Maggie's Farm

Is age. Bad luck probably comes in second:

This is something that gets obscured in today's medical reporting--everyone, as they get older, will get sick for some reason and die at some point. The biggest risk factor for heart disease and cancer isn't BMI, cholesterol, blood pressure, etc....it's age. And to a large extent, the incidence of those diseases is random; doing everything right lowers your risk of disease, but not to zero, and usually not to that small a fraction of the risk for the general population.

We recently linked When eating healthy turns obsessive.

We have periodically posted here about eating obsessions, whether overeating, anorexia, "organic" preoccupations, people whose approach to food verges on the medicinal, vegetarianism, food fads and food quackery, etc. We shrinks call it all "orality."

As we have often said here, anybody in the Western World would need to make a full-time effort to avoid an adequate diet. Furthermore, medical science has yet to come up with a consensus on what a "healthy diet" really is. Eskimos thrive on seal fat and sea gull meat.  Despite what Mrs. Obama or anybody else tells you, it's all Old Wives Tales. We all would enjoy believing that we can control Fate in some way by one sort of magic or another. Eat fruit? Why? It's pure carbs and just makes you fat. Spend good money on vitamins? Why? It's all Magical Thinking.

During most of human history, any food was scarce and costly to obtain. We have tons of good food, cheap. If anything, too much and too tasty, and we don't have to do drudge labor in the fields all day to get some of it.

I have seen plenty of sturdy young athletes grow up on nothing but Cheerios, macaroni and cheese, and peanut butter and jelly sandwiches. Eat what you like, and thank God we have food choices.

Where's my Big Mac? I've been waiting here two minutes already.

We posted on The Art of Choosing a little while ago. It got me to thinking about one of my favorite topics, the choices of life goals.

There tends to be a political assumption that everybody is most motivated by material and financial goals, but it just is not true for many people unless they are in dire straights. Sad to say, many are these days.

However, in normal times, normal people choose their goals, and construct their plans to achieve them for all sorts of reasons: religious, following a passion, "life style" reasons, security, wanting to "make a difference," following a calling, etc. So, while most people could always use more money, that cannot be assumed to be what most people base their choices on. Just ask a toll-collector on the Mass Pike, or a Mass. State Representative why he/she picked the job.

As Prof. Mankiw says:

... one reason that people differ in their incomes is that some people care more about having a high income than others. To put it in geekspeak, preferences over pecuniary goods (say, consumption) and nonpecuniary goods (say, leisure) are heterogeneous.

The heterogeneity is the point. We make compromises, don't we, between our practical goals and our emotional goals in the endless pursuit of life satisfaction? However, most people do not have a career-related passion, in which case money and material often become our culture's default choice. I am fortunate in having a spouse with two absorbing passions: doing deals and playing sports. The former frees me up to pursue my less-lucrative academic work and charitable interests, and the latter keeps him out of trouble (except for orthopedic trouble).

If leisure is your life goal, here are The Highest-Paying Jobs With The Most Time Off.

If your preference is to work hard and long, with rewards potentially commensurate with effort but with plenty of risk too, I suggest starting a business.

One fine fact about life is that we can change our goals as we grow.

When is enough pleasure and instant gratification enough?

Oh, maybe never, I hear my readers thinking. 

I put the word "addiction" in quotes because I am not referring to physiological addictions such as to narcotics or alcohol, but to the pop culture use of the word, as applied to chocolate, food, sex, money, power, buying, etc. The casual use of the term, of course, refers to the difficulty in stopping the behavior when it doesn't make sense.

I opened the topic earlier, in The bad news: Eating less keeps your brain younger and more vigorous (with comments on satiety)

Some people are studying the brain to try to understand satiety. Some, interested in overweight, are studying foods. I think they are barking up the wrong tree (Yankees might not realize that that is a reference to coon hunting with coon hounds).

I believe that most of these "addictions" are more subcultural and psychological than physiological. Returning to the topic of food, the well-respected scientific journal Elle points this out in Satisfaction Guaranteed:

As a child, were you encouraged to clean your plate and then go back for seconds? If so, you probably didn’t grow up in France, where children are taught to savor the feeling of longing, or envie, for their next course (just think of the cheese!). Our differing notions of satisfaction were examined in a 2006 study of 133 Parisians and 145 Chicagoans published in the journal Obesity. While the French paid attention to an internal cue, the feeling of fullness, the Windy City-ers relied on the external: when their plate was empty; when their companion had finished eating; or when—quelle horreur!—the credits started to roll on the TV show they were watching.

Many Americans ignore the body’s subtler signals of hunger and fullness, hearing only the clanging gong at each end of the pendulum—Starving! Stuffed!—and rarely pausing to enjoy the much more pleasant midpoint: Ahhh, satisfied.

Some subcultures believe in big eating, some in savoring, some in minimalist eating, and, for some, food is just not a central part of life at all - Northern Europeans, for example. I was raised, for example, to learn that a lady always eats slowly, and never finishes the food on her plate. Not in public, anyway. It's not considered ladylike.

The wonderful Prof Antonio Damasio:

From Yale Psychiatrist (and author of Comfortably Numb: How Psychiatry Is Medicating a Nation) Charles Barber on the above topic in The Wilson Quarterly, a quote:

The new neuroscience has emerged from the last two decades of formidable progress in brain science, psychopharmacology, and brain imaging, bringing together research related to the human nervous system in fields as diverse as genetics and computer science. It has flowered into one of the hottest fields in academia, where almost anything "neuro" now generates excitement, along with neologisms, neuroeconomics, neurophilosophy, neuromarketing. The torrent of money flowing into the field can only be described in superlatives - hundreds of millions of dollars for efforts such as Princeton's Center for the Study of Brain, Mind, and Behavior and MIT's McGovern Institute for Brain Research.

Psychiatrists have been in the forefront of the transformation, eagerly shrugging off the vestiges of "talk therapy" for the bold new paradigms of neuroscience. By the late 1980s, academic psychiatrists were beginning literally to reinvent parts of the discipline, hanging out new signs saying Department of Neuropsychiatry in some medical schools. A similar transformation has occurred in academic psychology.

A layperson leafing through a mainstream psychiatric journal today might easily conclude that biologists had taken over the profession. "Acute Stress and Nicotine Cues Interact to Unveil Locomotor Arousal" and "Activity-Dependent Gene Expression in the Prefrontal Cortex" are titles of typical offerings. The field has so thoroughly cast its lot with biology, and with the biology induced by psychoactive drugs, that psychiatrists can hardly hope to publish in one of the mainstream journals if their article tells the story of an individual patient, or includes any personal thoughts or feelings about the people or the work that patient was engaged with, or fails to include a large dose of statistical data. Psychiatry used to be all theories, urges, and ids. Now it's all a search for genes, receptors, and neurotransmitters.

Read Barber's whole essay here.

A few comments: He correctly describes the currents in Psychiatry today - the emphasis on the mechanistic view. Of course, this is just one view of the elephant, and you cannot eliminate the words "mind" or "soul." After all, the main role of current neuroscience is to understand "the mind." I try to take a balanced view. I am fascinated by the neurosciences, and I think our psychiatric medicines are Godsends for many. But, for many problems - let's use addictions as an easy example - I believe that a soul-change is needed, and is possible. I think it's best if we shrinks remain modest about our knowledge and our powers.

Another quote from Barber:

You have to be skeptical about any report, but this is worth consideration.

After all, there is no doubt that eating less does keep one's body younger, more sexual, and more vigorous, and, as with sleep, the older you get the less food you need. For women, there is a definite connection between weight, insulin-resistance, and breast cancer too.

Works for me. I have not finished a meal in a restaurant for 20 years, and I never would. We prosperous, overweight Americans probably need to re-learn when enough is enough, to re-learn to identify the inborn sensation of satiety if we wish to be fit, strong, and light on our feet. Tasty and abundant food is wonderful, but we need very little of it to remain healthy unless we spend the day digging ditches with shovels.

Carbs? I only touch them on weekends, and in small amounts even if we do daily work-outs and plenty of recreational sports. No, I am far from being anorectic, but I will never leave my muscular Size 6 Tall.

It's not all that much about grim "self-control" as it is about identifying the point at which hunger is alleviated. It doesn't take much food to do that. Unless you're a growing kid, amazingly little. A small handful of almonds or olives will do it. The best, tastiest restaurants serve the tiniest portions for good reason. You pay for the flavor and the quality, not for volume.

In the Western world, and increasingly everywhere on earth, prosperity and food abundance make it possible for every day to become a secular Feast Day of some sort, making the sensation of satiety fade into the background. Still, being able to identify satiety is a more general theme, whether in possessions, substances, money, love, food, etc. I should expand on the topic here, someday. Not at Christmastime, though, when saturnalian greed and self-indulgence were somehow added to the Roman Mass and Feast Day of the Nativity of Christ. I blame those three wise men for that, even though I'm sure they meant well.

In the end, I believe that what we are insatiable for, if we feel insatiable, is for relationship with God. We displace that hunger elsewhere, into the fun and easy stuff. I guess it's all good, but not great.

Where's my Eggnog?

The studies like this, of course, are more correlation than causation, but, in my experience, red-blooded men require more than three. The healthier fellows will be more vigorous and horny, so they will have more of these things. Strong young men in energetic relationships seem to need 2-3 per day.

But what about women? How many orgasms per week correlate with health and well-being?

It's gift time, and I have been thinking about my own gifts, such as they are. Besides being fairly tall, possessed of regular features, a Victoria's Secret killer shape despite 3 kids, and a functional IQ and an athletic nature, what are the gifts with which God has endowed me? Am I doing justice to those gifts?

I have recently made a project of listing my strengths and weaknesses, and my special abilities which I view as my gifts. Middle age will do this to a person. Like most people, my list of weaknesses and of abilities is long, but my talents are f.

Do I use my semi-talents well, those gifts of the spirit, and do I use them in service of the Lord? Do I neglect them, or do I use them only for my foolish personal wants? I do love my foolish personal wants, however pointless they may be. Like a certain Michael Kors handbag. For what?

That's my sermon to myself this afternoon.

"Locus of control" is a psychological concept popularized and studied by psychologist Julius Rotter. It refers mainly to the extent to which a person thinks of himself as master of, or at least as prime determinant of, his life and fate. Captain of his ship, so to speak, or at least Navigator.

In America, we consider an "internal locus of control" as a sign of character strength (associated with determination, a can-do spirit, resilience, etc), and "external locus of control" as a sign of characterologic frailty (associated with blaming, excuses, scapegoating, dependency, complaints of unfairness, etc).

I say "in America" because some cultures support external localization while some cultures disparage the tendency to attribute unwelcome results to external forces, whether human, luck, God, or whatever. Northern European cultures tend towards the "no excuses," "take your lumps and learn from them" end of the spectrum.

Character is Destiny, or so claimed the ancient Greeks - and Freud.

People who tend towards the external side of things (in my field, we term it "externalizing," or "externalizing defenses") are often less successful in pursuing their goals. These are the people who are unlikely to admit "I screwed up," or "I was wrong," "I failed at so-and-so," "I handled that poorly," or "I don't understand it." The externalizing sorts of defenses are most commonly used to maintain a positive, or inflated, self-image in the face of disappointment but, on the other hand (revealing the internal contradiction) such people are the first to take credit for their successes and achievements.

The modern classic line which dramatizes the two ends of the spectrum is Jimmy Buffet's "Some people claim there's a woman to blame, but I know it's my own damn fault." In America, rightly or wrongly, our traditions respect those who say "It's my own damn fault" instead of blaming external circumstances, life history, bad luck, etc.

We preach that every move we make, or do not make, is a decision for which moral and practical responsibility must be taken, and the consequences of which we must man-up and deal with. Women must man-up, too.

The American ideal of self-reliance and self-responsibility comes into regular conflict with Christian views of God's will and evil forces, with ego-enhancing psychological defences, and also with dependency and victimization attitudes, ideologies and politics. It all keeps life interesting. 

Freeman Dyson discusses Daniel Kahneman's Thinking, Fast and Slow in the NYRB. A quote:

(A) theme of Kahneman’s book, proclaimed in the title, is the existence in our brains of two independent sytems for organizing knowledge. Kahneman calls them System One and System Two. System One is amazingly fast, allowing us to recognize faces and understand speech in a fraction of a second. It must have evolved from the ancient little brains that allowed our agile mammalian ancestors to survive in a world of big reptilian predators. Survival in the jungle requires a brain that makes quick decisions based on limited information. Intuition is the name we give to judgments based on the quick action of System One. It makes judgments and takes action without waiting for our conscious awareness to catch up with it. The most remarkable fact about System One is that it has immediate access to a vast store of memories that it uses as a basis for judgment. The memories that are most accessible are those associated with strong emotions, with fear and pain and hatred. The resulting judgments are often wrong, but in the world of the jungle it is safer to be wrong and quick than to be right and slow.

System Two is the slow process of forming judgments based on conscious thinking and critical examination of evidence. It appraises the actions of System One. It gives us a chance to correct mistakes and revise opinions. It probably evolved more recently than System One, after our primate ancestors became arboreal and had the leisure to think things over. An ape in a tree is not so much concerned with predators as with the acquisition and defense of territory. System Two enables a family group to make plans and coordinate activities. After we became human, System Two enabled us to create art and culture.

His "System One" is more prone to illusions, but it takes less mental effort, as does getting through Dyson's intelligent article.

From Jung At Heart (h/t to Dr X, who also posts a follow-up to that post), More than a civil war:

Steve Diamond made an interesting post last week describing the longstanding tension between the brain/behavioral and the mind/psychodynamic camps in psychology as a civil war. I have written here a number of times about this conflict, one that is at the heart of what is happening in psychiatry as well (if you are interested in the state of affairs in mental health, you really should read 1BoringOldMan who does a superb job of taking apart the trail of studies and inflated promises that got us here). I wish that what we are in were a civil war because then at least there would be active debate and engagement on these issues, but the takeover of psychology by the cognitive behavioral/brain folks is near complete on the academic level so that many younger clinicians have no idea of what is/was missing in their training. My side, the psychodynamic/mind side finds voice mostly through blogs like this one and those of other likeminded psychologists, psychoanalysts and psychiatrists. But together our voices are far less audible than those of the pharmaceutical and insurance companies and those of mental health professionals whose careers have been built on the effort to topple us. And the average person seeking help has no idea that these issues even exist. Yeah, it makes me kind of pessimistic at times.

I often feel that same way. Much of Psychiatric writing today has become so "medicalized," or "pseudo-medicalized," that you get the sense that it is check lists being treated rather than real people. Indeed, the two views of the patient - the hurting person - have developed different languages such that they cannot communicate well, and the alienation has become so extreme that I have heard them accuse eachother of malpractice.

Some of us attempt to straddle the divide, but it is difficult to rapidly alternate world-views.

This is how it begins: Doctors urged to limit practices. Next come the "guidleines," then come the one-size-fits-all requirements. At that point, the patient becomes helpless and choice-less, and the physician becomes an agent of the state rather than a confidential and private partner with his patient.

At that point, I will reluctantly quit and abandon you suffering patients - and myself when illness comes my way - to whatever unionized government lackeys, technicians, and drones they can find who are willing to pretend to take care of you, between their mandated lunch, coffee breaks, and 1 hour/day study time to master the government treatment manuals which will tell them what they can do for your age and category.

I have seen that kind of medicine, and will not be part of it. Watch for the politicization of medical care. Ugly. Every real and imaginary disease, and every real or imaginary treatment, will have a lobby in DC.

Government contaminates and corrupts almost everything it touches. Why any Psychiatrist or psychotherapist could be anything but Libertarian-minded is beyond my comprehension, because we are all about freedom, individuation, self-determination, and self-reliance.

No time to check the hearts of girls' dollies. A damn shame.

Just kill off those nasty fat cells that you have been over-feeding: Obese Monkeys Lose Weight On Drug That Attacks Blood Supply of Fat Cells.

Assuming this will be somewhat safer than bariatric surgery, we'll all be able to eat all we want and as inactive as we want, and we'll all be as skinny as models. Being in shape will lose all of its virtue because it will be effortless.

Maybe being fat will then come into fashion.

Like Megan McArdle, I don't give a darn about income inequality or asset inequality as long as people do not starve in the streets, and have opportunity and freedom to make their own path in life, but, in many years of talking to people, the patterns and major causes of very low reported income - bottom 1-4% - just call it the 1% because Life has a bell curve for economics -are obvious to me:

- Youth, career beginning, and education debt
- Single motherhood
- temporary unemployment
- Life style choice
- Lack of marketable skills
- Living where there are no jobs to match skills
- Very bad luck
- Mental illness, addiction, etc.
- Lack of cultural mastery, whether via recent immigration or whatever
- Chronic disabling illness
- A history of poor decision-making and life strategizing
- Low IQ
- Character traits such as laziness, inability to get along with people, lack of organization, initiative, goals, self-discipline, or ambition, no discipline to save money, impulsivity, poor planning, lousy judgement, etc etc.
- Income data gaps due to the numbers of people who work off the books (for a dramatic example, our clinic realised that there was a 30-woman prostitution ring working out of a nearby government housing project)
- Choosing to work the welfare/disability/food stamp/child care etc. system (with a couple of kids, the all with full government benefits brings them up to a working class standard of living without working. That ought to be good enough, roughly equivalent to a $40,000 salary). Our support system will bring you close to $30,000/yr in cash and/or benefits including unlimited free medical care)
- History of criminality or career criminality

Everybody knows these things, but they are never talked about. I think that list covers pretty much all of the income poverty that I have seen. I have been lucky, and have worked my butt off as a physician, and still am not wealthy. I work because I need to be useful. For wealth-building, being a traditional gal, I rely on my beloved hubby. I stand by my statement, however, that money isn't happiness. It just provides choices.

You have to have things and people that you love, independence, and integrity, to make a good life.

I have had a few interesting experiences with my patients and bill paying over the past few weeks.The business aspect of my practice is usually routine and unremarkable, but these stood out: 

1. Phone message from a wealthy law firm partner one hour before his initial consultation: "Dr. Bliss, I just found out that you are not on my insurance so I decided not to come in."

(I threw a fit.)

2. An email from a college student patient with no money who I have seen on a charity basis "Dr. Bliss, my Dad" (who is unemployed) "and I were talking, and decided that we need to pay you something for the phone time and emails to adjust my medicine while I'm away at school. Please calculate something and put it on my account."

(I explained that I do not charge for brief phone calls or emails.)

3. Patient in the office "Dr. Bliss, you made a mistake on last month's bill." "Oh I did. I'm sorry." "Yes, it's the second time in two years when you undercharged me. Please correct it."

(I was naturally pleased by her honesty.)

4. Patient in the office: "My husband nickels and dimes me about every expense for the kids, and last week he went out and paid cash for a new Escalade for himself." "Did he?" I replied, "That's funny, because he told me on the phone that you all had no cash and asked that I give you a discount for a while."  "Oh yes," she said. "I'm not surprised. His rule is 'Only suckers pay retail.'"

(I told her that as of today, it will be the full original fee because I was not pleased being one of his suckers.)

5. Business guy: "Doctor, will you take a discount for cash?"

("No. I happen to be one of those people who reports all of my income.")

Dr. X posted a list of the texts which have most helped or influenced him in his work.

It's a good list, and I endorse it except for the Kohut. I cannot understand Kohut. My list would also include:

A couple of Roy Shafer's books

A couple of Charles Brenner's books

A couple of Glen Gabbard's books

I have a GI friend and colleague who makes most of his living sticking tubes down people's esophagi and up their behinds.

He told me that he recently took on a 1 day/week job at a Medicaid clinic to keep busy in this economy, and to do some low-fee work for the benefit of the community. Apparently people who pay or partly-pay for their own scopings are putting it off.

After four months of it, he was frustrated. He told me that over half of the scheduled patients do not keep their office appointments, and 2/3 do not show up for their scope appointments. He is quitting that experiment (leaving them without any GI person), and told me "No wonder these people are on Medicaid. If they cannot at least treat their doctors' time with respect, how can they hope to function in the normal world? It almost seems like they just do whatever they feel like doing. I end up just sitting there, like a chump while I pay my malpractice insurance bills to cover the work."

Well, yes, often enough. That is, of course, not an effective life plan for them. A sense of entitlement will get you nowhere in life.

Readers know that I donate one day each week to a charity clinic at which I decided to take no compensation. It is a component of my tithing. I told him that I give my charity patients two chances, but he rightly explained to me that, as a specialist with only consultation appointments, people feel no ongoing relationship with him, view him as a free government technician while he wants to be caring, engaged, and of help to them. Their physician, in other words.

I told him what he had already learned. The poor often do not have good health stats because they do not take care of themselves, and are often stuck in bad circumstances because they do not function reliably or behave respectfully in the world. I advised him that he was wrong to take it personally. He said that he could not help but to take it personally because he had made a serious decision to be of help to people in need and could not tolerate the lack of gratitude and respect. Said he would rather be on the golf course where his frustration would be on his own terms.

Also, forgot to mention his relevant unpleasant detail that when they do show up, they often have not accurately followed the pre-scoping directions, making his job impossible and disgusting. "It's a set-up for lawsuits," he said. "Can't see a freaking thing. I am not Roto-Rooter."

I tell him that that is the same as people who lie to me. He is right that some greedy and dishonorable people are looking for lawsuits anywhere they can find them, but you cannot practice good medicine with that at the top of your mind. Medical care is not a "service," it is a very human collaboration. Fortunately or unfortunately, you cannot "service" your body and/or mind like you do your car. 

That is something that the bureaucrats just don't get. They will want us docs to be auto mechanics.

From an interview with Michael Gazzaniga:

Brain science “will eventually begin to influence how the public views justice and responsibility,” Dr. Gazzaniga said at a recent conference here sponsored by the Edge Foundation.

And there is no guarantee, he added, that its influence will be a good one.

Prof Gazzaniga is a good, humble scientist who knows the limits of what his area can offer us.

My colleague Dr. Allen Frances asks Should Temper Tantrums Be Made Into A DSM-5 Diagnosis?

Of course not. I regard the planned proliferation of "disorders" as a bit of a joke, but some people take it all very seriously. Internet Addiction Disorder? Tobacco Use Disorder? Sex Addiction?

In my view, the person is the issue, not the so-called diagnosis. Most of the time, I try to be of help to individual people, not diagnoses. There is a major division in Psychiatry today between those who treat diagnoses and those who treat people. Everybody has neurotic quirks.

Remember Sybil? 

Schniederman provides the update on all of that.

As he points out, this nonsense led indirectly to the terrible child abuse "hidden memory" epidemic which destroyed many peoples' lives before finally being fully discredited.

Four Small Things Good Parents Do That Hurt Their Kids in Big Ways. It begins:

We may now have scores of sophisticated books written by highly esteemed PhDs and a well-tread, lollipops over Castor oil, time-outs over spankings parenting path, but our progressive march through human history has ultimately produced adults that are… well, still childish.

Worse, we’ve managed to add an extra decade to adolescence.

How could this happen?

If you can't find utility in the concept of sin and evil, then I don't know how you can find utility in the concept of the good.

At Slate on evil, Neuroscientists suggest there is no such thing. Are they right? A quote:

Of course, people still commit innumerable bad actions, but the idea that people make conscious decisions to hurt or harm is no longer sustainable, say the new brain scientists. For one thing, there is no such thing as "free will" with which to decide to commit evil. (Like evil, free will is an antiquated concept for most.) Autonomous, conscious decision-making itself may well be an illusion. And thus intentional evil is impossible.

Many people do make conscious decisions to be hurtful or destructive. What could be more obvious? These neuroscientist folks can't see the mind for the neurons, it seems to me. As always in such cases, however, a conversation with the scientists would reveal that they do, themselves, lead lives in which good, evil, and choice are operative. Otherwise, they would deserve no recognition for their research because it was just their neurons making them do it.

Relevant good book: Columbia Prof Andrew Delbanco's The Death of Satan

From Dalrymple's Of Love, etc:

Our system is founded on our inalienable right to pursue our own happiness in our own way, a right that is supposed actually to result in happiness, or at least in more happiness than if we did not enjoy such a right. When it comes to choosing a mate, we have to consider only our inclinations, and not such things as obligations to society or parents. And when the marriage no longer suits, when the immortal beloved begins to bore us in a way incompatible with the chronic ecstasy we have come to expect as the only worthwhile state for a man (or woman) to be in, we dissolve the marriage and go off in search of another potential source of undiluted and everlasting bliss.

Unfortunately, the pool of candidates has in the meantime contracted. Gone are our student days, when the field seemed so ripe for the harvest. The field has thinned out like the hair on a man’s head. It is time to advertise.