Maggie's Farm

Lyme Disease (Borreliosis) is endemic in the Northeast US, and probably always has been. That complicates diagnosis because so many people in the area have been exposed to the germ, and thus show some degree of antibodies to it. Many if not most cases of Lyme are subclinical and never diagnosed.

The spirochete-like bug is transmitted by the bite of a mostly-mouse-born tick called a Black-Legged Tick or Deer Tick. The Tick is much smaller than the common dog tick, and much harder to find on your body. Ordinary dog ticks are harmless, if annoying, and can not be confused with the Deer Tick.

Lyme Disease is readily treated with antibiotics, but about ten years ago one of those disease fads came along, so appealing to hypochondriacs and hysterics, called "Chronic Lyme."

As with other fake disease fads like Chronic Fatigue and, in my opinion, Fibromyalgia, Chronic Lyme believers often made themselves into invalids with vague aches and pains.

I thought the Chronic Lyme fad had passed into the history of medical faddism, but I see this odd and credulous article in The New Yorker: The Lyme Wars. The Lyme-disease infection rate is growing. So is the battle over how to treat it.

There are two serious errors right in the title. The infection rate is not growing: the diagnosis is growing and probably many people with aches and pains are being unnecessarily treated for Lyme just because they have been exposed to it at some point in their life. Second, I have never heard of any credible Infectious Disease doc in New England who had any question about how to treat real Lyme.

Here's one brief index to fad diagnoses but I am sure there is a better, more comprehensive one. The current fad is "gluten intolerance." There are a few quacks out there, but many more crocks.

From Dr. Frances, DSM-5 Badly Flunks the Writing Test

I do not have time to put together a coherent post on the topic today, but I believe that the mandarins of my profession have lost all connection to what taking care of hurting people is all about.

Dr. Frances does not go far enough, at all.

Sexual interest is obviously one of the primary human motivators. Blame it on biology, or God, or whatever. Wherever you put people together, especially young people in their prime, sexual curiosity will be in the air. This epidemic has been forever.

It doesn't matter whether they are gay, straight, or mixed-up. It happens when you put people together. People of strong character do not act on impulse when it is inappropriate, but many cannot resist the pull or just don't want to resist. It's fighting nature, and the addition of alcohol or other substances doesn't help. Neither does being away from home. People do get attached, form bonds, develop partnerships, loyalty, etc but raw desire has no respect for these civilized things. Furthermore, people need, at the very least, some form of "maintenance sex" for comfort but it is no insulation from reckless desires and romantic aspirations.

It seems to me that "sexual harassment" has come to include many expressions of virile or feminine sexual interest, extending the concept far beyond physical aggression (which is illegal. That is termed "assault," and can be felonious) to "unwelcome" advances.

In my life, I have been subject to hundreds of unwelcome advances from both men and women, and some of them were, well, forceful but not physically forceful. Weaker women might view much of it as harassment, but I took most of it in good humor because my brothers, my protectors, taught me about male tendencies. Women learn how to brush them off, but one of those advances turned out to be my husband of quite a few years and up to the present. A good guy, very shy and very smart, but who got up his courage to act like any other jerk because he felt he could not resist me. I could somehow tell that he was a good guy.

Now I read that the US Navy doesn't want guys looking at pictures of girls in the bathroom. What do they want these fellows to do for relief? Do they want an all-gay Navy? Or eunuchs?

From John Derbyshire, The Sexual Harassment Panic

The PC attitude seems to be to overstimulate children, but to de-sexualize adults. Or de-sexualize heterosexual adults, anyway. Does that make sense?

What psychiatry’s new diagnostic manual means for people on the autism spectrum.

The problem with the DSM is that it (the booklet) is taken too seriously. Nobody knows whether there is an Autism Spectrum.

A harsh critique of the "Psychiatry bible" (which is far from it): The Book of Woe: The DSM and the Unmaking of Psychiatry

The most curious aspect of the status quo in psychiatry, though, is how a scientific-looking manual put out by a small organisation with no public accountability has come to be viewed with such reverence. Not for nothing is the DSM known as “the psychiatric bible”. Perhaps its bullet-pointed diagnoses do satisfy a religious need, the old existential ache for reassurance that “even the hairs of your head are all counted” and there’s no reason to be afraid.

The humane treatment of the mentally ill was a major civilizational advance. At a time when there were really no effective treatments for the major disabling mental illnesses (ie Schizophrenias and Bipolar Disorder), providing these patients asylum from the rigors of real life was better than Bedlam or locking Aunt Jane in the attic.

Today, our treatments for Bipolar Disorder (aka Manic-Depression) are pretty good. Our treatments for the group of Schizophrenias are not very good. We can often remove acute symptoms but can not help people function at a normal level. They are mis-wired.

Efforts to help the seriously-ill, in hospitals, hospices, was termed "Moral Treatment." The asylum approach was largely undone with the deinstitutionalization movement under JFK. Thus bag ladies.

Here's a summary: A New Moral Treatment - Humane institutionalization can help the mentally ill and protect society. He might be right. I am not sure.

Under what circumstances is, or should underage sex be illegal? It's a complicated topic. We all know how much underage sexual activity takes place these days. How does one distinguish a sexual predator from a hormone-intoxicated person? And what does age have to do with it?

I have no answers. It's discussed here: Kaitlyn Hunt and the Romeo and Juliet problem.

Memory is famously faulty. Just as politicians and journalists attempt to create stories and "narratives" out of data points, all humans do the same. Often, our conscious memory stories are designed to support our positive self-regard, to rationalize, blame, find excuses, and so forth. Temperamentally melancholy people tend to do the opposite and are often more honest with themselves.

Psychiatrists and Psychoanalysts know how to listen stories and information as "memory data" with all of the selection, distortion, factual accounts, mental constructions, etc. which are part of memory. We are trained to listen as if watching a movie. Since we are not judges or juries, "truth" is not necessarily our pursuit although we can be quick to call "bullshit" when needed because people lie and manipulate too. We are not truth-relativists, but our focus is elsewhere.

One of the fascinating things about Psychoanalysis is to see how memory narratives change during the process.

Even recent memories are subject to distortion: Trust your memory? Maybe you shouldn't.

That's the view of Dr. Alan Frances, and I tend to agree. However, I never liked the DSM 4 either. 

Psychiatry's New Diagnostic Manual: "Don't Buy It. Don't Use It. Don't Teach
It."

Related, from Dr. McHugh: DSM-5: A Manual Run Amok - It's time for psychiatry to drop its field guide and try to
learn about mental ills

Salt is one of those things that drive dietary cranks, control-freaks, and ignorant do-gooders nuts.

There really is no reason for that. Most of us docs have been saying this for years and I have made this point here in the past. Salt is an absolutely necessary nutrient for all animals, and very low levels of sodium chloride can make you sick or dead.

The average, normal human body contains around 50 quarts of salt water.

The reason people used to advise "low-salt" diet is because excess dietary sodium is a bad idea for people with kidney failure and congestive heart failure, and people with uncontrolled high blood pressure (with its associated higher risks of heart attack and stroke).

However, salt does not cause those things.

Significantly-high blood pressure is easily dealt with these days. Heart failure will likely kill you in time regardless of what you do (barring a heart transplant), but it is treatable with medicines and some salt restriction.

The new study from the CDC: No Benefit in Salt Restriction.

The American Heart Association is not up to date on the topic: Sodium is Your enemy.

If you have high blood pressure, get it under reasonable control with your doctor. If you have organ failure (eg kidney or heart failure), or have some other ailment, do whatever your doc says. If you're healthy, enjoy your salt. It makes food taste better.

One recipe tip: I always season a salad with salt and pepper. It makes rabbit food taste almost good. Don't get me on the topic of whether green salad is "healthy." (It's neither healthy nor unhealthy. It's just filler.)

Readers know that we do not approve of using mental health terms as ad hominems against those with whom we have honest disagreements on political, or other, topics. I have been guilty of sometimes opining that "big, benign government types" are indulging in infantile fantasies of ideal parents, and I should not do that.

World-views differ, as do views of human nature. It makes life interesting and interestingly-contentious.`

Still, once you get past the insulting title this is a good post: On the Arrested Development of the Left:

At some point, one needs to grow up. The fact is, the human quest for salvation, whether personal or social, cannot be left to the reckoning of children. Given the perilous condition to which progressivist utopianism is taking our country, its pubescent psychology deserves to be even more carefully scrutinized. The soft-focus, Pollyanna attitude of the left, which has come to be known as the therapeutic perspective on the world, is often accompanied by unmitigated savagery. Even if the assault on culture is not physical but legislative, its effects are almost universally devastating. The historical register shows that the effort to improve the world by revolutionary violence or by comprehensive and indiscriminate cultural revisionism — therapy gone wild — is practically guaranteed to cause far more misery than it attempts to alleviate.

Addressing the tough realities of the real world, and the depressing limits of one's own self, are the best vitamins.

Mr. Solway references Rieff's challenging book, The Triumph of the Therapeutic: Uses of Faith after Freud.

I've mentioned here several times that the DSM is no "bible" for me or for most of my colleagues. We rarely find our patients in there, or human beings, for that matter. When the premise is wrong (that surface symptoms and complaints lead directly back to a neuro-chemical abnormality), then the entire endeavor is only useful for completing insurance forms (with a handful of partial exceptions).

A few relevant and interesting links:

- The Real Problems With Psychiatry - A psychotherapist contends that the DSM, psychiatry's "bible" that defines all mental illness, is not scientific but a product of unscrupulous politics and bureaucracy.

Not to mention the pharmaceutical industry. Always question Authority!

- Psychiatry’s Guide Is Out of Touch With Science, Experts Say in the NYT via 1 Boring Old Man's Groundhog Day

- How Scientific Is Psychiatry?

Like many fields of endeavor, good Psychiatry is part art, part science, but mixed with much life experience, much interpersonal experience, and as much painful self-knowledge as the doc him- or herself can handle to "sharpen the scalpel" as it were. We are called upon to be experts in real life, relationships, religion, the brain, the mind, the body, and the soul. It's a tall order which is why it is often termed "the impossible profession."

Readers know that I have trademarked the term "psycho-utopianism" to refer to the naive and reductionistic notion that, if all our our chemicals and all of our neurons were straightened out, and if we docs could fix it all by a cookbook, we'd all be some kind of "normal" and some kind of moral and some kind of "happy" of a serene, bourgeois sort. It ain't never gonna happen, and it's for the best that it cannot.

It would not be human, and it would not be real life. I recently was referred an evaluation for depression. Patient fit the DSM perfectly, but it didn't "smell right" to me so I took a chance and ordered her a total body MRI. She had an undiagnosed gastric cancer.

Executive decision-making is a skill. Good executive decision-making seems to be a talent. These are neither skills nor talents that I was blessed with, but that's probably just as well. I've never been much of a leader, and never a good follower either. My major life decisions have always made me nauseous. Medicine has been the right field for me. Independent work, endlessly interesting, and cautious, careful, conservative decision-making comes easily to me.

From Harvard Biz School, "While elevated narcissism and self-promotion has been shown to result in quicker promotion early in one's career, its negative impacts are revealed in positions of higher authority."

As in the sports world, in the biz world, if you cannot produce winning decisions consistently and with integrity, you will eventually go down. It's rough out there. I hear all of the stories and all of the excuses, but the most talented and honest do pretty well and never make excuses for their disappointments. Competition is a big part of life, and an exciting part of it.

Reflections of a Medical Ex-Practitioner - The glow of the personal relationship with patients is being extinguished:

 When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment...

There is no "should". This foolish and, I think, exhibitionistic piece in the WSJ, How Often Should Married Couples Have Sex?, has been getting attention all over. I don't think it is very illuminating. Sexual frustration, however, does make both guys and gals cranky, and tends to make them want to look elsewhere for their instinctual romantic and sensual drives (which normal people do anyway, but even more so).

In my professional opinion, younger guys seem to be OK and relatively calm with sex twice daily. They are monkeys. Older fellows seem to get by with anywhere from daily to 3-4 times/week, depending on how hard and long they work at their jobs. Women are an entirely different topic, but my general advice to women is to remove the TV from the bedroom. Not to worry ladies - they will put it back in our bedrooms 24 hrs/day when we're demented widows in the nursing home. We can catch up with our shows and movies then. Carpe diem.

Apropos of the topic, I saw that Glenn Reynolds linked this book: Lube Jobs: A Woman's Guide to Great Maintenance Sex. Library journal commented about it, "Most people spend the largest part of their adulthood slogging through committed relationships, and they need books like this." 

Good cozy marital snuggles can make up for a lot of troubles. But "slogging"? If you're slogging, it's your own darn fault. I have patients deep into their 70s and 80s with quite satisfying and jolly sex lives even when they know far more than they want to know about their spouses, and when their equipment is not what it once was. We are, in part, biological beings.

Have Americans lost the sense of evil? I don't really think so. Some say that, nowadays, the cognoscenti can only use the word ironically, but I don't agree with that entirely either. After all, I have read too much vitriol from the Left directed towards people like me, labeling us (non-ironically) as evil.

In other words, I think "evil" has been secularized or politicized. At the same time, attempts are made to psycho-babbleize it away.

Without writing an opus on the topic, I'll make just a few points about evil (from a non-religious standpoint). Evil thoughts and impulses exist in everyone, to varying degrees, whether consciously or unconsciously. It never appears in pure form. 

A normal human conscience, along with social pressures, fear, a desire not to be destructive, etc. permit most of us to live without enacting very many evil deeds. Some people, in denial of their own dark sides, project evil into others. Some people attempt to deny the existence of evil anywhere. Some people try to erase the presence of evil by what we call "identification with the aggressor", of which the Stockholm Syndrome is an extreme example.

To look upon evil, wherever it is and however banal it may appear on the surface, is frightening. In the movies it can be exciting, but in real life it is deeply scary. Thus thoughts like this: St. Louis U. student asks, “Why don’t we talk about evil anymore?” and this: Why Does Evil Make Liberals Stupid? A quote from that:

This piece in The Atlantic is a good exemplar of the mushy liberal commentary that has proliferated in recent days. Authored by one Megan Garber, it is titled: “The Boston Bombers Were Muslim: So?” Before taking a close look at Ms. Garber’s article, let’s advise The Atlantic not to put away that headline. It could come in handy so often. “The Cole Bombers Were Muslim: So?” “The Embassy Bombers Were Muslim: So?” “The First World Trade Center Bombers Were Muslim: So?” “The September 11 Bombers Were Muslim: So?” “The Madrid Bombers Were Muslim: So?” “The London Bombers Were Muslim: So?” “The Shoebomber Was Muslim: So?” The Underwear Bomber Was Muslim: So?” “The Fort Hood Shooter Was Muslim: So?” “The Beslan Child-Murderers Were Muslim: So?” “The Times Square Bomber Was Muslim: So?”

And this one:  Jihad Will Not Be Wished Away - But willful blindness remains the order of the day.

I am sorry to say that Mukasey has it right:  Make No Mistake, It Was Jihad - Let's hope the administration gets over its reluctance to recognize attacks on the U.S. for what they are.

All sorts of things can help unleash the cruelty and destructiveness in people, but I won't get into all of that now because I only want to mention one of the things: communal support of evil. If only 7% of Muslims are inclined to active Jihad, that's 100 million people. That's no mob - that's a large nation of killers and would-be killers of infidels and they are all on the same page.

Jihadists believe the West is evil. "Submit or die." They are convinced of their virtuousness, but they are as wrong as can be because all that we in the West want is to be left alone and to truly "coexist" peacefully.

Here's an interesting 1996 book by Columbia Prof Andrew Delblanco: The Death of Satan: How Americans Have Lost the Sense of Evil

I have been saving two links about Tallis' 2011 book, Aping Mankind: Neuromania, Darwinitis and the Misrepresentation of Humanity, until I found time to say something interesting about the ideas. I could not add anything, as it turned out, because Mark Signorelli says it so well in his review.

Tallis, a neurologist (and amateur and impressive philosopher) wrote the book as a critique of biological and evolutionary reductionism. 

Here's a brief review from the WSJ.One quote:

 In his vigorously argued "Aping Mankind," Raymond Tallis takes on what he calls "neuromania" (the belief that we are our physical brains and nothing more) and "Darwinitis" (the insistence that our consciousness can be reduced to evolutionary terms) in a robust defense of the unique nature of human consciousness. Mr. Tallis, a doctor and researcher in clinical neuroscience, believes that most contemporary accounts of human consciousness fail to understand the lived experience of individual minds. Reducing man to simply another animal in a real sense de-humanizes us, with disastrous effects in areas from social policy to the interpretation of art and literature, which the author touches on in engaging asides.

Aping Mankind is negative research. While most popular-science writers attempt to weave compelling stories from the latest neuroscience experiments to explain 'why we are the way we are', Tallis attempts to show why these stories simply cannot be true. If you are skeptical of media--and scientific journal--headlines such as "Researchers discover the location of love in the brain", then you may enjoy Aping Mankind. In this work Tallis exposes the odd proclivity of scholars, from biologists to literary critics, to anthropomorphize pieces of matter while simultaneously dehumanizing human beings. In effect we are systematically transferring our humanity to matter, and this may not be good for our health--just like vitamins.

Returning to Signorelli's impressive review which opens like this:

I can recall very clearly the moment at which the spread of Darwinian ideology became a matter of concern for me. Previously, I had been acquainted with such ideology, and recognized it as but one more strain of fashionable cant, promoted by a set of persons quite obviously unfamiliar with elementary philosophical reasoning. Having attended college in the late twentieth century, I, like many of my generation, simply became accustomed to dwelling in an intellectual atmosphere poisoned by noxious dogmas, whether deconstructionist, multi-cultural, or what have you; Darwinism was evidently just such another doctrine, and so I took no great alarm at its prevalence. That changed one evening when, surfing idly across the internet, I came across the late Denis Dutton’s article on “Aesthetics and Evolutionary Psychology” in the Oxford Handbook of Aesthetics, an article which proposed the advantages of applying evolutionary theory to our inquiries regarding the arts and literature. This was the first time I had encountered Darwinism in such a context, and when I looked into the matter subsequently, I found that Dutton was by no means alone in his project; quite a body of literature had amassed by that point, purporting to offer evolutionary accounts of poetry, dance, and painting, among other things. Now I became alarmed, and greatly so. Literature (understood in the broad sense of learning, or letters) has been everything to me, the source of all my consolation, and all my self-understanding. To see it threatened by this dirty little creed, with its invariable tendency to degrade whatever comes under its purview, was deeply worrying to me. So I began writing against it, with that same defensive urgency that motivates a man to fight for kin and country.

I am a big fan of AA as a help with addiction and as a method for personal growth and maturity.

It's not the only way, but it might be the best way for those who have trouble with it. Recently, people have recommended two books by Allen Carr:

The Easy Way to Stop Drinking

Allen Carr's Easyway to Stop Smoking

It's been far too long since I studied, or used statistics other than to read medical journal articles. Everybody talks about Bayesian Statistics nowadays. They are the new old thing, almost 100 years older than Fisher Statistics (Fisher was an interesting fellow).

In my youth, I learned to be always skeptical about any research results, but I am told that running data through Bayesian methods is a good test of data.

Can somebody explain the concept to me in simple English? I don't intend to use it, just to get the ideas (I can do the math, but I want something conceptual for starters.) Most Liberal Arts students learned basic Stats in college, the p and the t-test, etc., but the Bayesian is new to me.

Reading Buzz Bissinger's confession, My Gucci Addiction, I would have to seriously consider the Bipolar possibility were I his doctor:

In the past few years, I've bought eighty-one leather jackets. Dozens of boots and leather gloves. I've purchased pants that cost $5,000. I own a $22,000 coat. This winter I took a tour of Milan's Fashion Week (all expenses paid by Gucci, in appreciation of my many, many purchases), where I spent tens of thousands more and began to seriously grapple, once and for all, with a compulsion that could cost me more than just my life savings. My name is Buzz Bissinger. I am 58 years old, the best-selling author of 'Friday Night Lights,' father of three, husband. And I am a shopaholic.

Not everybody who does crazy things has a diagnosis, but unless Mr. Bissinger has inherited $100 million, somebody ought to try to stop him before he blows himself up. It does not sound like his wife is likely to do that.

I saw a nice lady for consultation a few years ago. She was distraught, wanted help in rebuilding her life and her emotional strength. Her husband, age 54, had, after an evening of good sex with her, informed her that he had realized that he was gay, and needed to leave her to pursue a gay life style because he did not want to deceive her or betray her.

They cried together and held eachother. She cried for two weeks. After that, she began having panic attacks. He moved out, and the legal aspects of the divorce proceedings had been easy and mutually agreeable.

Six months had gone by and she still felt shattered. The reality of her life had been exploded. I told her that grief takes at least a year.  Mind you, this was a sophisticated urban woman who had once been in the fashion business and who assured me she could readily identify gay guys at a distance. He had always been a loving, sexy, loyal husband with no hyper-macho ways, and no stereotypical gay interests or mannerisms. Good father, too. He worked in finance.

In the six months apart, she told me that he had seemed to transform himself from an ordinary fellow into a flamboyantly gay man who drinks too much, dyes his hair, spends weekends in Provincetown and weeknights in gay bars. He told her it took him 40 years "to find his inner fag." He says he'll love her forever, support her and the kids, but now has found his real self and feels happier than he ever had.

I thought to myself "That was a real gay marriage." I also wondered whether he was Bipolar, but it didn't matter because it was over and her challenge was to write what I term "a new chapter."

I had seen this a number of times before, in mid-life men and in women too. I can't say I understand it. Nobody really does, but I do understand the grief. Agonizing. I also understand the horror of wondering whether much of one's life has been fraudulently-lived in a fake reality.

In my line of work, I encounter plenty of people who live in fake realities of their own construction, but it's not ordinarily about sexual matters. It's usually about other things. I carry the burden of a thousand stories in my soul, but don't feel sorry for me. It's a privilege, and I get paid to carry them.

(nb: real details of this story are totally altered and combined - fake but true)

If psychotherapists "screw up" their children any more than anybody else, I haven't seen the data. (My own kids, BTW, are perfect.) Biggest issue with parenting these days? Trying to be friends with the young. They can be pals when they grow up and achieve independence but, until then, make your own friends.

It's a perennial topic, however. If therapist-types do, I think it comes from being over-attentive, over-protective, overly-empathic, and not respecting kids' resilience and adaptability.  How Therapists Screw Up their Children.

It's important for therapist-types to put their work hat on before work, and to take it off after work.

This on parenting is related: Please Do Not Adjust Your Child

Unlike, it seems, some or many of the young women in Medicine today (50%), I never had any interest in being anybody's employee.

The Doctor Won't See You Now. He's Clocked Out. ObamaCare is pushing physicians into becoming hospital employees. The results aren't encouraging.

My freedom in practice is to see people anytime I want or can, to work whatever hours I want to, to follow no imposed treatment protocols, to set my own fees and to provide as much charity as I wish, and to help anybody I chose to.

Nobody tells me what to do or how to do it. Maybe I'm a dinosaur. I'll see patients on a Saturday or Sunday if need be.

A quote from the article:

Once they work for hospitals, physicians change their behavior in two principal ways. Often they see fewer patients and perform fewer timely procedures. Continuity of care also declines, since a physician's responsibilities end when his shift is over. This means reduced incentives for doctors to cover weekend calls, see patients in the ER, squeeze in an office visit, or take phone calls rather than turfing them to nurses. It also means physicians no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.

Most hospitals exacerbate these strains by measuring the productivity of the physician practices they purchase in "Relative Value Units." This is a formula that Medicare already uses to set doctor-payment rates. RVUs are supposed to measure how much time and physical effort a doctor requires to perform different clinical endeavors.

Amateur addicts always have an excuse, but those who are honest with themselves will admit that it just makes them feel good and that they have addictive tendencies.

There's a Reason That Addicts Say Yes to Drugs.