Maggie's Farm

Guidelines have consequences – intended and unintended.

I don't know what practicing clinician has time to make guidelines for other docs, but guidelines are nothing but trouble. The best medical care is both art and science. Knowledge is always incomplete, patients are individuals with unique situations, and all docs have their own preferences and points of view. Guidelines end up being little more than fodder for tort lawyers and time-wasters.

Worst of all, young docs feel as if they have to follow them. Many things go wrong when practicing by the book.

At Shrinkrap radio, a discussion with a friend on The Unification of Clinical Science and Psychotherapy with Jeffrey Magnavita
PhD.

Blackness Ever Blackening: My Lifetime of Depression.

Confessionals like this one can sometimes help those people blessed with sunny dispositions to have some understanding of those unfortunates without such dispositions.

Educated people often make doctors’ worst patients: anti-vaxxers, cancer treatment rejecters, herbal remedy enthusiasts. Why do otherwise brilliant minds ignore science and reject modern medicine?

Read the article. I think people tend to be skeptical because "the science" is always in flux so many would rather go with their relatively-uninformed judgement than with the expert judgement of the day which may be obsolete next year. Remember the big scare about hormone replacement? Remember when they claimed that broccoli was good for you? Etc. People do know that physicians are smart and well-educated, but they like to make their own decisions for better or worse.

In recent history, sexual interests and inclinations outside of bourgeois Judeo-Christian monogamy have been labeled as immoral and "perversions" in the Western world, and in Western Psychiatry. Western Psychiatry has even categorized them in detail but some (such as homosexuality, which I find to be often a dubious categorization of people) have fallen out of favor due to political pressure.

Among the things which the Western world has relatively-recently and variously considered antisocial (lacking in normal conscience) or perverse (defined as outside local social norms) and/or illegal are polygamy, adultery, promiscuity, nymphomania, rape, incest, pedophilia, necrophilia, miscengenation,  internet pron, homosexuality, orgies and wife-swapping and related debaucheries, cross-dressing, childrens' pre-pubertal sexual interests, transgenderism, paraphilias and many fetishes like masochism, etc, prostitution, whoremongering, zoophilia, and so forth.

These are all culturally and/or religiously-determined categories of the wacky and disorderly, Bonobo-like vicissitudes of the human sex drive and of human psychology. Many humans successfully repress their inner Bonobo and happily adhere to their local cultural and moral codes, more or less. Many others lack a strong Bonobo streak, but it's not as if normal people never have wacky and aberrant fantasies and "curiosities".

As a Psychiatrist in the Western world, I can easily accept that many such things are statistically abnormal (ie at ends of bell curves), but high IQ is "abnormal" too.

I recently read this: 'Pedophilia is natural and normal for males'. Not "normal," I think, but certainly culturally-normative in parts of the Arab and Asian worlds. Some of our readers are quick to label perversions as "sick" if not just plain appalling or revolting. So is my natural inclination, but I think that inclination is culturally- and religiously- determined. Many human cultures view things otherwise.

Is there a Western socio-cultural trend to normalize previously-perverse and antisocial behaviors and to abnormalize conventional morality? I think so. In Psychoanalysis, we think of these things as embedded in problematic personality structures, but we could be wrong.

More:

Planned Parenthood Teaches 15 Year-Old on Bondage, Whipping, Gagging & Defecation

British Academics: ‘Paedophilia is natural and normal’

A judicial move to normalize incest

I am not claiming that I do not make moral or social judgements about behavior. All I claim is that it's complicated because living in a culture is part of being human, so "natural" loses meaning.

I will await discussion, but I may need to tie you up with duct tape and whip you. Here's your fun fetish joke du jour:

 Four friends spent weeks planning a perfect desert camping and riding trip. Two days before the group is to leave Rob's wife puts her foot down and tells him he isn't going. Rob's friends are very upset that he can't go, but what can they do?

Two days later the three get to the camping site only to find Rob sitting there with a tent set up, firewood gathered, and supper cooking on the fire. "Dang man, how long you been here and how did you talk your wife into letting you go?"

"Well, I've been here since yesterday. Yesterday evening I was sitting in my chair when my wife came up behind me, put her hands over my eyes and said 'guess who'?" I pulled her hands off and she was wearing a brand new see- through nightie. She took my hand and took me to our bedroom. The room had two dozen candles and rose pedals all over. On the bed, she had handcuffs and ropes! She told me to tie and cuff her to the bed so I did. Then she said, 'Now, you can do whatever you want.' So here I am."

Dr. Friedman blames it on the hormones and slow brain maturation: Why Teenagers Act Crazy:

... most adolescents do not develop anxiety disorders, but acquire the skill to modulate their fear as their prefrontal cortex matures in young adulthood, at around age 25. But up to 20 percent of adolescents in the United States experience a diagnosable anxiety disorder, like generalized anxiety or panic attacks, probably resulting from a mix of genetic factors and environmental influences. The prevalence of anxiety disorders and risky behavior (both of which reflect this developmental disjunction in the brain) have been relatively steady, which suggests to me that the biological contribution is very significant.

I am not sure why Obamacare rules require coverage for sexual conveniences. Sex is not a disease and, indeed, it is a sign of health. I recall that major medical policies frequently do not even cover labor and delivery because pregnancy is not a disease either.

The Obamacare rules do not require coverage for cosmetic surgery, at least not yet. Somebody will lobby for "Sagging Jowl Syndrome," you can be certain, in the future. When government gets involved with medicine, medicine becomes politicized and "diseases", "disorders", and "dysfunctions" proliferate.

It is not black and white. This brief interview about gay and straight is accurate and reasonable, in my view: The invention of the heterosexual - The history of straightness is much shorter than you'd think. An expert explains its origins.

As I have said before, humans are a highly-sexualized animal with omnivorous and often confused and confusing appetites and impulses.

A few links:

Rabbi Boteach wants women to get lustier in marriage (video)

When women earn more, promiscuity is more accepted

Why marriages fail: Romance just isn’t enough

Childless Elite, Spouseless Poor

Casual Sex Is Actually Excellent for You, If You Love Casual Sex

Is there any normal anymore? 

Mental Illness And Crime: What The Legacy Of Dorothea Dix Hath Wrought:

 Dorothea Dix was the activist whose efforts led to the first generation of American mental asylums. At the age of 39, she happened to visit a local jail to do a Sunday school sermon for female inmates. She found that criminals, retarded people and the mentally ill all lived together in terrible, unheated conditions. When she asked why, she was told  "the insane do not feel heat or cold" (Viney&Zorich, 1982).

IQ is always an interesting topic. Ashkenazi Jews and Asians have the highest average IQs, and IQ testing correlates well with the SAT tests.

How genetic is it, and how moveable is it? Those are always studied and always in dispute. I always enjoy the company of people with higher IQs than mine, just as I enjoy playing tennis with more talented players.

How important is life "success" and life happiness to IQ? Not very much, I think, unless one aspires to being a Physics or Math genius. IQ is just one factor in a human personality but it is one, like height, which is readily apparent.

Via this post on IQ, Last Call at the Milk Bar, I was led to this good and detailed essay on IQ:  Race, IQ, and Wealth - What the facts tell us about a taboo subject.

In the end, the facts do not tell us much.

People he wants to help, but can not: Evil and the Conservative Mind.

We’re a bit slow in maintaining consistency, although I suppose we will eventually succeed in making everyone equal. That means treating someone with a serious mental illness as if her preferences are merely preferences. It means only allowing for a voluntary commitment, a non-secure transport, and a facility from which you are free to leave at any time. It is one thing to remove gender so that sexual delusion can find itself comfortable in a nondescript stall… but it seems quite another thing to remove sanity so that all the world can be an asylum. It seems terribly obvious to look at prisons and madhouses and recidivism, to observe that this system of ours is broken in the sense that it is imperfect in its attempt to create a utopia; almost as obvious as to look at the results of closing them all down, and observe that Eden is no closer, and the world is still broken. But like the Bolsheviks who rallied for change and destruction, rightly pointing to existing flaws, we stand staring at Chesterton’s fence; we see the cracks and want to remove it, wholly unable to articulate why it was placed there to begin with.

I have no answer. There are many people who can not be helped. The world is an asylum, and life is tragic.

When it comes to sex, will humans ever be liberated from the basic biological needs that drove our evolutionary past?

Let's hope not. Actually the article is a critique of behavioral genetics, aka evolutionary psychology, as much as anything else.

Humans are a highly-sexualized sort of ape, with no estrus period as most mammals and even monkeys have (except for the "great apes" of which we are one). It's difficult if not impossible to determine what sexual behaviors are "natural" for humans because mental activity, fantasy, relationships, and culture are such major parts of being human. After all, rape, murder, theft, violence, pedophilia, etc. are all sort-of "natural" for humankind, and there are cultures in which monogamy is considered a mental illness or a form of infantile behavior. It's safe to say that the Western bourgeois ideal of lifelong monogamous marriage and the nuclear family is very far from "natural" despite being fairly effective for child-rearing and overall life stability in Western culture.

It also is safe to say that humans are the horniest of animals and, with our capacity for wild imagination and strange (by animal terms) sexual desires and fantasies, a rather insane species.

Freud explained a lot of that.

Not really. I don't know any doctors who get them.

Annual physical exam is probably unnecessary if you’re generally healthy

It's about brain scans, mind-body, and mechanical reductionism: The Limits of Neuro-Talk:

 I would like to make the case for giving due deference to ordinary human experience as the proper guide for understanding human beings. Such deference may be contrasted with the field of “neurophilosophy” (most famously, the work of Paul and Patricia Churchland), which is intent on replacing “folk terms” — such as “reflection” and “deliberation” — with terms that describe brain states. Needless to say, brain states are objective facts, whereas our introspective experience of our own mental life is inherently subjective. But this divide between the objective and subjective, between the brain and the mind, does not map neatly onto cause and effect, nor onto any clear distinction between a layer of reality that is somehow more fundamental and one that is merely epiphenomenal. For example, if you are told your mother has died, your dismayed comprehension of the fact, which is a subjective mental event, will cause an objective physiological change in your brain.

In light of this causal power of the mental over the physical, we begin to wonder if it is right to think of these two types of reality as layered, in the sense that one is more causally effective than the other. It would follow from this doubt that re-describing our introspective experience of our own mental life in terms of brain states is optional, in this sense: the choice of description ought to depend on what you’re trying to explain. Each description answers to a different sort of “explanatory request,” issuing from different realms of practice. The “folk” description answers to the realm of everyday human experience, and the brain description answers to the realm of physiological investigation.

Joy Pullmann on her Dad: Here's to the strong, silent types who nevertheless feel deeply inside.

My Father and Hospitalists - Obamacare can be deadly. It was for my father.

It's all the rage these days. Salaried docs who work for the hospital on shifts, like nurses.

Nicholas Wade’s credible new book challenges conventional wisdom about genetics.

There is nothing new there in the age-old nature-nurture game. Does it really need saying that people who are more closely related likely have more traits in common? "Race" and "ethnicity" are just words for common ancestry, like "distant cousins." Early humans spread around the earth, and bred with others in their own neighborhoods just like Darwin's finches. Naturally, differences happened but not to the extent of new species, but enough so that people recognize their cousins.

AA is a wonderful thing which has helped countless people, and countless patients of mine.

I have no idea why our internet friend thinks that we shrinks do not appreciate it immensely: Does AA Work? In fact, I have often said that there should be an AA for non-alcoholics. Its general approach could help people grow up even if they aren't drunks.

As we have posted in the past, the format of AA was based on a Methodist program for personal spiritual growth, and spiritual and emotional maturity.

From Condemned to Joy - The Western cult of happiness is a mirthless enterprise:

 The Western cult of happiness is indeed a strange adventure, something like a collective intoxication. In the guise of emancipation, it transforms a high ideal into its opposite. Condemned to joy, we must be happy or lose all standing in society. It is not a question of knowing whether we are more or less happy than our ancestors; our conception of the thing itself has changed, and we are probably the first society in history to make people unhappy for not being happy.

The science says they are.

We are also informed that PSA testing is useless. Indeed, many medical tests may be useless.

- The Neuroscientist Who Discovered He Was a Psychopath

No, he did not. You cannot make a diagnosis based on brain imagery.

- An entertaining site, found via AVI: Neuroskeptic

At Maggie's Farm, we are always skeptics

- Does hyper-parenting damage marriages? Of course it does.

Marriage must always come first. It's the job of kids to adapt to the family, not vice-versa.

- Another link re Schneiderman's book: "The Last Psychoanalyst"

Have not read it, but I can sort of guess where he is coming from. However, many of us are still transforming lives with psychoanalytic principles.

Like many if not most medical students, I spent some time at the VA hospital attached to the school. I did a thoracic surgery rotation and a psychiatry rotation there, at least. Also worked in their ER, which was inexplicably and redundantly separate from the general hospital's ER a block away.

The joint medical school-VA staff there were wonderful and more practically-minded than the full-time academics and researchers at the med school. They let us do things and procedures which the regular med center would never have let us do, and that was good experience. The patients, mostly WW 2 and Korea vets, but some Vietnam vets (they were still youthful and healthy then) were poor, on the whole, lacking in financial and overall life resources. There were plenty of veterans admitted to the regular medical center too but, at the time, I had no interest in how these systems worked.

Now I understand the the VA is plain old government medicine. Here's Charles Krauthammer, MD:

CHARLES KRAUTHAMMER: If you are non-ideological, if you brought in some experts and say how do you attack the problem right now? You give everybody on the list a voucher to go anywhere they want and they'll get their care within days. And if the budget won't hold it, then you do a separate appropriation. I can't see anybody in Congress who would oppose that. However, as you point out, this administration has been arguing for five years that the government knows best, it should allocate resources, and we won't even think of this.

And for the long-run, I think the question is this -- you know, this was started by Abraham Lincoln after the Civil War and at the time it made sense. But now that the country is so much larger, medicine is so much dispersed in areas of the country where there are other expertise. The budget for the VA is $85 billion a year, the number of patients is 6.5 [million] or so. Do the math. That's almost $10,000 a year per patient.

Why not have each of those vets get a voucher for $10,000 to purchase private insurance and to go anywhere? But of course an administration like this would never even contemplate that. But it is a question. If these problems are systemic and chronic, and they are from the bureaucrat structure of a government-run system, why wouldn't you contemplate voucherizing and privatizing it?

This article is good: Transform The VA Into A Pro-Growth Model For First Rate Health Care. There is no reason for the VA to exist today. It's an obsolete government program and does no favors to American vets.