Monthly Archives: October 2018

A Theory of Addiction

By Dr David Laing Dawson

My new theory about addictions, at least about the explosive increase in serious opioid addictions in the last few years:

I am well aware of the culpability of Purdue Pharma promoting Oxycodone, Oxycontin as “non-addictive”, coupled with an “academic” push to have doctors pay more attention to chronic pain, and then some sloppy prescription practices after acute injuries. And I am well aware that some addictions begin as self-medicating, usually self-medicating a mood or anxiety disorder.

I understand how hooked they are. How, once addicted, consciousness is reduced to getting that fix. Empathy is lost along with any ability to think beyond the fix and the avoidance of withdrawal. By that point there are brain changes and it is a disease.

And pockets of addiction can be found alongside unemployment, poverty and despair.

But this is 2018. Not 1932. There really is no shortage of easily acquired food, and despite the cries for more affordable housing for families, there really is no shortage of basic shelter for single men.

So why now are so many men sleeping on benches and on the hustle for drugs around the Sally Ann in my neighbourhood? And why is the otherwise fit looking man with his German Shepard dog willing to stand for hours in a cold drizzle at a busy intersection collecting coins from every tenth car that stops? And why on earth does anyone ever inject a substance into his vein that has a ?10, ?20 percent chance of killing him?

I have also had many clinical experiences of addicts, vague, unhappy, scattered in thought, pathetic in actions, but laser focused and energetic when it comes down to the moment of trying to persuade me to write a prescription. Tenacious, persistent, with far more stamina than I.

And here are two more seemingly unrelated bits of information: When we go on holiday our sense of well being peaks on day 8. It is downhill after that. Time to go back to work, we say, by day 12. And some zoos have learned that making the carnivorous animals hunt for their food, rather than just giving it to them, makes them happier and healthier. And the retired couple, free now of children, mortgage and job, free to roam in an RV. What do they always do? They get a dog, or two dogs to fuss over, look after.

We humans were not made for leisure. Our DNA tells us we need to hustle. We need to hunt for food, check the barricades, repair the roof, fashion the spear, dig the trenches, work for ten hours in the mine, or kitchen. We are programmed to be busy. And our busy-ness rewards us with food, safety, or some small achievement. (I am quite amazed how delighted I am when I manage to complete a New York Times Crossword puzzle and then cast it aside to look for a new one.)

Challenge, occupation, risk, reward, repeat. (note that this is the same sequence video games provide)

Our focus has been on the reward, the drug, swallowed, snorted or injected. We can make that safer with safe injection sites. We can eliminate the need for the hustle if we provide the drug. But what of the challenge, the occupation, the risk and the repeat? What of the need for the hustle?

My new theory is that these last few decades have removed the natural life challenges and occupations for more and more men, and that drug addiction provides just that. That is, it provides not just the reward (the drug) but also the challenge and occupation, the risk and repeat.

As do video games for the young man in his parents’ basement.

We can “treat” addiction, try to eliminate drugs, or provide the drugs legally, but how do we replace challenge, occupation, risk, reward, repeat as the robots take over all the work?

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The Art of Psychiatry

By Dr David Laing Dawson

The Eyes, ahh, the Eyes.

Some years ago a psychiatrist asked me to see one of his patients on the ward of the mental hospital. She had been admitted in a state of psychosis; he had prescribed appropriate medication, and then later increased that medication, and now she sat alone all day, communicating with no one. Was the dose too high? Had he made her toxic? Should he stop the medication?

In her room the woman sat fully clothed on the side of her bed staring straight ahead. I introduced myself and talked with her. I sat beside her on the bed and talked to her. I received no answer, verbal or non-verbal. I looked closely at her eyes.

I left her room and talked with her doctor. Increase her medication I told him. He raised his eyebrows. No, I said, I’m sure.

He did so and the patient recovered, first in small ways, acknowledging the presence of others, and then talking, engaging, and plans for discharge were made.

Her eyes told me she was in a state of high arousal, not drugged at all, but rather in turmoil, flooded by fears and anxieties to the point of immobility. Her eyes were alive but focused internally.

It is easier to be a poet than a scientist when it comes to eyes. A nurse might say to me about a patient, “The lights are on but nobody’s home.” It is an apt phrase, so accurately describing a state of dementia. In early dementia the right image, phrase or music might bring that person back home for a while, but then she will leave home again, and, eventually, not return.

And then there is the stare of the true believer, aroused and focused, all knowing, all seeing. They are the same eyes one sees in delusional states. Perhaps they are daring one to challenge them. They send no signal of welcome, no invitation for discourse, no flicker of doubt. They are the easiest to imitate.

Boys on the ASD spectrum avoid eye contact, and when they are coaxed into making such “contact”, the eyes quickly touch and then slip away, as we do when we glance at the sun.

The girls, the ASD girls sometimes stare fixedly, unblinking. They make “good” eye contact we notice, but the dance is wrong, the movement static, the intent unreadable; my smile goes unanswered by her eyes.

The eyes of the man with schizophrenia are similar, but often flit from certainty to perplexity and back again, as if they are trying to decipher a very difficult passage in an ancient text.

Depression is always present in the eyes. The light is dimmed, the person home, but slow to answer the door. Sometimes they are hooded and dull, but other times, in agitated depression, fearful and searching.

And then mania. If it is an angry mania I sit low in my chair and make only fleeting eye contact, for fear of adding fuel to the blazing fire within my patient’s eyes. If it is a grandiose mania, I watch the eyes of delusion and true belief and wait for a moment of doubt, a shadow to cross those eyes, before I offer a comforting smile and some medication.

Smart Phones and Mental Health

By Marvin Ross

Can your smartphone usage predict your mental health? Silicon Valley seems to think so and millions are pouring into a start up called Mindstrong. The concept is that its “app, based on cognitive functioning research, can help detect troubling mental health patterns by collecting data on a person’s smartphone usage — how quickly they type or scroll, for instance.”

The app has generated tens of millions of dollars in investments from people like Jeff Bezos of Amazon and one of the company’s executives in Dr Tom Insell the former head of the National Institute on Mental Health. He acknowledged that the app isn’t perfect but the CEO told STAT that it “could provide unprecedented insight into conditions like depression”. They also told STAT that it “can even predict how a person will feel next week, or at least how a person will perform on the Hamilton Rating Scale for depression — kind of like a weather app for your mood.”

There is one little problem with the hype for this company. The program has never been validated by independent scientists and none of the results from 5 clinical trials have been released. They did publish a pilot study of 27 subjects and presented a poster of that which states that this is feasible.

This project came to my attention while I was reading Bad Blood Secrets and Lies in a Silicon Valley Startup by John Carreyrou of the Wall Street Journal. The book deals with a long standing health startup begun by a 19 year old Stanford dropout. Elizabeth Holmes was afraid of needles and decided that it would be possible to perform all blood testing with just a small finger stick as is done with blood sugar levels. Her idea was that the testing could be done instantaneously and people could even have these units in their homes.

She patented the idea, set up a company and managed to raise sufficient funds to value her company at $9 billion. Members of her board included former US Secretaries of State George Schultz and Henry Kissinger as well as General Mad Dog Mattis who went on to become Secretary of Defence under the Trumpster and Rupert Murdoch. Along the way, she managed to get testing done with the US Military and two pharmaceutical companies but those efforts failed. She also had arrangements with Safeway and Walgreens Pharmacy chain.

Investors have lost over $600 million in the venture including over $100 million by US Secretary of Education, Betsy Devos, and the heirs to the Walmart fortune. The founder was recently charged with criminal fraud.

So, if I’m a tad skeptical about using smartphones to measure mental illness, there is a reason. First, let’s have the data subjected to peer review in reputable journals.

Conrad Black and Donald Trump

By David Laing Dawson

I made the mistake of reading an article by Conrad Black. I usually avoid reading Lord Black of Crossharbour (“on leave”) for I find his over-use of penultimate, supercilious, pretentious, swank, grandiloquent, Miltonian, show-offy adjectives very annoying.

But I did read his paean to Donald Trump, and then went for a bicycle ride to clear my head. But what should one expect from a man who gave up his Canadian citizenship for a Peerage in the UK, and once flew across the Atlantic to attend a costume party dressed as Cardinal Richelieu?

He refers to all immigrants entering the US through the border with Mexico as illiterate peasants and he thinks Donald Trump is the leader America needs. He does find Trump “grating” and that he takes “liberties with the truth”, but he thinks that Trump can make America Great Again, and by that I think he is referring to a degree of respect we all must show for the man holding the true weapons of mass destruction in his hand. And by “respect” I think he means fear. Donald does seem to be on track for making America a country we soon will all fear.

Of course, Conrad Black, as a man barred from entering the United States, may simply be, like so many others, currying favour with the one man who could and might pardon him.

And then I read another by Lord Black along the same lines but more of a dissection of the geopolitical game afoot. And I was reminded of an experience from 1964. Bear with me for a moment.

Our first year medical school class went on a weekend retreat with faculty. This entailed a 90 minute bus ride to a resort north of Vancouver. By chance I sat next to our Professor of Physiology. The Vietnam war raged and was about to expand. My companion on that trip had fled McCarthy era USA rather than testify against his colleagues, who might or might not have attended a communist party meeting. So we talked Vietnam.

I was 24 at the time, but worldly and cynical. I argued geopolitics along the lines that it was better for the two major superpowers, the two competing ideologies, to be squaring off in the jungles of Vietnam rather than in the skies over Moscow and New York. He disagreed. It was simpler than that for my professor, who must have been in his 40’s or 50’s at the time. For him it was simply immoral. It was immoral for Americans to take their guns, their napalm, their warships and their helicopters to Vietnam and kill people. It was simply wrong.

By the end of that trip I had concluded that if he could remain idealistic in his 50’s, surely cynicism in my 20’s was, at least, premature. It wasn’t long after that I found myself in a placard carrying crowd in front of the American Consulate chanting: “Hey, Hey, LBJ, how many kids did you kill today?”

But why I was reminded of this was because Conrad Black was writing with his usual elegance and erudition about the geopolitics of recent years, the new balance of power, the symbolic chess game played by nation states, and prognosticating about the geopolitics of the future. And it is this examination of geopolitics that I can hear from other politicians, commentators, advisors, other writers. And it reminds me of my self, age 24, arguing, albeit more naively, about these world events and shifts and movements and power struggles as if they are being played on large chessboards by giants, with the pawns and rooks representing a few million to a billion people. And talking about it and playing the game as if they experience, think about, Joseph Stalin’s famous observation as advice, rather than the cynical observation of a sociopath. “One man’s death is a tragedy; the death of millions is a statistic”.

My medical school professor could see beyond the geopolitics and the million death statistic to the terrified little girl fleeing the sticky horror of napalm.

The Bannons, Boltons, Millers, Trumps and Conrad Blacks of this world do not, cannot.

I do not want them to have any influence over myself or the lives of my children and grandchildren. We need to stop listening to them and focus instead on the little girl fleeing the napalm and the kid from Honduras locked in an American cage.

Trump, Dr Ford, and A Warning to Americans

By Dr David Laing Dawson

I wrote a blog before the 2016 election of Donald Trump titled “the mental and emotional age of Donald Trump”. I looked at a range of his behaviours and his speech patterns and considered the age at which such a behaviour would be typical for a boy or man, though not exemplary, not necessarily good, maybe even requiring some parental admonition, just typical. I arrived at an average of 14. Though some Trump statements required a pre-teen brain and some rose at least to 18 year-old jock talk.

A comment someone left on that blog was that I was being generous; it would have to be a particularly entitled and narcissistic 14 year-old.

More recently I listened to Trump mock the testimony of Dr. Ford and then go on about the threat the #MeToo movement poses for fine young men. He took on the voice of a boy talking to his mother about all the hard work he’s done, about being offered a great job, but all this is over because some woman he’s never even met is accusing him of things he’s never done. How terrible this is for men and boys.

I might run across a small group of 14 year old boys with one of them going on in this vein, and two might be laughing, though more at the outrageous display of disregard for propriety than the content itself; another two would be cringing, but unable to break the code of teenage boys to never be a “pussy”.

So the comment was fair. Only a nasty, narcissistic, and probably guilty 14 year-old could talk the way Trump so often talks.

Donald may be but a symptom of some other struggle in your country, my American friends, and I know you have some wide divides that need major bridgework, but he is doing damage to your country, more and more damage each day he has a voice.

They were laughing at him at the U.N. Much of the world is appalled by him and all he represents. He throws oil on your fires; he cozies up to nasty dictators; he is stripping the USA of any moral high ground it ever might have had; he is creating fizzures in your country it may take decades to repair. He has reduced political discourse to a schoolyard brawl and international relations to flea market bartering.

He represents you, my friends, and how we see him we will begin to view you. We don’t care how you see us, you may say, we are better than that. But there is a bit of psychology here you might not like. For gradually, whatever traits we assign to you, you will absorb, you will become.

This midterm you can show the world you are not all Trumpets; you can clip his wings and put him in a tail spin. Please do so.

Anti-Psychiatry

By Dr David Laing Dawson

As a personal addendum to Marvin’s piece:

In the years before I studied medicine and then entered psychiatry, the mental hospitals, the Asylums, were full. I believe the largest in North America housed about 13,000 patients. There were no effective treatments (with the exception of ECT) though many things were tried, from field work and prayer to cold baths, spinning chairs, and insulin coma. These Asylums themselves grew from an increasing social awareness, acceptance of social responsibility, and recognition of the need for the state to look after the intellectually, cognitively, emotionally, and socially disabled among us. (roughly 1850 to 1990)

The doctors, the Alienists, and then the psychiatrists were given wide latitude to hold, to keep, and to treat.

Curiously I do not recall any active anti-psychiatry movement then or through the years 1960 to 2000 (with the exception of Scientology). And it was through those years that actually effective treatments were developed. And by effective I mean scientifically proven to be effective.

I can now prescribe something that quells mania in a few days, that pulls someone from a stuporous depression in two weeks, that reduces panic attacks, that eliminates the excruciating pain of agitated depression, that tempers debilitating obsessions and compulsions and that gradually returns the insane to a state of sanity – if my patient will let me.

And it is now, again curiously, at a time when psychiatrists do have effective tools to treat mental illness and when they are very restricted in any use of these treatments without explicit consent and when those Asylums have been reduced to a tenth the capacity they once had, that an anti-psychiatry movement has developed.

I have to conclude that the motivation for this anti-psychiatry movement is not the welfare of others but of professional rivalry and fear. And like some other attitudes today (anti-vaccination, anti-global alliances, pro-alternative medicine, anti-fluoridation), it has to be based on memory loss – that is, a profound memory loss of childhood death from diphtheria, WWI & II, the crippling polio epidemics of the 1950’s, the rotten teeth of the average kid in 1930, and the wards of catatonic or raving and tormented souls in the lunatic Asylums, and, before that, in the jails and stockades, tied to poles, or expelled from villages.

Of course there is much to discuss in the liberal arts and social sciences about how societies have defined normal and abnormal, and all the forces at play in each Era, and about the uses and abuses of power, and about the benefits of capitalism (all effective modern medicines have been developed within capitalist systems) and the horrors of unregulated capitalism.

And these (along with the philosophy of science and the successes and limitations of the disease model of human ailments) can all be discussed and investigated within schools of social work and medicine in an academic fashion without prejudice. In fact, a really good academic question to ask would be: Why is there now a strong anti-psychiatry, anti-vaccination movement? Is it related to the anti-science zeitgeist of Trump world? Is it a failure to teach real history? Is it fear of a loss of the sense of a perfect God-made homunculous within each of us? Is it the fault of the internet? Have our entertainments (think Dr. House, Hannibal Lecter, and Jack Nicholson receiving ECT) overwhelmed our perception of reality?

Or is it just some social workers and psychologists wanting more power and status?