We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
Parts 1 and 2 were re-posted over the past two days.
I mentioned in an earlier post that a person's ability to adjust reasonably well to adult life does not necessarily depend on their DSM diagnosis (if they have one), but instead on their personality traits. Most of the personality traits we observe in people have to do with what we call "ego functions."
For just a few examples, what is their physical, mental and emotional stamina and endurance? What is their stress-tolerance, and how easily are they overwhelmed? How good are they at assigning themselves tasks and completing them? Are they reasonably honest, or connivers? What are their relationships like, and what sorts of relationships do they like to have? Are they socially appropriate? How sound does their judgement seem to be? How do they do with maintaining boundaries? How smart are they? How flexible is their thinking? How do they do with delaying gratification? Are they reliable or erratic? How self-regulating are they, or do they depend on external structures to function well? How often do they make excuses or blame? What do they want out of life? What motivates them? Do they have wholesome outlets? Are they emotionally mature? How do they view themselves, and how consistent is that with the reality?
Furthermore, what traits are out of line and give the person trouble managing life?
As I mentioned before, it is foolish to hold any standard of human perfection: I call that Psycho-utopianism. Let's just say that we are interested in a person's profile.
For the final post on the topic pf Psychiatric Diagnostics, let's take a closer look at Leo Bellak's list of ego functions, from Dr. Blatner's site which I linked last week. (It's not the best list. I wrote up a better one years ago, but cannot find it.)
1. Reality Testing: This can range from Disorientation to Distortion to Accurate Perception. Lots of seemingly normal people don't really check out their impressions of reality and operate with mild to moderate levels of distortion! 2. Judgment. This can range from "Infantile Omnipotence"--that sense that if I want to do it, I can-- to a more sophisticated Degree of Appraisal of Consequences. Even political leaders can lack this. Again, many of these variables are not always at the top end for many adults. 3. Sense of Reality. Most people sense their objective reality and can differentiate it from dream. 4. Regulation/Control Affects/Impulses: This can go in either the directions of being too impulsive or on the other hand, too over-controlled. With maturity and health, people learn to vary the degrees of control, allowing spontaneity in some settings, being more low-key in others, and making the transitions smoothly, but few adults still do this very well, enjoying full spontaneity; many are all too habitually self-controlled. A few allow themselves to be excessively impulsive regarding anger, or shopping, or in dealing with sexual temptation, etc.. 5. Object Relations: What is the person's capacity to engage in a caring or close relationship, with a romantic partner, a good friend, family members, or close co-workers. Does the person tend to be excessively detached or, again, going to the other extreme, overdependent? Do they shift among these positions, playing a lot of what Eric Berne would call interpersonal "games"? (i.e., what used to be called "neurotic.") Or can they engage with mutuality and flexibility? 6. Thought Processes. This variable includes not just intelligence, but also psychological states that avoid the anxiety of thinking, so they fail to engage in abstract reasoning. Or can they, instead, manage conceptual thinking? Many people are in the middle on this one. 7. Adaptive Regression in Service of Ego (ARISE): This is a fancy psychoanalytic term to explain the capacity to enjoy imaginativeness, the innocence of daydreaming, the freedom of the best of childhood's pretending and playfulness. The lack of this can itself add a good deal of rigidity to the personality. 8. Defensive Functioning: Some people use more mature defenses, humor, sublimation, suppression, and the like. Others tend to use more habitual, automatic, and immature defenses, sometimes even fairly primitive ones that waver on the edge (or go over the edge) of mental illness. 9. Stimulus Barrier: Some folks are hypersensitive, others too dense. To the extent that one is over-sensitive, what coping maneuvers are they capable of to compensate for this sensitivity? 10. Autonomous Functioning. Aside from any emotional issues in life, how competent is the person, or free of pervasive inner conflicts, so that they're able to perform daily tasks regarding personal hygiene, communicating with others, being able to do simple or more complex work roles. Many people are pretty functional, but sometimes blocked if they're upset. Some have developed healthy--and occasionally unhealthy--abilities to resist any intrusion of personal issues on their hobbies or work skills. 11. Synthetic-Integrative Functioning. Some folks are fairly good in one area and terrible in other areas. How well can they manage to integrate all the other variables being spoken about here? 12. Mastery-Competence: Some people have low initiative and are under-achievers. Others may have significant emotional wounds, but yet able to perform remarkably well in work, sports, and so forth. 13. Superego Adaptation. Again, this can be too much, or too little, strongly blaming oneself, or shockingly lacking in guilt or shame, tending toward the puritan or happy-go-lucky type. More mature people are able to acknowledge errors and seek to rectify them, moving toward a more balanced type of social conscience. 14. Strength of Drives: Some people are more sexual than others, and in some cases this may be more extreme in either direction, from the asexual to the hyper-sexual or driven. This can be affected by hormones, overstimulation, and other factors. Another drive is the aggressive, which can be diverted into hostility, grumpiness, or more focused as competition and work. Other people are less driven, and at the extreme, "un-motivated."
When we try to assess these things, we know that we are looking at surface manifestations, not at what is going on in depth. Like geologists gazing at a landscape, we speculate about what is underground based on what we see above ground, and then test our speculations with test drilling.
Modern Psychiatrists and Psychoanalysts often tend to focus on the "Object Relations" item, believing that, developmentally, the integration of mental relationships effects the stability and integration of the adult person (and that aberrations can be improved with Psychotherapy). I am a friendly skeptic about that, and more inclined towards the genetic basis of personality traits (which by no means implies that they are immutable).
OK, I am going to avoid depth psychology here because my purpose with these posts was to give a sense of the sorts of things shrinks think about when they evaluate somebody and not about Psychotherapy or Psychoanalysis. As for the medical students who will not specialize in Psychiatry, these sorts of methodical ways of thinking about people are quite practical, not especially theoretical, and, I believe, useful to everybody in their dealings with others.
Photo is Anna Freud, the more-or-less founder of Ego Psychology.
I took Chemistry from a Nobel winner chemist in a classroom of 250 eager students, many of them hopeful pre-meds. He clearly had been assigned to one undergrad class, but he didn't seem to resent it.
He had fun talking to a class of undergrads, but he talked about whatever he wanted to, whatever was on his mind. He liked to talk about how the planet was running out of oil so there would be no substrate left for medicines and organic chemicals. He said everything you need to know is in the textbook and, if you are confused, try to grab a TA.
Well, the impatient TAs had zero interest in that chore. As a result, many of us formed study groups which were great fun. I wanted to learn Chem so as not to be an ignorant person, and later took Organic for the same reason, despite being a History major. The Chem exams were a bitch. The five in my study group all got As, back before grade inflation. Science grades were curved. The reason our group did so well was partly because one of our study approaches was to create difficult problems for eachother. We'd meet at night in an empty classroom and do everything on the blackboard (remember them?).
(This series is a peek - a few samples - into what goes on in Third-year Psychiatry in Medical School. Very few of the students will select Psychiatry as a specialty, but all do clinical rotations through Surgery, Pediatrics, Internal Medicine, Psychiatry, OB-GYN, etc. - and further elective rotations in the 4th Year. I focused on Surgery and Orthopedic Surgery in my 4th Year. The Surgeons did their best to win me over, and almost did.)
In one of the teaching sessions, we watch a video of a half-hour intake interview of a patient in the Internal Medicine clinic, done by a third-year medical student. At the end of it, I ask "Let's list everything we now know, or might speculate about knowing, about this patient."
We go through the medical history, the patient's demeanor (what's their style? Dramatic? Passive? Grouchy? Warm? Arrogant? Sneaky? etc), physical appearance, dress, posture, eye-contact, tone of voice, nature of his interaction with the interviewer, apparent intelligence, knowledge about health issues, work history, family, special concerns, and so forth.
The students who have been science nurds and wizards are often astonished by how much information can be collected from a simple half-hour medical - non-psychiatric interview. I write it all down on the whiteboard, some as facts and some with a ?.
It usually fills the entire board, especially if I write large enough.
In Psychiatry, we have no high tech diagnostic tools - just our eyes and ears.
Moving to Psychiatry, let's assume that we are meeting with a patient in the Psychiatric consulting room - a new patient who does not require any sort of acute crisis intervention or triage. What do we want to know about this new patient right away, after they tell us why they are here?
First things first. We want to know about their general health. That is from their story, and via eyeball. (Over the years, I have diagnosed hypothyroidism, brain tumors, Lyme disease, MS, GI cancers, Parkinson's Disease, early Dementia, etc. in people who have come to me for Psychiatric help).
Then the obvious things. Their life story, their family history, their current life situation. We assume we are never getting the whole story, but we need a provisional frame for the picture. In the process of asking our questions and following up topics of interest, there are a number of other things we get from initial interviews, using our bag of tricks and our sensitive ears, which are solid data.
For some examples:
- We determine how self-observing they are, their capacity for "insight" - We determine their motivation to deal with their problem - We usually get a provisional DSM Axis 1 diagnosis - if they have one - We get an idea of what their coping devices are, and when and how they fail - We get a good idea of their IQ, their life skills, fund of knowledge, their adaptive success - what we call their "ego strengths" and level of functioning in important areas of life (eg relationships, work, avocations, etc) - We get a sense of how they relate to others (to us, being the case at hand), rapport, relatedness, and a sense of what their personality is like, their appropriateness, manners, boundaries, attentiveness, sense of humor, etc. etc. - We would like to be able to say something about the style of their thinking, and especially their patterns of defenses - We would like to know how they respond to our observations and comments (eg defensive? interested? insulted? embarassed?) - Try to assess their morality and impulse control, reliability, and any sociopathy or secondary gain, or manipulativeness (this can be difficult but, with experience, one can smell it)
(These are the sorts of observations that make some folks uncomfortable with shrinks in social settings. People are often not aware that when we shrinks are out of the office, we probably think about these things less than the average person. For us, it's work.)
The point is that the Psychiatric interview is just a variant of the medical interview, but one which usually takes more than a half hour. Sometimes, much more. With healthy patients with neurotic problems, sometimes it can take me 5 or 6 one-hour meetings just to come up with a provisional case formulation and treatment plan (if needed). With very ill patients, 3 minutes can be enough to make a triage plan (eg Agitated guy fighting with security guards and cops yelling that they are CIA trying to implant more transmitters in his brain. Easy. Get the guards to hold him down and give him IM Haldol and Ativan with a little Cogentin...and wait a while.)
What's our goal? Our goal is a thorough Psychiatric Diagnosis and a Case Formulation. In medical school, in Psychiatric Residency, and in an Analytic Institute you have to write these up as lengthy formal presentations, but at my stage you just kinda do it in your head and store it in your head, except in special circumstances.
As rank amateurs, medical students cannot be expected to do either of these in an expert way, but we require that they produce a couple of these on some of the patients they are following.
Maggie's Farm readers are frequent guests of Bird Dog on his visits to the arts in Manhattan. I was shocked, really, actually shocked, when Bird Dog told me he'd never been to Brooklyn. By itself, Brooklyn is the 4th largest city in the United States. About 10% of Americans' families trace their families to originally being Brooklynites. Many of America's most famous celebrities hailed from Brooklyn, ranging from the early Dutch settlers who also bought Manhattan for trinkets and Thomas Paine, John Greeleaf Whittier and Walt Whitman, Mae West and W.C. Fields, George Gershwin and Aaron Copeland, John Steinbeck and Joseph Heller, Woody Allen and Barbara Streisand (my sister was at Erasmus Hall High School with her, Erasmus having the highest number of Westinghouse and National Merit Scholars in the nation), Lena Horne and W.E.B. DuBois, Gil Hodges and Sandy Koufax, to .........the list goes on and on. It contains top flight colleges. Prospect Park rivals Central Park. Its restaurants and arts are world class. There are far more beautiful brownstones than anywhere else. And, then, to top it off, its beaches have been New York's summer playgrounds and winter strolls for generations. One of those beach communities, next to Coney Island, is Brighton Beach. My grandmother and, later, my mother, in their old age lived in Brighton Beach highrises looking over the Atlantic and if you craned your neck you could see the Statue of Liberty. Here's a terrific photo homage to the Brooklyn that I grew up in. The video below is about Brighton Beach today, a thriving enclave for Russian emigres. They settled there because most were Jewish and the area was Jewish.
Bird Dog, doggit, you've got to get thee to Brooklyn, often. Manhattan midtown is where people not from New York City hang out, missing the real New York City.
If the Supreme Court could decide that a “living constitution” reflected the failures of laissez-faire capitalism in the 1930s, which is what we’re told it did, then why can’t it decide that a living constitution must recognize the failures of big government in the 21st Century?
These posts are bits from a short series of presentations which I give to medical students during their required Third Year Psychiatry rotations. Which is to say, it is more or less directed to the general public but oriented towards general-physicians-to-be.
(Very few of these medical students will choose Psychiatry as a career, given all of their choices. More of them will chose Radiology than Psychiatry - wherein they will have plenty of fun and much to learn but never even have to talk to a patient at all - or Dermatology, wherein they will never have to be on call for the hospital. However, most will select Internal Medicine for their internships, which itself is a path to other specialties. FYI, all American-trained Psychiatrists do internships which include Internal Medicine or Pediatrics, plus Neurology, and get Board certification from the American Board of Psychiatry and Neurology.)
My presentation is not about making specific diagnoses (that comes from other Profs) - it's about the preliminaries: how all Docs can think about their patients, if they want to, and how shrinks think about their patients.
It's partly meant to be a corrective to the often-stated idea that the DSM is any gold standard of diagnosis, and it is meant to encourage young docs to think about their patients' lives, not just about their diagnoses - whether psychiatric or otherwise. And if I can interest them in the sorts of things shrinks think about, and gain some appreciation for what shrinks do, so much the better.
My presentation is based on the idea that, in the end, the job we shrinks get paid to do is to figure out what interferes with a person's ability to make a reasonably mature and effective adjustment to life if they wish to do so, and to try to reduce pathological mental pain, impairment, and anguish (but not healthy pain, worry, and anguish, like guilt, regret, sadness, realistic anxiety, or grief).
It's not to try to make people "normal," because "normal" doesn't really apply. People are wonderfully different, each with his own unique fingerprint of strengths, weaknesses, neuroses, interests, abilities, ego strength profile (about which more later), etc. In fact, unusual characters are a fine addition to the fabric of life.
I usually end my first session with a case example, for example, of a 42 year-old patient with hypertension coming in for a routine follow-up with his internist or GP. He has been prescribed 20 mg of Coreg/day for a month, and his systolic BP is 170 (had been 180 at his last visit).
I do my rapid-fire Socratic shtick. I ask them "So, Doctor, what do you want to know about this guy?"
"Is he compliant with the meds?" somebody wonders.
"Compliant!" I say. "What is he, your servant?" "Isn't the right question whether he is concerned enough about it to take the pills every day? Whether he can afford the meds? Does he need your free samples? Whether his life is too disorganized to do it? Whether it's the right medicine or the right dose? Or whether he even cares?"
We go on like this for around ten or fifteen minutes, and end up constructing a picture of a middle-management sales guy who is recently unemployed, divorced with two kids, mildly depressed, worried about money and alimony and child support, living in a small rented condo with rental furniture on take-out junk food and Chinese food, with some tendency for denial because he feels overwhelmed, with some deterioration in his self-care since his divorce made worse by the lack of structure and discipline in his unemployed life. His BP is the least of his concerns, but he does want to maintain a good relationship with the Doc, who he views as a friend and as a caring emotional support.
You rapidly move past the notion of A Case of Hypertension to the uniquely human and individual. It's good fun for all of us, and a good break for them from the fascinating but mechanistic details of caring for the renal functions of unconscious gomers in the ICU. It's about the art of doctoring, not medical science. You cannot do medicine "by the book," because each patient is his own book.
Then I tell them that they have just made a first step towards Real Psychiatric Diagnosis - and the real practice of clinical, office medicine as opposed to our equally wonderful technological medicine. It's about wondering "Who is this person who is asking me for help?" and not just about "What ails them?" After all, hypertension is painless, and doesn't really "ail him" at all. If you want to help this guy, all of this information about him might be useful to you.
In conclusion, I warn them that the same thing applies to Psychiatric diagnostics. Some people with Schizophrenia - a dread and incurable disease - have more satisfactory lives than some addicts - a sort-of fully curable problem. People are complicated, and so, often, are their lives.
Then I command the students to read MacKinnon and Michels' The Psychiatric Interview as their first of several readings for my series. A Psychiatric interview isn't much different from any other medical consultation with a new Internist or Family Doc, really - except no physical exam other than that of the well-informed medical eyeball (which can detect a lot).
Yes, I will interrogate them on their readings just as the Surgical Profs do with their text on the examination of the abdomen, or Neurologist Profs do with the diagnosis of stupor and coma (or, as we termed it in medical school, the Diagnosis of Stupor, Coma, and Death. Funnily enough, the diagnosis of death isn't always so easy).
Parts 2 and 3, and maybe 4, later. Why am I posting this? To help me collect my thoughts and to improve my presentations.
Photo is Dr. Emil Kraepelin, father of modern Psychiatric diagnosis who, among many other things, distinguished Manic-Depression from Dementia Praecox (Schizophrenia).
A whole pisspot full of computers are going to lose their Internet connection this July 9th. Let's find out if yours will be one of them.
It's actually kind of a bizarre story. Your computer connects to the Internet using DNS numbers. Some bad guys in Estonia ran a fake advertising scheme and infected a shitload of computers around the world with a DNS hijacking program which changed the computer's DNS numbers. It would still connect with the Internet just fine, albeit occasionally the user might find some new browser window open advertising this or that, which is how the bad guys made their money.
Enter the authorities, who catch the bad guys but then are faced with a problem. If they had just confiscated their servers, every infected machine on the planet would have immediately lost its Internet connection — and without the owners having the slightest idea why.
Rather than risk global anarchy, the FBI substituted the servers with some rental servers to give people time to clean up their computers, but time is running out and the servers are going to be unplugged this July 9th. There's already been one court-ordered 'stay' of 3 months, and it doesn't look like there's going to be another.
The reason anti-virus programs don't catch the little rascal is because it's not actually a virus; it's not even a program, just a web file. The second someone clicked on the original fraudulent ad, the damage was done. No file was ever downloaded so there wasn't anything for the anti-virus program to analyze and stop.
If so, head here for some fix-it tools, and please let us know in the comments which tool you used and on what operating system.
Mac users: If you use a browser with a Windows emulation program, check the FBI file for how to access your DNS numbers so you can compare them to the above list. If you're not running emulation, don't worry about it.
Router users: Check the router section in the FBI file. The router has its own DNS numbers that need to be manually checked against the list.
I suppose I should note the historical impact of the event. While there have been innumerable viruses, worms and trojans over the years that were expected to ignite on a certain date, creating Gawd knows what kind of havoc, almost none of them ever panned out. This time, however, we're being given a specific date and it's a damn good guess it'll actually happen.
Most voters don't know what the heck is going on, and don't care very much. We often forget this although in ordinary life we encounter such ignorance every day. Friend Sissy recently objected to my pointing this out, but I will stand by my first-hand impression.
Our readers seem to be highly-informed and engaged about policy, but pols know that such voters do not matter much.
Ilya discusses informed and uninformed (and uninterested) citizenry in his usual charming and amusing way, below:
My post at The New Criterionis up, “Judaic Studies and Western Civilization”. Judaic Studies in one form or another for centuries was a core subject in college curriculum, in order to best understand the West's Judeo-Christian civilization. Now, Judaic Studies has faded from centrality, as has much of the focus on Western civilization. That focus in Judaic Studies is what is needed to reinvigorate student interest and to keep Judaic Studies from degenerating into the sort of PCism and irrelevancy of other studies departments.
While visiting The New Criterion and enjoying its always interesting literacy, I encourage you to click its Donation page.
For those who refuse to click over to read my piece at The New Criterion, it is also below the fold.
For every person who says “I’m unhappy” there must now be a thousand who say “I’m depressed.” The change in semantics is important: the person who says he is unhappy knows that there is something wrong with his life that he should try to alter if he can; whereas the person who says “I’m depressed” is ill, and it is therefore the responsibility of someone else — the doctor — to make him better.
For the sorts of Psychiatrists who find it valuable to probe below the surface, there are many sorts of depression and many causes. Even grief can sometimes lead to a debilitating depression.
In my private office, the most common "cause" of agonizing, if not always debilitating, depression is narcissistic injury. These patients often can benefit enormously by psychotherapy alone, and can end up far healthier and stronger than before.
Since unions are non-profits, I have never understood how they can legally engage in partisan political efforts at all. But what do I know?
Forbes says:
The most far-reaching effect of the decision may be the court’s requirement of an opt-in system for public-sector unions when they impose a special assessment or dues increase. The court seems to be carving out a special case for public-sector unions, perhaps because of the political power they have to elect politicians who will serve their interests and diminish the political power of employees who disagree with them.
The simple truth why there are so many national security leaks is that the prime actors -- government officials, Congress, the media -- want them or are unwilling to stop them.
The current spate of serious leaks is not the first time this has occurred. There were major leaks during the Bush administration damaging to the post-9/11 ramping up of anti-terror activities, with no punishment of the offenders. By comparison, the leak of Valerie Plame’s not-so-secret CIA employment became the subject of a Special Prosecutor, and abuse of that process. These two examples revealed that prosecution and follow-up on leaks depended on whose political position was furthered and whose political ox was gored rather than the actual damage to national security.
There are laws on the books, federal agencies with the responsibility, and contracts signed that can be used to find and bring leakers to justice. Justifiably, national security professionals and front-line Special Operations forces have protested the lack of enforcement. Self-servingly, media has demanded even more impunity via a federal shield law. Partisanly, Congress has abdicated its oversight role. Avoidingly, Presidents have mouthed platitudes or claimed innocence.
The abdication of responsibility by those responsible or who should be deeply concerned about national security during the Bush administration has been taken to blatant new depths by the Obama administration’s re-election campaign.
The obvious truth is that these and other leaks are rarely the result of independent investigative reporting. Rather, someone in power secretly goes to the media with the damaging details, either to obstruct policy or to garner support for their own political ends.
Former US Attorney General Michael Mukasey writes...
Parts 1 and 2 were re-posted over the past two days.
I am taking Sundays off from my morning links this summer. 
Part 1 was re-posted yesterday
Genius Israeli scientists have produced a 
A History of Women’s Bathing Suits
These posts are bits from a short series of presentations which I give to medical students during their required Third Year Psychiatry rotations. Which is to say, it is more or less directed to the general public but oriented towards general-physicians-to-be.
A whole pisspot full of computers are going to lose their Internet connection this July 9th. Let's find out if yours will be one of them.
Sex in the park
Impact of Student Debt on Future Housing Demand