state Street

a steeple with a glowing dial-clock

measures the weary hours,

the merciless march of professional feet.

Even this shy distrustful ego

sometimes walked on top of the blazing roof,

and felt those flashes

that char the discharged cells of the brain.

Look at the faces--

Longfellow, Lowell, Holmes and Whittier!

Study the grizzled silver of their beards.

Hawthorne's picture,

however, has a blond mustache

and golden General Custer scalp.

He looks like a Civil War officer.

He shines in the firelight. His hard

survivor's smile is touched with fire.

Leave him alone for a moment ot two,

and you'll see him with his head

bent down, brooding, brooding,

eyes fixed on some chip

some stone, some common plant,

the commonest thing,

as if it were the clue.

The disturbed eyes rise,

furtive, foiled, dissatisfied

from meditation on the true

and insignificant.

Gross Anatomy for Psychiatrists

Alas, poor Yorick. I knew him, Horatio--a fellow of infinite jest, of most excellent fancy. He hath borne me on his back a thousand times; and now, how abhorred my imagination is! My gorge rises at it. Here hung those lips that I have kissed I know not how oft.

Hamlet

It is a psychiatry resident, Christine Montross, M.D., who makes the case in the NYT for cadavers over digital "equivalents" in medical education. As a doctor who nowadays never touches a patient beyond a handshake, I couldn't agree more, even though the experience of real dissection 18 years ago now was intellectually and existentially stressful in the extreme at the time.

Like any experience both transformative and traumatic, medical school leaves a number of indelible memories, but prominent among them was walking into the Gross Anatomy lab for the first time, where in my room there were perhaps a dozen cadavers, each shared by a team of four students. Before the actual dissections began, the entire class was brought in on an evening to be introduced, as it were, as was appropriate to the situation. The bodies bore no identification or information beyond what could be inferred from, well, their anatomy. "Mine" was a thin old man; I wondered endlessly what his life had been like and how he wound up there.

Medical school was plenty anxiogenic overall in an intellectual sense, of course, but Gross Anatomy added a reverential depth to the endeavor. Sure, there were the whisperings and gigglings over body parts, carried out to dispel anxiety most likely, but overall, the experience conveyed the message that the business of medicine was, literally, dead serious, about real people with real bodies that, as all bodies eventually do, failed. Our job was to find out why and to try to prevent it from happening to others in the future insofar as we were able.

The existential encounter was unforgettable; the actual dissection was, to me, a relatively distasteful denouement. It was clear early on that I was more of a theory person than a procedure person, although until I hit a superb VA psychiatry clerkship in my third year, I would have speculated that internal medicine or neurology was where I was headed. But inasmuch as in traditional medical programs, such as mine still was in 1991, the first two years was primarily about mastering massive quantities of abstract information, the experience of read cadavers was a crucial and concrete corrective, a reminder that medicine is about very specific lives and deaths. Gross Anatomy done virtually, in a disembodied fashion, would be very different indeed; like many rites of passage, this one gains in importance with time.

My wife's grandmother died not long ago, at the age of 95, and donated her body to a medical school. I can't imagine a better way to go.

Where is Wisdom to be Found?

A commenter helpfully brought up the question of how to go about finding, one hopes, above average psychiatric care. I don't claim any special expertise here, but as usual I can be induced to give an opinion.

What would constitute above average? I envision a psychiatrist who has both a healthy respect for the claims of biology and an acceptance of the ambiguity and limitations of our understanding and our technology. You don't want someone who is continually touting the newest thing, because in contemporary psychiatry unfortunately, newer is not always better; but neither do you want someone who hasn't heard of the newest thing, because even if newer isn't necessarily better, it may at least be an alternative.

You want someone who is creative with meds and won't give up on them (or other biological treatments) too soon, but who isn't focused on them to the exclusion of all else. He should offer a differential diagnosis that is shorter than DSM-IV, but he should keep the options open. Human nature being what it is, I would have to say you'd be looking for someone with a marked resemblance to yours truly (humble too).

If you see an $80,000 vehicle parked outside the office, that is a bad sign, as is a waiting room festooned with drug company paraphernalia, because that means he isn't thoughtful about appearances if nothing else. If he seems rushed and doesn't make eye contact, you're probably not getting your money's worth. With all due respect to foreign medical graduates, if you can't make out his words easily or he can't make out yours, he should have chosen a specialty less dependent upon verbal exchange. If he guarantees recovery or even improvement, beware, but if he despairs of the efficacy of his own interventions, suggest a career change.

I wish there were a pat answer for locating this hypothetical sage. Grading doctors and medical facilities on treatment outcomes is the growing if controversial rage, but as always this would always have to be more imprecise in psychiatry (if we can't all agree on the scope of some diagnoses, how could we agree on treatment parameters for those diagnoses?).

Obviously picking someone out of the phone book is the worst option, although it may well be better than nothing. The Internet is somewhat better--there may be a website that reveals the doc's mindset in some way, or a Google search can often reveal a surprisingly detailed trail of even minor publications or conference appearances.

A recommendation from another doctor or therapist is better yet, although keep in mind that they are usually going on inferences based on a psychiatrist's reputation or how he interacts with (referring) colleagues, which may be very different from his bedside manner or clinical acumen. Best of all is word of mouth from folks who have been actual patients--they have the point of view most worth having. But even this isn't foolproof--is he well-liked by patients because he doles out Xanax like candy?

If I had nothing else to go on I would go with an academic center if one with a psychiatry department were less than perhaps an hour away. Even if you get a resident, which is likely, the (relative) enthusiasm, eagerness to please, and exposure to new information may more than compensate for lack of experience, although you would need to confirm that there is supervision by an attending psychiatrist. Academia has all kinds of drawbacks, but in a field as variable and nebulous as psychiatry a large institution usually offers a degree of quality control.

If I were screening a psychiatrist for, say, a family member with severe depression or bipolar disorder, I can think of some questions that might assess clinical flexibility and subtlety. What are side effects of SSRI's? (If sex isn't mentioned, it's already time to move on). What are side effects of mood stabilizers? (If weight gain isn't mentioned, move on). What is your opinion on lithium? Is there an off-label role for drugs like Neurontin and Topamax? Do you feel comfortable prescribing MAOI's and tricyclics? What is the role of ECT? How much do meds usually cost? Are you comfortable with prescribing stimulants or benzodiazepines (the proper answer, essentially, is "It depends").

These are the thoughts that come to mind.

Junkies

Weave a circle round him thrice,
And close your eyes with holy dread,
For he on honey-dew hath fed,
And drunk the milk of Paradise.

"Kubla Khan"


1. Referrals to the clinic in the last few months have suggested an uptick in heroin availability, relatively cheap and "high-quality" stuff, in this area. Hard to resist, apparently, at least when you're young, bored, and have few prospects. It brings to mind Mexican drug violence, which has been in the news more lately and which for me had come appallingly to life in Robert Bolano's fictionalized account in 2666. It makes me wonder, with any given person, what awful things happened so that this guy could get his fix?

Folks in Mexico complain that the real problem is demand north of the border--is this due to our uniquely depraved American culture, or merely disposable income enabling the potential depravity of human nature? As a moral argument this is terrible; a prostitute could similarly say, "Well, the guys want it and will pay for it, so what's a gal to do?" Worse than vice is the inciting of vice in others. Purely as a practical argument, though, it does pay to arrest the Johns too. And the flood of American guns to Mexico sounds like another good reason for gun control to me. But I'm just a Liberal with a crush on Obama.

2. What is one to make of marijuana habits? It's illegal, it's bad for the lungs, and some studies suggest long-term cognitive damage with extended and heavy use. Rarely, it makes someone psychotic. But the problem is that in some areas, such as the ones I've worked in, its occasional use is endemic, and if one focuses on that with everyone who uses it a few times per month, one would never talk about anything else. And the evidence for marijuana as a "gateway drug" or as a cause of other mental disorders is pretty flimsy.

I don't use it and as a physician I don't condone it, but psychiatry doesn't seem to be too worked up about it. My current Textbook of Psychiatry (American Psychiatric Publishing, Inc.) devotes about one and a half out of nearly 1800 pages to cannabis. My Textbook of Substance Abuse Treatment (also APPI) devotes separate chapters to alcohol, nicotine, opioids, cocaine, stimulants, sedatives, and hallucinogens, but not to cannabis. Patients are surprisingly forthcoming about their marijuana, as if they not only don't see it as a problem, but can't imagine that even a stuffy shrink would either.

3. In Psychology Today Stephen Mason, Ph. D. makes a questionable attempt to revive the generally discredited notion of the "addictive personality." But the concept has all kinds of problems, including its tendency to overdefine a person and the splitting of folks into addicts and non-addicts. If one considers behaviors like eating, sex, the Internet, and gambling, I'm not sure there is even a consensus on what qualifies as addiction, much less any coherent construct of an addictive personality.

"Addicts" comprise a surprisingly diverse group and a wide spectrum of severity. Those who really will use any psychotropic substance within reach are rare. It is far more common to see the pure alcoholic, or the opioid abuser with no taste for cocaine, or the cocaine abuser with no taste for opioids. There are, to be sure, people whose impulsivity and whose need for external rewards put them at risk for problematic behaviors--I'm thinking of a former patient who was morbidly obese (largely due to binge eating) and who also had a pathological shopping habit, but she didn't abuse substances. It is hard to see how the notion of "addictive personality" is really helpful, unless it amounts to a global admonition like "If you drink or use drugs you will go to hell." On the contrary, individualize, individualize, individualize...

Sprung

Busy busy, time today only to note that in these latitudes it is March, not April, that is the cruellest month. So, a pair from W. B. Yeats (italics in original):

Her Anxiety

Earth in beauty dressed

Awaits returning spring.

All true love must die,

Alter at the best

Into some lesser thing.

Prove that I lie.

Such body lovers have,

Such exacting breath,

That they touch or sigh.

Every touch they give,

Love is nearer death.

Prove that I lie.

After Long Silence

Speech after long silence; it is right,

All other lovers being estranged or dead,

Unfriendly lamplight hid under its shade,

The curtains drawn upon unfriendly night,

That we descant and yet again descant

Upon the supreme theme of Art and Song:

Bodily decrepitude is wisdom; young

We loved each other and were ignorant.

Squawk

I had seen this local piece not long ago (by J. Peder Zane on the Twitter phenomenon) and then saw it again today on Arts and Letters Daily.

Do I need Twitter? Will it enhance my life? Or is this the tipping point at which my nervous system finally falls a fatal step behind the curve, starting the long stagger into senescence?

Shall I disturb the universe with Tweets? (That always reminds me of Peeps, the appallingly sweet and gooey Easter candy my kids love). More importantly, could I do so with a straight face?

What would Harrison Bergeron say?

What would Emily say?

No bobolink -- reverse His Singing

When the Only Tree

Ever He minded occupying

By the Farmer be --

Clove to the Root --

His Spacious Future --

Best Horizon -- gone --

Whose music be His

Only Anodyne --

Brave Bobolink --